The Fight, Flight or Freeze Response

The fight or flight response has been around as long as human beings have been around. It’s the body’s hardwired alarm system. If you think of the human body as a computer, the fight-­or-­flight response is an essential part of the operating system. You couldn’t really function (or live that long) without it.

When you encounter a dangerous or threatening situation, this alarm system goes off, and your body goes through a number of changes. For example, during the fight-­or-­flight response, you may experience the following symptoms:

  • An increase in heart rate
  • Perspiration or sweating
  • Narrowing of field of vision (also called “tunnel vision”)
  • Muscle tension
  • Sensitive hearing
  • Racing thoughts
  • Shortness of breath
  • Goose bumps
  • Dry mouth

These experiences aren’t random; they all serve a very important purpose. They prepare you for immediate action. They are preparing you either to flee the situation to avoid any harm or to fight if escape is not possible. In situations where fleeing or fighting is not necessarily a good option, your body may also freeze (kind of like a deer caught in a car’s headlights).

This response is automatic. It occurs without thinking. This is important because it allows you to respond quickly when you are in a dangerous situation. For example, let’s say that you are walking through the woods and come across a bear. Your fight-­or-­flight response will be activated, and you will likely freeze or flee. The sudden and automatic changes that your body goes through will help keep you alive in this dangerous situation. Now, if you had to think about the situation before the fight-­or-­flight response was activated, you would waste precious time. You would have to evaluate the size of the bear and the sharpness of its claws and teeth. And, by the time you figured all of that out, you would probably be supper for the bear! Therefore, the fight-­or-­flight response is incredibly helpful and adaptive. We likely wouldn’t be alive as a species today without it.

Sources: The Dialectical Behavior Therapy Skills Workbook for Anxiety

Identify Your “Triggers”

Each person has specific types of situations that set their automatic negative path in motion; these are their triggers. To address your problems, you need to know which situations are difficult and trigger your negative path.

While many people are aware of their triggers, some have trouble identifying their specific trigger situations. For example, a person may tell you that they are “always” sad, or “always” drink too much, and can’t identify specific problematic situations. Identifying your triggers helps you start to see patterns and then know what to focus on in therapy.

A helpful first step is to monitor your problematic feelings or behaviors and see if there are some situations where your feelings are stronger or your behavior is more extreme. For example, a person came to therapy because they were always angry. When asked for examples of specific situations, they responded that they were angry “all the time.” The first homework assignment was to monitor their angry feelings and see when they were strongest. They came back having discovered that they were the most angry when their teenage son didn’t do what they wanted him to do; for example, when he did his homework at 2 a.m., broke curfew, or did not do his chores. They discovered that their anger toward her son was spilling over into the rest of her life.

Frequently, people will describe their trigger situation in vague terms, and don’t really understand what happened. They need to become more specific and concrete. A specific and concrete description includes what happened, with whom, and the specific time and place it occurred. For example, a vague description of a situation would be “My partner doesn’t respect my work”; a more concrete and specific description would be “My partner told me that they thought their work was more important than mine.”

The more specific and concrete your description of the situation, the more you will be emotionally engaged with the situation, and the more you will have access to your feelings and thoughts. Think of someone you are a little annoyed with. Now, think of a specific situation when you were annoyed with this person. Try to remember the situation in detail. Chances are that as you thought about a specific situation, you became more annoyed and your feelings and thoughts became more immediate.

Sometimes your situation is a long, complicated story. In this case, consider the whole story and then ask what was the worst or most difficult part for you. It is helpful to identify a situation that lasts from a few seconds to three minutes, any longer and you will probably have a large variety of feelings and thoughts, and it will be hard to focus on the main ones.

Sources: CBT Made Simple

A Structured Cognitive Behavioral Therapy (CBT) Session

A structured session means that there is an order and organization to the therapy session. Here is a brief overview of the five basic components.

Check in. This is a quick update on what has happened since the previous session and includes a bridge to that session.

Set the agenda. You and your therapist decide together which problems to focus on in the current session. Homework from the previous session can be reviewed during the check-in or as part of the agenda-setting process.

Work the agenda. This involves addressing the identified problems on the agenda.

Homework. You and your therapist collaborate to develop homework for the following session.

Review. At the end of the session you briefly review with your therapist what was covered in the current session and give feedback.

