I man the PODS helpline on a Tuesday evening from 6 to 8 pm and take other calls by appointment throughout the week. On average I take about 12 calls from people with a dissociative disorder every month, and most of them last between 30 minutes and an hour. On top of that I respond to around 30 helpline emails every month – these aren’t just requests for information, or enquiries about training days, or orders for resources, but emails asking significant questions, looking for significant answers. And when I stand back from it all and have supervision, one of the things that continues to strike me is slightly obvious, very simple, but hugely important: almost every single person behind every single call and email has a significant level of anxiety and/or distress in their life.

I think it’s fair to say that most trauma survivors live with intolerable levels of anxiety on a day-to-day basis. Having a dissociative disorder is understandable, logical, even reasonable – but it’s not much fun. It is really difficult for most trauma survivors to manage their emotions in such a way that they are not regularly experiencing anxiety, distress and even crisis. A really important part of the recovery process is to learn how to manage anxiety and distress before it spirals into a crisis. Learning how to calm down from being ‘in a state’ is vital, and many of the people who speak to me or email me are either asking the question “How do I manage feeling like this?!” or it is a fundamental question behind their presenting problem.

In many ways I think that ‘recovery’ from dissociative disorders, rather than being specifically about resolving traumatic memories and ‘integrating’ dissociative parts of the personality, can be quantified in much simpler terms. I would suggest that recovery can be measured by how frequent ‘crises’ are, and how quickly the survivor or client can return to normal life after them. Is that ‘bounce-back’ time getting shorter, and are the gaps between crises getting longer? Can they manage life with less distress and anxiety than they used to? That’s not a particularly scientific or analytical way of looking at, but it’s been something that Carolyn and I have developed for ourselves in assessing where she is at on this invisible and somewhat conceptual ‘pathway to recovery’. We’ve come to firmly believe that there is nothing wrong with having DID in and of itself. Carolyn has no idea whether she will one day ‘integrate’ all the different parts of her personality and cease to present with the so-called ‘symptoms’ of a dissociative disorder. But what she does know is that it is essential is to reduce the distress that so often comes from living with a dissociative state of being – these heightened states of anxiety which sometimes explode into full-blown, self-endangering ‘crises’.

As well as running PODS, I’m in the latter states of my training to become a counsellor and I am currently in the middle of my placement with the mental health charity, Mind. So in the course of an ordinary week I come across a whole range of people, not just those that we might consider to be at the ‘extreme end’ of the spectrum with a dissociative disorder or a significant trauma history, but people without a mental health diagnosis but who are nonetheless regularly experiencing states of unbearable anxiety. So what does anxiety look like in the people I talk to, counsel, email and live with?

Some symptoms of anxiety are as follows:

  • chronic and excessive worrying
  • restlessness
  • feeling keyed-up or on edge
  • being easily fatigued
  • difficulty concentrating or mind going blank
  • irritability
  • muscle tension
  • sleep disturbance
  • feelings of distress
  • inability to relax or wind down
  • panicky thoughts and sensations
  • fast heartbeat
  • racing thoughts
  • digestive disturbances

That’s just a selection – bullet-point lists are never very accurate at detailing how something is actually experienced. But it’s enough to give a general idea. Anxiety is difficult to live with, affecting your emotions, your thoughts and your body – it’s not just ‘in your head’; it’s everywhere. For someone with a dissociative disorder, anxiety might be held by discrete ‘parts’ of the personality or ‘alters’ and may intrude suddenly into consciousness (as in during a switch) or it may be a generalised background hum that is always there. Whatever it’s like, it’s highly unpleasant and makes the rest of life so much more difficult to cope with. It has an undermining, debilitative effect and for people with extreme trauma, it’s unbearably difficult to manage even ordinary day-to-day activities with its constant interference.

