INTERVIEWER: You mentioned that you feel that you can never feel safe again. How strongly do you feel this?
VICTIM: I know that for a fact. I will never ever feel safe again.
INTERVIEWER: OK. On a scale of 0–100, how sure are you of that?
VICTIM: Oh, very sure. I’d say about a 90.
This psychopathological response to highly stressful situations is enabled by two core cognitions: the maladaptive appraisals of the stressor and its aftermath, and disturbances in autobiographical memory that involve impaired retrieval and strong associative memory.
There is ample research evidence that people who suffer from acute and chronic stress exaggerate both the probability of future negative events occurring and the adverse effects of these events. Other research shows that acute stress triggers a cognitive bias for events related to physical harm, negative bodily sensations, and concerns about social relationships.
Experimental studies indicate that highly stressed individuals respond to a normal hyperventilation reaction (for example, following a weather event) with more dysfunctional interpretations about their reactions than non-stressed individuals. There is also evidence that a catastrophic appraisals about one’s resources needed to cope after exposure to stress can predict the onset of PTSD. The soldier who believes himself or herself as incapable to withstand the pressure of combat is less likely to take evasive and self-protecting measures that are well-timed and effective.
In the same vein, the attributions about the stressor that are made shortly after the event appear to influences longer-term functioning. Prospective studies indicate that attributing responsibility to another person and attributions of shame to the self in the acute phase of stress are predictors of later PTSD onset.
I just couldn’t bring myself to help my buddy. I should have gone in after him and brought him out… but I just couldn’t do it. I feel so ashamed of being such a yellow-belly.
Cognitive stress management begins with education about stress reactions and the rationale for change. The goals of this education are to reframe the way in which individuals understand their current symptoms, develop some mastery over their reactions, and acquire the skills to produce more adaptive and ultimately healthier response to stressful situations.
What needs to change?
The elements needed to induce a cognitive reappraisal of stress, and thus facilitate a more appropriate response to it, are determined by each individual situation. In general, though, one or more of the following outcomes are observable in most individuals:
Avoidance of the stressor, either physical or mental by diversion.
Flight away from the stressor, either physical or mental by disassociation.
Fight against the stressor, either physical or emotional, e.g. anger.
Freeze response to the stressor, either by physical immobility or emotional paralyzing grief or anxiety.
Acquisition of catastrophic beliefs that diminish self-esteem, ability to cope with future stressors, belief that nothing can be done to improve on the situation or on available resources.
Biopsychosocial consequences, such as physical illness, depression, poor relationships.
None of these are per se maladaptive and psychopathological. When they resolve within a relatively short time and are replaced by a more adaptive reappraisal of past events, current resources and future outcomes, these reactions are quite normal. They can and should be allowed to run their course. It would be unrealistic to expect minimal stress and subdued and highly controlled reactions in the face of serious stressors such as combat, severe pain, surgery, financial loss, criminal investigations, property loss, interpersonal breakdown, or media attention.
Cognitive stress management involves primarily an education about the normality of stress reactions and the acquisition of skills on how to manage these reactions and the ability to choose an adaptive medium- to long-term response. Thus, the above cognitions and reactions would translate into a new albeit similar set of choices:
Avoidance of stressor that can and should be avoided, as in refraining from viewing a film whose content would be known to engender a negative state of mind.
Flight away from a stressor that can be harmful, as in not engaging in a discussion of significance while fatigued or otherwise preoccupied.
Fight against a stressor that should be fought, as in when someone or something is threatening physical harm to a loved one.
Freeze in the face of a stressor that can be defused, such as not moving when spotting a mountain lion on the hiking trail.
Reframing catastrophic beliefs in better terms, avoiding absolute statements such as never, ever, always, and everyone, and coming up with a more realistic appraisal of one’s resources and capabilities.
Protective measures against negative consequences of stress, such as exercise, good nutrition, optimism, and social contact.