Sources: CBT Made Simple

Communication Styles and Mental Health

Passive Communication
Passive people often don’t communicate verbally. They tend to bottle up their emotions instead of expressing them, perhaps out of fear of hurting others or making them uncomfortable, or maybe because they don’t believe their feelings or opinions matter as much as those of others. People with a passive communication style usually fear confrontation and believe that voicing their opinions, beliefs, or emotions will cause conflict. Their goal is usually to keep the peace and not rock the boat, so they sit back and say little.

Aggressive Communication
Aggressive communicators attempt to control others. They’re concerned with getting their own way, regardless of the cost to others. Aggressive people are direct, but in a forceful, demanding, and perhaps even vicious way. They tend to leave others feeling resentful, hurt, and afraid. They might get what they want, but it’s usually at the expense of others, and sometimes at their own expense, as they may later feel guilty, regretful, or ashamed because of how they behaved.

Passive-Aggressive Communication
Like passive communicators, those who have a passive-aggressive style fear confrontation and don’t express themselves directly. However, because of their aggressive tendencies, their goal is to get their way, but they tend to use indirect techniques that more subtly express their emotions, such as sarcasm, the silent treatment, or saying they’ll do something for others but then “forgetting.”

Assertive Communication
Assertive people express their wishes, thoughts, feelings, and beliefs in a direct and honest way that’s respectful both of themselves and of others. They attempt to get their own needs met but also try to meet the needs of others as much as possible. They listen and negotiate, so others often choose to cooperate with them because they’re also getting something out of the interaction. Others tend to respect and value assertive communicators because this communication style makes them feel respected and valued.

Sources: DBT Made Simple

Watch Your Emotions

People often try to avoid their emotions because they find them too painful. When you haven’t learned how to regulate your emotions you are in a lot of pain, and you don’t have the skills to manage and tolerate your emotions. You can use the acronym WATCH to help summarize the skills that will help them reduce their avoidance of emotions and improve their ability to manage emotions:

Watch: Watch your emotions. Mentally note your experience of an emotion, acknowledging how it feels physically, the thoughts, memories, or images that accompany it, and so on.

Avoid acting: Don’t act immediately. Remember that it’s just an emotion, not a fact, and that you don’t necessarily need to do anything about it.

Think: Think of your emotion as a wave. Remember that it will recede naturally if you don’t try to push it away.

Choose: Choose to let yourself experience the emotion. Remind yourself that not avoiding the emotion is in your best interests and will help you work toward your long-term goals.

Helpers: Remember that emotions are helpers. They all serve a purpose and arise to tell you something important. Let them do their job!

Sources: DBT Made Simple

Three Levels of Self-Validation

Acknowledging: The most basic level of self-validation is simply acknowledging the presence of the emotion rather than judging it; for example, telling yourself, I feel unhappy. Just acknowledging or naming the emotion and putting a period on the end of the sentence rather than going down the road of judging it validates the emotion.

Allowing: The second level of self-validation is allowing, which is essentially giving yourself permission to feel the feeling; for example, telling yourself, It’s okay that I feel unhappy. This takes not judging the feeling one step further, affirming that it’s okay to feel this way. This doesn’t mean liking the feeling or wanting it to hang around; it just means acknowledging that you’re allowed to feel the emotion.

Understanding: The highest (and hardest) level of self-validation is understanding. This level, which goes beyond not judging the emotion and saying it’s okay to feel it, involves having an understanding of it; for example, It makes sense that I feel unhappy, given the difficulties I have managing my emotions and the chaos this causes in my relationships and my life.

Source: DBT Made Simple

Crisis Prevention: Experience Intense Sensations

Experience Intense Sensations

Sometimes generating intense physical sensations can distract the mind from painful emotions. This helps explain why many people resort to cutting or hurting themselves in other ways: because it can actually help them feel better temporarily. Obviously, the key here is to help identify intense sensations that aren’t harmful. Think about physical sensations you can generate that might take your mind off a crisis. For people who engage in self-harm, try holding an ice cube in one hand. This can cause physical pain if held long enough, and the sensation is intense. For some people, this can take the place of self-harming behaviors. Here are some examples of other things you might do to get your mind off a crisis:

  • Take a hot or cold bath or shower.
  • Keep a rubber band on one wrist and snap it—not so hard that it causes a lot of physical pain, but hard enough to generate a sensation that will temporarily occupy the mind.
  • Chew on crushed ice or frozen fruit.
  • Go for a walk in cold or hot weather.
  • Lie in the hot sun (with sunscreen on!).

Again, add whatever intense sensations you can think of to your list of activities to help survive a crisis.

