Post Traumatic Stress – An NHS self help guide for people in prison
These are thoughts and feelings of two people who have experienced traumatic incidents.
“I feel terrible, very restless and irritable. This is not like me at all. The car crash happened six months ago but I still couldn’t feel safe in a car. Pictures of the accident come flashing into my mind, they won’t go away and even at night my dreams are more like nightmares with scenes of the crash happening again and again… I can’t stop shaking when I think I could have died”
“Everything has changed, I keep thinking why us? I feel guilty thinking that I could have done more to save my friend. I re-live the experience all the time, I keep thinking, ‘if only I had done this, if only I had done that’… I am very low and depressed most of the time… I think of the future…I feel helpless”.
This guide is written by psychologists and people who have experienced prison. It aims to help you understand these and other common reactions and offers some practical suggestions to help you cope. If you feel unable to use this guide you may also be able to ask a prison listener or member of the healthcare team to go through the guide with you.
What is a traumatic incident?
A traumatic event is something out of the ordinary that happens which is deeply distressing to someone.
Many things can have this impact. It could be a fire, a serious accident, a robbery or burglary, an attack, being a witness to a traumatic event such as a death. This could happen anywhere: at home, in prison, during a war or conflict situation. It can be physical or sexual abuse including childhood or domestic abuse. It could be torture. It can be large scale such as a major disaster involving many people or a personal event involving yourself, friends or family members.
It can also be trauma related to serious health problems or childbirth experiences, such as admission to intensive care or trauma during childbirth and neonatal death.
How do people react after a traumatic incident?
The following are some of the reactions you may experience after a traumatic event. In general, people’s reactions will fall into the following five groups:
- Re-living the trauma in your mind
- Avoiding things to do with the trauma
- Feeling more tense, irritable or jumpy than usual
- Feeling depressed, crying
- Blaming others or self
It may help you to check and see if you are experiencing any of these symptoms:
Re-experiencing the trauma in your mind and body
- Having unwanted pictures or images (often called flashbacks) of the distressing event appearing in your mind.
- Having upsetting dreams about the trauma or dreams about other things that frighten you.
- Feeling that the trauma is happening again – strong sensations of re-living the trauma.
- Feeling very distressed at coming across situations or feelings that remind you of the trauma.
- Experiencing distressing physical reactions, for example heart beating faster, dizziness and so on when you are faced with memories of the trauma or situations that remind you of it.
- Having bodily physical reactions including pain or pressure but not necessarily realising that these relate to trauma.
Avoiding things related to the trauma and numbing
- Trying to avoid thoughts, feelings and conversations about the trauma.
- Avoiding activities, places or people that remind you of the trauma.
- Being unable to remember things about the trauma.
- Having periods of your life that you cannot recall.
- Losing interest in life, feeling detached from others or not having your usual feelings.
- Feeling that you are living on borrowed time.
- Trying not to be seen as weak in front of others.
Feeling more tense and irritable than usual
- Feeling angry or irritable.
- Not being able to concentrate.
- Finding it difficult to fall asleep.
- Feeling over alert all the time and easily startled.
- Lack of tolerance, being unforgiving.
Post-traumatic stress reactions can affect us in at least four different ways:
- How we feel
- The way we think
- The way our body works
- The way we behave
It may help you understand how you are feeling by making a note of any of these symptoms you experience regularly:
How do you feel?
- Anxious, nervous, worried, frightened
- Feeling something dreadful is going to happen
- Tense, uptight, on edge, unsettled
- Jumpy and restless
- Easily startled
- Unreal, strange, woozy, detached, dissociated
- Feeling emotionally numb
- Depressed, low, at a loss
- Angry, irritable
What happens to your body?
- Heart racing and pounding
- Chest feels tight
- Muscles are tense or stiff
- Feel tired/exhausted
- Body aching
- Feel dizzy, light headed
- Feel panicky
- Disturbed sleep and nightmares
- Stomach churning
How do you think?
