However, your risk of exposure to some type of nonlethal, violent event is much greater. For example, around 3 million (about 1 percent) of all Americans will be involved in a serious motor vehicle accident in any given year. And about 1.4 million (slightly less than a half a percent) of the people of the United States alone will fall victim to some type of violent crime.
For those who sign up to serve and protect our country through the military, the risk of injury in combat varies greatly over time and also depends on the particular war. However, for someone in a combat zone, the risk of death pales in comparison to the chances that the person will experience serious injury or witness acts of severe violence to others — and then struggle emotionally afterward.
Any exposure to violence, including just witnessing it, poses a major risk factor for developing what's known as post-traumatic stress disorder (PTSD). PTSD is a serious type of anxiety disorder that often follows exposure to one or more traumatic events. People find themselves having intrusive images of the event(s) and often work hard to avoid reminders of it. They also frequently lose sleep, become easily startled, and experience increased irritability (see Chapters 2 and 8 for more information about PTSD). The following section reviews what you can do to reduce your risks of experiencing trauma.
Maximizing Your Preparedness
No matter what your risks for experiencing violence, we advise taking reasonable precautions to keep yourself safe. A little preparation usually doesn't cost a lot in terms of either time or money. The key is making active decisions about what seems reasonable and then trying to let your worry go because you've done what makes sense. If, instead, you listen to the anxious, obsessional part of your mind, you'll never stop spending time preparing — and needlessly upset your life in the process.
Taking charge of personal safety
Chapter 15 lists important preparatory steps you can take in possible anticipation of natural disasters. Those same items apply to being prepared for terrorism and other violent situations. In addition, we recommend you consider a few more actions:
Always have a stash of cash on hand.
Have extra prescription medication for important medical conditions.
Have a store of critical supplies, such as tissues and toilet paper.
Have a multi-tool that can function as a screwdriver, can opener, knife, and so on.
Have some duct tape and plastic sheeting. Duct tape can fix a lot of things in a pinch and also serve to prevent windows from shattering. Plastic sheeting can be used to seal out toxic plumes.
Have painters' masks for everyone to reduce exposure to smoke and fumes.
Always keep at least a three-day supply of food and water for each household member.
Avoiding unnecessary risks
The best way to minimize your risk of experiencing or witnessing violence is to avoid taking unnecessary risks. Of course, regardless of what you do, you can't protect yourself from life. People don't ask to be victims of crime, terrorism, or accidents, and you can't prevent such events from ever occurring.
But you don't have to ask for trouble either. We suggest the following, fully realizing that some of these may sound a little obvious. But because people often don't follow these suggestions, here they are:
Wear seatbelts; need we say more?
Hold onto purses or bags tightly when walking in crowded areas.
If you have a wallet, carry it in your front pocket.
If you're traveling, research the area for known risks. The U.S. State Department lists areas deemed unsafe for travel because of terrorism or other known risks at http://travel.state.gov.
Make copies of your passport; give one to someone before you leave, and put another in your luggage separate from the bag you carry.
Don't wear expensive jewelry when you travel.
Don't drive in terrible weather conditions.
Consider carrying a loud whistle in your purse or pocket.
Heed the oft-given advice to report any unattended baggage in airports, train stations, or hotel lobbies.
If you're in a hotel room, don't answer the door unless you know who it is. If you're not sure, call the front desk.
If you do have to walk in an unsafe area, walk quickly and pay attention.
Have your keys out and ready as you approach your car, and look before you get in.
Try not to walk alone in dark, secluded areas.
Finally, don't limit your ability to enjoy life. Realize some risks are inevitable. Consider travel to places other than your backyard! Get to know some people from other cultures and lands. See some interesting landscapes. In other words, don't wall yourself off from the world.
Dealing with Trauma
We hope you're never a victim of nor a witness to severe violence, but we know it's a real possibility. Violence occurs in war, on the streets, and even in the workplace. So if you've recently been a victim, you may be experiencing some serious signs of anxiety or distress. That reaction is pretty normal. And the first thing we're going to tell you is that, unless your symptoms are quite severe and interfering greatly with your life, don't seek out mental-health treatment right away! That's because, in many cases, your mind's own natural healing process will suffice.