Sources: DBT Made Simple

Distress Tolerance Skills: Reframe

Reframing refers to changing one’s perspective about something—in other words, helping make lemons out of lemonade or helping to see the silver lining. Of course a therapist, has to be careful that in doing so they don’t invalidate patients or minimize their worries. Here’s an example:

Patient: I can’t believe that I’ve been in therapy and doing all of this work for almost two years, and I’ve started bingeing again. What’s wrong with me that I can’t stop? I know how unhealthy it is, and I don’t want to gain weight again!

Therapist: Yes, you’re struggling, Anna, but it makes sense given all of the stressors in your life right now (validation). If this was two years ago, how do you think you’d be coping with everything that’s going on?

Patient: Well I’d probably be in the hospital already. At the very least, I’d be feeling suicidal and wouldn’t be functioning very well.

Therapist: Right. So even though you’ve gone back to an unhealthy behavior, you’re not where you were two years ago. In fact, you’re coping quite a bit better than you were back then, right?

Patient: Yeah, I guess you’re right.

There are many different ways to reframe. The above dialogue is an example of a patient comparing herself now to how she was in the past, at a time when she wasn’t coping as well. This can often help patients acknowledge the changes they’ve made, even though they may still be struggling.

The way patients talk to themselves about what’s happening in their lives can also change the way they think and feel about things. Often, especially when depression and anxiety are a problem, people tend to get fixated on the negatives. They focus on how bad the situation is and catastrophize or think about the worst possible thing that could happen. If you can change how you think about the situation, you’ll find that it’s more bearable than first imagined and you will be more likely to get through it without engaging in behaviors that could make it worse.

To help with self-talk, you should write out coping statements to use when you get into situations that you’re struggling with and that trigger intense emotions. That way you won’t make it worse with self-talk and can actually help yourself cope more effectively. Here are some examples:

  • I can get through this.
  • The emotions are intense and uncomfortable, but I know they won’t hurt me.
  • This pain won’t last forever.

Sources: DBT Made Simple by Sheri Van Dijk

Exercise as a Coping Strategy

Exercise is, of course, a natural antidepressant. It leads to the release of endorphins, those chemicals in the brain that help us relax and feel happy. Exercise also simply helps people feel good about themselves because they know they’re acting effectively and doing something that’s good for them. Some studies suggest that exercise is as effective as antidepressant medications at reducing symptoms of depression among adults diagnosed with major depression. Both the biological effects and the psychological effects (increasing self-efficacy and self-esteem and reducing negative thinking) of exercise are thought to be responsible for its positive influence on mood.

In addition, there is abundant evidence that exercise has positive effects on blood pressure and cardiovascular disorders, improves learning and memory, delays age-related cognitive decline, reduces risk for dementia, and improves medical conditions such as diabetes, osteoporosis, and Alzheimer’s disease.

While there are guidelines about how much exercise people should get, anything more than what you’re currently doing is a great start. This perspective helps take the pressure off and makes it more likely that you’ll actually increase your exercise, whereas telling yourself you need to exercise for twenty minutes three times a week could overwhelm you and result in not exercising at all. Of course, if you are working to reform an eating disorder, you may need do the opposite and reduce compulsive or excessive exercise.

Source: DBT Made Simple, by Sheri Van Dijk

Grounding

What is grounding?

Grounding is a set of simple strategies to detach from emotional pain (for example, drug cravings, self-harm Impulses, anger, sadness). Distraction works by focusing outward on the external world– rather than Inward toward the self. You can also think of it as “distraction,” “centering,” “a safe place,” “looking outward,” or “healthy detachment.”

Why do grounding?

When you are overwhelmed with emotional pain, you need a way to detach so that you can gain control over your feelings and stay safe. As long as you are grounding, you cannot possibly use substances or hurt yourself! Grounding “anchors” you to the present and to reality.

Many people with ptsd and substance abuse struggle with either feeling too much (overwhelming emotions and memories) or too little (numbing and dissociation). In grounding, you attain balance between the two– conscious of reality and able to tolerate it.

Guidelines

  • grounding can be done any time, any place, anywhere and no one has to know.
  • use grounding when you are: faced with a trigger, having a flashback, dissociating, having a substance craving, or when your emotional pain goes above 6 (on a 0-10 scale). Grounding puts healthy distance between you and these negative feelings.
  • keep your eyes open, scan the room, and turn the light on to stay in touch with the present.
  • rate your mood before and after to test whether it worked.before grounding, rate your level of emotional pain (0-10, where means “extreme pain”). Then re-rate it afterwards. Has it gone down?
  • no talking about negative feelings or journal writing. You want to distract away from negative feelings, not get in touch with them.
  • stay neutral– no judgments of “good” and “bad”. For example, “the walls are blue; i dislike blue because it reminds me of depression.” Simply say “the walls are blue” and move on.
  • focus on the present, not the past or future.
  • note that grounding is not the same as relaxation training.grounding is much more active, focuses on distraction strategies, and is intended to help extreme negative feelings. It is believed to be more effective for Ptsd than relaxation training.