- Worry constantly
- Can’t concentrate
- Experience flashbacks – pictures of the trauma coming into your mind, including nightmares
- Blame yourself for all or part of the trauma
- Think it will happen again
- Feel unable to make a decision
- Feel regret, shame or bitterness
- Thoughts racing and jumping about
- “It was my fault”
- “I’m cracking up”
- “I’m going to have a heart attack”
- “It’s controlling me, I can’t control the thoughts”
- “I can’t cope”
- “I’m going to faint”
- “Other people want to harm me and the world is dangerous”
- “Why did it have to happen”
- “I can’t see the point anymore”
- “If only I…”
What you do
- Pace up and down
- Avoid things that remind you of the trauma
- Can’t sit and relax
- Avoid people
- Avoid being alone
- Are snappy and irritable
- Spoil relationships
- Drink/smoke more
- Depend on others too much
- Use drugs
Why do we react so strongly to trauma?
There are many reasons why trauma leaves such a strong impact on us.
Firstly, it often shatters the basic beliefs we may have about life: that life is fairly safe and secure, that life for us has a particular form, meaning and purpose. It may be that the image that we have about ourselves is shattered, we may have responded differently from how we expected or wanted to behave.
Secondly, trauma usually occurs suddenly and without warning. We have no time to adjust to this new experience. It will usually be outside our normal range of experience and we are faced with not knowing what to do or how to behave. You may have felt you were going to die, people around you may have died, you are shocked. In the face of this danger our mind holds on to the memory of the trauma very strongly, probably as a natural form of self-protection to ensure you never get into that situation again. The result of this is that you are left with the post-traumatic reactions we have described.
For most people the reactions will have reduced or disappeared within a few weeks but for some people they can continue. For others the reaction does not start immediately after the traumatic event but begins after a delay.
What can I do to help overcome the trauma?
It is important to understand that the reactions you are experiencing are very common following trauma, they are not a sign of weakness or cracking up. The following suggestions may help you begin to cope with the post traumatic reactions.
Things that we describe which may help you are:
- Making sense of the trauma
- Dealing with flashbacks and nightmares
- Overcoming tension, irritability and anger
- Overcoming avoidance
- Overcoming low mood
Making sense of the trauma
Try and find out as much as you can about what really happened. This will allow you to piece together a picture and understanding of the event more clearly. This can help you in your recovery.
If others were involved, talk or write to them and ask them their views of events. Other victims, helpers from the rescue service, or passers by, may all be people who would help you gain a broader view of what happened. The rescue services may be able to help you in these circumstances or someone may contact them on your behalf.
It may help you to think it through with other people. You may feel the trauma has altered your whole view of life. It is helpful to try and clarify how you now feel and talking can help you do this.
Some people talk to a friend, family member, partner or Listener, others may be able to get help through the prison Health Centre or Chaplaincy. Other people have found that it helps to write down their experience.
Try to spend a few minutes thinking of ways that you may be able to make sense of what you have been through. Try and write down some ideas. For example:
- People to talk it over with
- Things you may do yourself, such as writing down your experiences
Dealing with flashbacks and nightmares
Many people try to put the experience of trauma behind them by attempting not to think of it. Although this may seem a natural thing to do, it does not always help them to overcome the problem. People may find that they continue to be troubled by unwanted pictures of the trauma in their mind (flashbacks) and by unpleasant dreams or nightmares related to the trauma.
One of the best approaches which has been found to reduce flashbacks and nightmares is to make time each day for reviewing and going over the unpleasant memories or nightmares. Many people have found that if they put time aside to calmly think over, talk over or write down notes on the trauma, their unwanted flashbacks and nightmares will gradually become less powerful and less frequent. If you have nightmares, it may help to do this soon before you go to bed. This may feel frightening, but research has shown that this review of memories does reduce the intensity of these experiences.
This can allow you to regain some control over these thoughts rather than them intruding upon you. It is important to try to keep calm and relaxed when looking back over the trauma you have experienced, if you possibly can.
Try the following approaches:
- Write down details of the flashbacks or nightmares you experience.
- Find a time of day when you could think over what has happened.
- Think of some positive things about your current situation: For example, “I survived it and I’m still here’, “I can now begin to plan for a new future”, “The worst is now over”.
Once you have made sense of the trauma by writing about it or talking about it then it is important not to spend a lot more time thinking about the event. Spending a lot of time thinking “what if” or “why” can trigger flashbacks and other symptoms. You can try and reduce this ‘rumination’ by distracting yourself and focusing your attention where you choose. If you find your mind going over and over the event, try shifting your attention elsewhere. Try to look around you. Study things in detail; pictures, what sort of shoes people are wearing, conversations. Distraction doesn’t usually work instantly, and you may need to distract yourself for at least three minutes before symptoms will begin to reduce. Another technique which may be helpful in managing flashbacks, mindful breathing, is described later in the guide. Distraction is not about trying to push thoughts of the trauma out of your mind, which is unlikely to work, and can in fact make things worse. Neither is distraction about avoidance, but is a technique that can help us control where we wish to focus our mind.