Furthermore, it's quite easy to interfere with natural recovery. For example, a single debriefing session often takes place after exposure to a traumatic event. In such a session, people are given basic information about trauma and its potential effects and are then encouraged to talk about how they're coping with it. But such a session may actually increase the risk of emotional symptoms occurring or continuing. If you're offered such a single-session intervention, we suggest skipping it unless it's obligatory. It's perfectly okay not to want to talk about the trauma right away.
So here's what we recommend you do first if you're unfortunate enough to witness or experience a highly traumatic event:
Realize that it's normal to feel fearful and distressed.
Talk to people you feel comfortable discussing the trauma with, but don't let yourself be pressured to talk by anyone.
Ask yourself what you've done in the past to get through tough times, and see whether that helps you get through this one. For example, some people find benefit from spiritual counseling, prayer, turning to friends, or increasing exercise.
If you're experiencing severe symptoms such as flashbacks, serious insomnia, significant irritability, or anxiety after a few months (even sooner if the symptoms are highly disturbing), consider seeing a mental-health professional for three or more sessions. Be sure to ask if your therapist uses evidence-based treatment (that is, supported by scientific research) for PTSD (see Chapters 2 and 8 for more information about PTSD).
In working on the ideas we discuss in the following sections, we strongly recommend that you do so in collaboration with a licensed mental-health professional who has experience treating PTSD.
Thinking through what happened
When people have been exposed to trauma, the experience never goes away. In other words, you can't ever completely erase the experience from your mind. But with help, the misery and pain can decrease, and life satisfaction can get much better.
Cognitive processing therapy (CPT) was developed by Patricia Resick and colleagues and has been shown to help some survivors get to a better place. With this approach, you take a hard look back and write a statement about the meaning that the traumatic event had for you in your life. In other words, describe how you think your life has changed:
Do you feel responsible for the trauma?
Do you feel unsafe everywhere you go?
Have you changed the way you feel about yourself as a person?
Are you angry, sad, or ashamed?
Your therapist will then help you explore your feelings and how your thoughts may be contributing to making things worse than they need to be for you. Among other things, your therapist may ask you these questions:
How does this event affect the way you see
yourself and the world?
What would you tell a friend that this event meant about him or her as a person? Can you accept saying the same thing to yourself?
Do you know anyone who has coped with something like this? If so, how did they do it?
Do you believe that you're more unsafe than anyone else? If so, what is the evidence that you are?
Did you want this traumatic event to happen to you? If not, can you stop blaming yourself?
Is there anything shameful about having been a victim of trauma or violence?
Can you think of a creative new possibility that could result from this challenge? For example, could you volunteer to help others in similar situations?
Finally, your therapist is likely to ask you to write about the actual traumatic event in great detail. Then you'll probably be asked to read that story out loud to yourself every single day for a period of time. As you do, don't try to squelch your emotions; instead, let the feelings flow. You can also embellish your story with more detail over time.
Some professionals consider this written account and the reading of the traumatic event to be a form of exposure therapy. Preliminary evidence suggests that this part of CPT may work as well as exposure, which we discuss in the next section. However, repeatedly reading your written account of the event may be somewhat less distressing than more direct exposure strategies.
Exposing yourself to the incident
Exposure therapy, as we describe in Chapter 8, has been supported by more research studies than any other approach for treating PTSD. Briefly, exposure therapy involves making extended contact with the traumatic event, usually through imagery. For example, a combat veteran may be asked to make an extensive list of all the details of his traumatic combat experiences. He would then be asked to list each detail and rate it for how much distress it causes him when he thinks about it.
The list is organized into a hierarchy, or what we call a staircase of fear. Starting with the least upsetting step, he would be asked to imagine it in detail until his anxiety and distress drop significantly. Then he would move on to the next step. See Chapter 8 for details and a specific example applied to PTSD.
The main problem with this approach lies in the fact that lots of trauma victims really don't want to revisit their trauma. Thus, the very idea of therapy elicits feelings of great distress. For some, exposure seems like adding more suffering to their already traumatized lives. For that reason, among others, far too many trauma victims fail to get treatment.
If you find that the prospect of exposure therapy seems completely overwhelming to you, consider seeking CPT first. Not every mental-health professional has been trained in both exposure therapy and CPT, so be sure to ask.