Mental grounding

  • Describe your environment in detail using all your senses. For example, “the walls are white, there are five pink chairs, there is a wooden bookshelf against the wall…” Describe objects, sounds, textures, colors, smells, shapes, numbers, and temperature. You can do this anywhere. For example, on the subway: “i’m on the subway. I’ll see the river soon. Those are the windows. This is the bench. The metal bar is silver. The subway map has four colors…”
  • play a “categories” game with yourself. Try to think of “types of dogs”, “jazz musicians”, “states that begin with ‘a’”, “cars”, “tv shows”, “writers”, “sports”, “songs”, “european cities.”
  • do an age progression. If you have regressed to a younger age (e.g., 8 years old), you can slowly work your way back up (e.g., “i’m now 9”; “i’m now 10”; “i’m now 11”…) until you are back to your current age.
  • describe an everyday activity in great detail. For example, describe a meal that you cook (e.g., “first i peel the potatoes and cut them into quarters, then i boil the water, i make an herb marinade of oregano, basil, garlic, and olive oil…”).
  • imagine. Use an image: glide along on skates away from your pain; change the tv channel to get to a better show; think of a wall as a buffer between you and your pain.
  • say a safety statement. “my name is ____; i am safe right now. I am in the present, not the past. I am located in _____; the date is _____.”
  • read something, saying each word to yourself. Or read each letter backwards so that you focus on the letters and not on the meaning of words.
  • use humor. Think of something funny to jolt yourself out of your mood.
  • count to 10 or say the alphabet, very s..l..o..w..l..y.
  • repeat a favorite saying to yourself over and over (e.g., the serenity prayer).

Physical grounding

  • run cool or warm water over your hands.
  • grab tightly onto your chair as hard as you can.
  • touch various objects around you: a pen, keys, your clothing, the table, the walls. Notice textures, colors, materials, weight, temperature. Compare objects you touch: is one colder? Lighter?
  • dig your heels into the floor– literally “grounding” them! Notice the tension centered in your heels as you do this. Remind yourself that you are connected to the ground.
  • carry a grounding object in your pocket– a small object (a small rock, clay, ring, piece of cloth or yarn) that you can touch whenever you feel triggered.
  • jump up and down.
  • notice your body: the weight of your body in the chair; wiggling your toes in your socks; the feel of your back against the chair. You are connected to the world.
  • stretch. Extend your fingers, arms or legs as far as you can; roll your head around.
  • walk slowly, noticing each footstep, saying “left”,”right” with each step.
  • eat something, describing the flavors in detail to yourself.
  • focus on your breathing, noticing each inhale and exhale. Repeat a pleasant word to yourself on each inhale (for example, a favorite color or a soothing word such as “safe,” or “easy”).

Soothing grounding

  • say kind statements, as if you were talking to a small child. E.g., “you are a good person going through a hard time. You’ll get through this.”
  • think of favorites. Think of your favorite color, animal, season, food, time of day, tv show.
  • picture people you care about (e.g., your children; and look at photographs of them).
  • remember the words to an inspiring song, quotation, or poem that makes you feel better (e.g., the serenity prayer).
  • remember a safe place. Describe a place that you find very soothing (perhaps the beach or mountains, or a favorite room); focus on everything about that place– the sounds, colors, shapes, objects, textures.
  • say a coping statement. “i can handle this”, “this feeling will pass.”
  • plan out a safe treat for yourself, such as a piece of candy, a nice dinner, or a warm bath.
  • think of things you are looking forward to in the next week, perhaps time with a friend or going to a movie.

What if grounding does not work?

  • practice as often as possible, even when you don’t “need” it, so that you’ll know it by heart.
  • practice faster. Speeding up the pace gets you focused on the outside world quickly.
  • try grounding for a looooooonnnnngggg time (20-30 minutes).and, repeat, repeat, repeat.
  • try to notice whether you do better with “physical” or “mental” grounding.
  • create your own methods of grounding. Any method you make up may be worth much more than those you read here because it is yours.
  • start grounding early in a negative mood cycle. Start when the substance craving just starts or when you have just started having a flashback.