If you are struggling with flashbacks and feeling detached from reality you can use grounding techniques to keep you in the present moment. Use the five senses – sight, sound, touch, smell, taste. The aim is to bring your attention back to the present moment.
- Sight – you could focus on things around you, the colours and the textures. Or maybe a photograph of something recent to bring you back into the present moment.
- Sound – you could listen to loud music and focus on it.
- Touch – you could touch something soft and silky or something smooth and cold and focus on this.
- Smell – sniff a strong smell which can bring you in to the present – perfume or aftershave can be a good choice.
- Taste – try tasting something strong – a strong mint or chilli or lemon can bring you in to the here and now.
A member of the mental health team may be able to help you with grounding techniques.
Overcoming tension, irritability and anger
Tension, irritability and anger are common aspects of a post-traumatic reaction. There may be physical symptoms too including breathlessness, heart racing, over breathing, dizziness and muscle tension. Try the following ways of reducing physical symptoms.
In order to reduce the severity of physical symptoms it is useful to nip them in the bud, by recognising the early signs of tension.
Once you have noticed early signs of tension, you can prevent anxiety becoming too severe by using relaxation techniques. Some people can relax through exercise, listening to music, watching TV or reading a book.
For others it is more helpful to have a set of exercises to follow. Some people might find relaxation or yoga most helpful.
Relaxation is a skill like any other which needs to be learned and takes time.
The following exercise teaches deep muscle relaxation and many people find it very helpful in reducing overall levels of tension and anxiety.
Deep muscle relaxation
It is helpful to listen to the instructions first and eventually to learn them. Choose a time of day when you feel most relaxed to begin with. Lie down, get comfortable, close your eyes. Concentrate on your breathing for a few minutes, breathing slowly and calmly: in, two-three and out, two-three.
Say the words calm or relax to yourself as you breathe out. The relaxation exercise takes you through different muscle groups, teaching you firstly to tense, then relax. You should breathe in when tensing and breathe out when you relax. Starting with your hands, clench one tightly. Think about the tension this produces in the muscles of your hand and forearm.
Study the tension for a few seconds and then relax your hand. Notice the difference between the tension and the relaxation. You might feel a slight tingling, this is the relaxation beginning to develop.
Do the same with the other hand.
Each time you relax a group of muscles think how they feel when they’re relaxed. Don’t try to relax, just let go of the tension. Allow your muscles to relax as much as you can. Think about the difference in the way they feel when they’re relaxed and when they’re tense. Now do the same for the other muscles of your body. Each time, tense them for a few seconds and then relax. Study the way they feel and then let go of the tension in them.
It is useful to stick to the same order as you work through the muscle groups:
- Hands – clench fist, then relax.
- Arms – bend your elbows and tense your arms. Feel the tension, especially in your upper arms. Remember, do this for a few seconds and then relax.
- Neck – tilt your head back and roll it from side to side slowly. Feel how the tension moves, then bring your head forward into a comfortable position.
- Face – there are several muscles here, but it is enough to think about your forehead and jaw. First lower your eyebrows in a frown. Relax your forehead. You can also raise your eyebrows, and then relax. Now, clench your jaw, notice the difference when you relax.
- Chest – take a deep breath, hold it for a few seconds, notice the tension, then relax. Let your breathing return to normal.
- Stomach – tense your stomach muscles as tightly as you can and relax.
- Buttocks – squeeze your buttocks together, and relax.
- Legs – straighten your legs and bend your feet towards your face. Finish by wiggling your toes.
Don’t try too hard, just let it happen.
To make best use of relaxation you need to:
- Practise daily.
- Start to use relaxation in everyday situations.
- Learn to relax without having to tense muscles.
- Use parts of the relaxation to help in difficult situations, example breathing slowly.
Remember, relaxation is a skill like any other and takes time to learn. Keep a note of how anxious you feel before and after relaxation, rating your anxiety 1-10.
Over breathing is very common when someone becomes anxious, angry or irritable. This is sometimes called over breathing. People often begin to gulp air, thinking that they are going to suffocate, or they begin to breathe really quickly. This has the effect of making them feel dizzy and therefore more anxious.