Accepting a Certain Degree of Uncertainty
Emotional distress stemming from traumas and violence presents a challenge, yet it's quite normal. It's important to realize that people can't control the emotions that arise from such causes. The more you can accept that fact, the more easily you'll be able to cope with life and whatever it deals you. The next two sections take a look at accepting uncertainty and risk.
Choosing to put yourself in high-risk situations
Some people, like police officers, emergency medical personnel, soldiers, and firefighters, choose to expose themselves to the best and worst of life. Their motives are positive: They may have a strong desire to help others, feel a deep sense of patriotism, or want to make a positive difference in the world. These people often become traumatized by the horrible events and disasters that they must deal with. And a good percentage of them end up with symptoms or a diagnosis of PTSD.
Those who fully understand and accept both the risks of the job and the fact that they may experience emotional distress from exposure to trauma just may be a little less vulnerable to traumatic events than those who see themselves as invincible. Paradoxically, the more you can accept whatever responses you have, the more easily you'll probably deal with them.
However, those who view themselves as indestructible may actually choose to go into their fields with an inflated sense of invulnerability. These people are more likely to have emotional pain from their experiences and refuse or shun help. They believe that part of their job is to handle whatever happens to them. Sadly, they're not immune to horror and trauma, yet they think that they should be.
If you or someone you care about has a front-line position in a field like medical care, law enforcement, or the military, you're at risk, just like everyone else, for getting a stress disorder from exposure to horrible events. This doesn't make you weak or less competent. You must bravely face your emotional pain and get help. Denying the emotional pain dulls your ability to continue to help others.
Experiencing danger in everyday places
A lot of people live lives in which they try to stay away from danger. But life happens to them as well. People are exposed to violence in places that were once considered safe: schools, churches, synagogues, mosques, parks, and the workplace. Uncertainty in this world is certain.
The only alternative to acceptance of risk and uncertainty is to devote your entire life to anticipating and avoiding risk. The problem here is that your efforts will still fail you. Even if you spend every waking moment trying to avoid risk, it won't work. So far we know of no one who has managed to avoid the ultimate risk of death.
The following story illustrates typical symptoms of PTSD following a motor vehicle accident, which is by far the most common avenue to getting PTSD in most parts of the world.
Lew had always assumed, like most people do, that a green light signals it's safe to proceed through an intersection. He had driven with that assumption for 20 years without mishap. One day on the way to work, Lew drives through an intersection that he has safely traversed hundreds of times before. Suddenly, an SUV barrels through the red light and broadsides Lew's sedan. Lew suffers serious injuries. After several weeks in the hospital, he spends months in rehabilitation.
When Lew returns to driving, he finds himself creeping through intersections with intense feelings of anxiety. He can barely make himself drive to work and back each day and avoids driving whenever possible. He frequently visualizes the accident, although he tries very hard not to. His body aches with tension. He wakes up in the middle of the night before he has to drive and can't go back to sleep. He's irritable and moody.
Lew's doctor tells him that he now has high blood pressure and that he needs to reduce his stress. Lew worries about his worry but doesn't know what he can do about it. He thinks he may have to take a leave of absence from work. His supervisor is losing patience with him. Desperate, Lew makes another appointment with his doctor. This time, the doctor takes time to ask Lew about his symptoms. He refers Lew to a psychotherapist who specializes in working with people with PTSD.
The therapist recommends exposure therapy (see the earlier section "Exposing yourself to the incident") involving a series of steps that start with talking about the accident and gradually increase in difficulty up to repeatedly driving through busy intersections. However, Lew can't get past the first couple of steps. He berates himself for failing to progress. Now Lew feels anger, not only about his accident but also toward himself.
The therapist backs up and works on acceptance. He helps Lew to see that feelings are just feelings, not something to be avoided. He teaches Lew how to remain in contact with his emotions without judging them. Lew gradually learns to accept his emotions for what they are. Then the therapist works on CPT (see the section "Thinking through what happened"), and Lew makes excellent progress.
Unusual, unpredictable endings
Consider asking yourself how you could avoid these calamitous yet impossible-to-predict events. Please realize that we're not trying to be funny about or make light of tragic, violent, and horrific events. Our point is simply that you can never know how to predict and avoid the unpredictable. As we said, life has risks.
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