Page 62 - Total War on PTSD

physically cannot only help them understand that what they are experiencing will not harm them, despite being distressing, but it can also help build rapport, as it gives structure to initial sessions and is not as anxiety provoking for the Veteran who may already feel resistant to therapy. Early treatment sessions should include education regarding how triggers form, breathing exercises to bring fight/flight symptoms under control, grounding exercises to pull back from anxious states, education regarding primary vs. secondary emotions, layers of PTSD (primary emotions-anxiety- anger) and mindfulness exercises to help them regain their ability to be present in the moment.
Breathing training is especially important as a concrete tool to teach Veterans when they first present for treatment. Techniques may include a breathe-and-hold technique to quickly reduce physical anxiety and panic-like symptoms, as well as a diaphragmatic breathing technique coupled with stress ball for less distressing moments. Breathing to control anxiety and fight/ flight symptoms at times is a hard sell to combat Veterans who feel this may be a bit too “feminine” of a coping skill, however, often being reminded that the military teaches breathing as part of weapons training to help calm the shooter and give them the most proficient performance helps in their acceptance of these techniques. Combat Veterans often feel more anxious when they slow down and their minds are not preoccupied, so breathing skills may initially evoke some anxiety in them. Again, this should be normalized and practicing sitting with their experiences can reduce this over time.
Many Veterans will present for psychotherapy, not due to their nightmares or even their anxiety, but due to anger issues and their spouses or loved ones insisting they get help. The triggering and agitation that are experienced secondary to the Veteran’s anxiety will often lead them to be reactive and snappy, as well as possibly have significant anger management issues. Although this is not true for all combat Veterans, it is a fairly common occurrence. Basic anger management skills, such as the ABCs of thinking, weighing stressors on a 1-10 scale to help keep them in proportion, and basic time-out skills will help at least keep damage in their relationships to a minimum until some of the underlying issues can be addressed.
Combat Veterans have ongoing safety beliefs they have developed related to their trauma, including a significant distrust of people, believing everyone is a potential enemy, and fearing
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