Try to recognise if you are doing this and slow your breathing down. Getting into a regular rhythm of in two-three and out two-three will soon return your breathing to normal. Other people have found breathing into a paper bag or cupped hands helpful. For this to work, you must cover your nose and mouth.
It takes at least three minutes of slow breathing or breathing into a bag for your breathing to return to normal.
This is a slightly different approach to managing the symptoms of PTSD. The goal of mindful breathing is to develop a calm, non-judging awareness that allows us to notice thoughts and feelings without getting caught up in them. It can help us to become more self-compassionate and kind to ourself. In mindful breathing we use the breath to anchor us in the here and now to help bring our awareness to the present moment, rather than the past or the future. Much of our anxiety is linked to thoughts and feelings about the past and the future. In PTSD these thoughts can trigger flashbacks, so learning to focus on the here and now can be very helpful.
To practice mindful breathing follow these instructions:
- Find a quiet space where you won’t be disturbed. Sit comfortably, with your eyes closed or if you struggle to close your eyes, fix them in a point on the floor in front of you.
- Try to sit as if you were paying attention to something important with your back straight.
- Bring your attention to your breathing. Notice where you experience the breath, in your body. It might be in your nose, tummy or chest.
- Notice the natural, gentle rhythm of your breathing as you breathe in and out, and focus only on this.
- Thoughts will come into your mind, and that’s okay, because that’s just what the mind does. Just notice those thoughts, then bring your attention back to where you notice your breathing.
- You may notice sounds, physical feelings, and emotions, but again, just bring your attention back to your breathing.
- Don’t follow those thoughts or feelings, don’t judge yourself for having them, or analyse them in any way. It’s okay for the thoughts and feelings to be there. Just notice them, and let them drift on by; bringing your attention back to your breathing.
- Whenever you notice that your attention has drifted off and is becoming caught up in thoughts or feelings, simply note this has happened, and then gently but firmly bring your attention back to your breathing.
- Thoughts will enter your awareness, and your attention will follow them. No matter how many times this happens, just keep bringing your attention back to your breathing. If you are very distracted it might help to say ‘in’ and ‘out’ as you breathe.
The more you can practice this exercise the better. Even five minutes a day can help your anxiety and reduce your symptoms.
If you take your mind off your symptoms, you will find that the symptoms often disappear. Try to look around you. Study things in detail: music playing, conversations and so on. Again, you need to distract yourself for at least three minutes before symptoms will begin to reduce.
It may be worth talking over your feelings of anger with those around you. Perhaps you could tell a prison officer, nurse, Listener or Samaritan that you think you can trust. Explain that your anger is not really directed at people around you even though at times it may seem that it is being taken out on them. Let them know that the anger is because of what you have been through. Ask for their patience until the anger and irritability pass, ask people not to take it personally. Exercise, such as going to the gym can help you deal with anger and stop you taking it out on others. The Chaplaincy can also offer help.
Some people who have experienced trauma are left feeling worthless, inferior and to blame. These feelings can be accompanied by deep feelings of guilt, shame or failure. It is very important to recognise this and to begin to develop self compassion. Self-compassion involves becoming more kind and understanding towards yourself, recognising and being mindful of negative self-judgement. This may involve understanding why you have behaved in certain ways and accepting responsibility for your actions.
Avoidance following a traumatic experience can take many forms. It can involve avoiding talking about the trauma, avoiding becoming upset about the trauma, it can also be that you avoid anything, anyone or any situation that reminds you of the trauma.
This avoidance prevents you from moving on from the trauma and in some cases it can prevent you getting on with your life in a normal way.
Try to recognise the things you are avoiding, it may help to write them down.
Set yourself very small goals to tackle these fears. We call this an anxiety ladder. Those situations that we only fear a little are at the bottom and our worst feared situations are at the top.
It may help to look at this example:
Shortly before coming into prison, Mick was in a car crash where his friend who was driving was killed. Mick now avoids talking about life outside because he feels anxious that he will not be able to cope if anyone asks him about his friend. He avoids the television if he thinks anything about road accidents is likely to be shown. He has made the following anxiety ladder.
Mick’s least feared situation, step 1, is looking at local newspaper reports about the car accident.
Step 2 is watching television, especially local news.
Step 3 is mentioning his friend’s death to a more trusted person.
Step 4 is mentioning his friend’s death to another person.
His most feared, step 5, is saying what happened to a group of people.
It may help to try and make your own anxiety ladder to tackle avoidance.
Remember you may feel anxious at first, but if you are able to stay in the feared situation you will gradually begin to feel calmer.
Overcoming low mood
People often experience low mood following trauma. This can sometimes give rise to feelings of low self worth, reduced confidence, helplessness and guilt. It is sometimes hard to recognise when your mood is low.
It is important not to let any gloomy or negative thoughts go unchallenged. Following trauma, people tend to think and expect the worst of themselves, their life and the future. Don’t just accept these thoughts. Remember, a thought isn’t a fact, and thinking something doesn’t mean it’s true.
To challenge your thoughts try to:
- Identify when your mood is very low.
- Write down the unpleasant thoughts you are having during that time.
- Try and counter these thoughts by writing down arguments against them. Imagine what you would say to friends if they had such negative thoughts about themselves. This is particularly important if you are feeling guilt.
It may help to keep a diary of things you have enjoyed or achieved during the week. This can help you to concentrate on the good things rather than the bad things in your life.
Do something active
Physical activity is particularly helpful. Walk, run, do sit-ups, press-ups, skip – anything that begins to increase your activity can help to improve how you feel. Plan 15-20 minutes of activity every day, or every other day to begin with. This activity is possible even in a confined space like a prison cell. Physical activity can actually begin to make you feel less tired and can lift your mood. Try and set yourself goals.
Find something that interests you and spend some time on it. Plan to focus on things you usually enjoy and build some time into each day for these activities. You might find it helpful to take up a new interest. Some people find that creative activities that help them to express their feelings such as painting, writing or playing music, can help them feel better.
Look after yourself
Resist the temptation to cope with your low mood by drinking alcohol, misusing medication or turning to illegal drugs. These may give some immediate relief but quite soon create further health and psychological problems for you to cope with.
Try to eat well; choose the healthy option from the prison menu whenever possible. A good diet can help to keep you in good health so recovery is easier.
When should I ask for further help?
We hope the suggestions made in this guide have been helpful to you. Distress following trauma usually fades with time. However, if you feel that you are making little progress then other help may be available to aid you in overcoming your problems. Consider this in particular, if you feel you are no longer coping, or you have had any thoughts of harming yourself. It is also worth considering seeking further help if your feelings are not improving after some months.
Should I consider taking prescribed medication?
NICE (National Institute for Health and Clinical Excellence) recommends talking therapy for the treatment of PTSD, but also suggests that antidepressants and other medications should be considered for treating PTSD in adults if talking therapies, such as cognitive behavioural therapy (CBT) have not been found helpful, if you are very depressed or if you would prefer medication to a talking therapy. Prescribed medication and talking therapy can work well together. Medication could be prescribed by your general practitioner or by a psychiatrist.
What further help is available?
We hope the suggestions made in this guide are helpful to you. They are based largely on Cognitive Behavioural Therapy, one of the recommended treatments for PTSD. Distress following trauma usually fades with time. However if you feel that you are making little progress then you should seek further help to aid you in overcoming your problems. This would normally be with your GP, nurse or other healthcare staff in the first instance. Consider this in particular if your wellbeing or relationships are being badly affected, you feel you are no longer coping, or you have had any thoughts of harming yourself. Your GP may refer you for a talking treatment.
The talking treatments that are recommended by NICE (the National Institute for Health and Care Excellence) are Trauma-focused Cognitive Behaviour Therapy (CBT) and Eye Movement Desensitisation and Reprocessing (EMDR). Cognitive Processing Therapy, Narrative Exposure Therapy and Prolongued Exposure Therapy.
Therapists delivering these treatments need to have special training and accreditation to practise these therapies which will help us to understand how our thinking, behaviour and symptoms affect us. It can help you manage your problems by changing the way you think and behave, as described in this guide. EMDR uses a patient’s own rapid, rhythmic eye movements (or sometimes other movements) to reduce the power of distressing memories or past traumatic events.
If you feel that you are making little progress, then other help is available to aid you in overcoming your problem. Discuss this with your key worker, case officer, a senior officer, someone in the Healthcare Centre, a Listener or Chaplain.
If you think that you are at risk of self-harming then please speak to a member of healthcare staff, a prison officer or a prison listener.
There are also guides in this series on:
- Depression and Low Mood
A list of useful contacts, books and references are available in the written version of this guide.
Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.
With thanks also to prison listeners in Northumberland