And it’s what we do to cope with anxiety that often leads to problems. How do you calm down if you’re in a state of constant restlessness and you’re exhausted but you can’t sleep, you feel panicky and on edge and you don’t even know why? Many people quite understandably turn to ‘alternative’ or even illicit methods to counteract this anxiety. For example there are what are essentially cognitive strategies, which if severe and chronic enough can end up being diagnosed as OCD (obsessive compulsive disorder) – the need to wash your hands constantly because there’s an overpowering anxiety and focus of attention on dirt or germs. Or the need to do things in sets of four, because it doesn’t feel ‘complete’ if you don’t, and sets of four reduce the tension and distress inside temporarily, while doing something three times or five times seems to heighten it. There are practical attempts to dull anxiety, such as through drinking alcohol, eating certain foods, smoking, drug-taking: all of these substances lead to a state, at least temporarily, of increased calm and a bit of relief from the gnawing agitation inside. Mentally, it’s easy to feel that the chocolate, or the cigarette, or the drink is what you actually need, rather than realising that you feel you need it because it gives relief from anxiety. If you continue to use it to reduce agitation, you can end up feeling ‘dependent’, taking on the label or the self-description as having a ‘drug problem’ or an ‘eating disorder’ or being a ‘drug addict’. In reality, often it’s just been a way to lower this constant distressing buzz of anxiety. It’s a coping mechanism, and it works – the downside is that food, alcohol, cigarettes and drugs leave a somewhat unpleasant legacy of health problems which makes their long-term use problematic.

When anxiety levels rise, often they are fuelled by factors in our environment – it very rarely happens for no reason. Crises are precipitated by outside stressors, such as involvement with the police (perhaps to report historic childhood abuse), an absent therapist (and it’s him or her that we use to manage our feelings, amongst other things), mounting life pressures such as relationship conflicts or job hassles or the boiler breaking or benefits being reduced. We all exist as part of a system, and when anxiety levels hike, it’s often important to try and identify what it is that is causing that – what is causing it outside of ourselves, because it’s too easy to blame ourselves for not being able to cope and for worrying, when in fact anyone would be stressed out if they had our particular soup of life circumstances to deal with. Sometimes the best remedy for anxiety is to deal with the thing that’s causing the stress – the difficult relationship, being in contact with abusive family members, a job that pays badly in return for crazy working conditions. Too often these circumstances can’t actually be changed, at least not immediately, but it’s important to try to identify if they can, because trauma leads to powerlessness, and sometimes there are things that can be changed that feel as if they can’t. Feeling stuck and trapped and powerless is a surefire way to spike anxiety.

A very real phenomenon that I have come across in dozens of people is the way that anxiety is often fuelled by the person’s sense of their own inability to manage feelings generally. It’s a sort of vicious cycle: “I’m stressed because I know I get stressed easily.” People with secure attachments and good resilience feel generally confident in facing down life’s challenges – they have confidence in themselves, so they deal with situations with less anxiety and concern. This frees them up to deal with the actual challenges themselves. But the opposite is true of people who have had a rough time growing up. If you feel that you’re not going to be able to cope, that in itself is anxiety-provoking. How are you going to get a job and pay the bills when you know you find interviews really hard and you tend to freeze or panic? How are you going to figure out what to do about your car breaking down when you get stressed and even triggered being around men and you don’t know what an alternator is and you have no idea if this grease-monkey is going to rip you off? Naturally, in those circumstances, your anxiety will rise because you feel less able to manage the situation. So you stress about the fact that you’re going to get stressed – and that’s very, very normal. It’s a really difficult vicious circle, but it’s one that many people, especially trauma survivors, are familiar with.

What is really important to realise, though, is that struggling to cope and remain calm in difficult circumstances is not because you’re ‘bad’. It’s not because in some way you are ‘defective’ and ‘worthless’ and ‘pathetic’. It’s a natural result of not having lived in a secure, stable, predictable world when you were growing up. Your edginess now, your hypervigilance to things going wrong and your suspicion that you’re going to be ripped off, is your brain’s adaptive attempt to be one step ahead of the game in a hostile world – it’s trying to anticipate things going wrong to give you increased time to respond to a potential threat. Your hyper-wired brain is actually trying to help! Taking the pressure of yourself for being somehow ‘bad’ and ‘defective’ is the first step in reducing anxiety, because otherwise your message to yourself constantly is, “I can’t handle this” and that sense of inadequacy and lack of control just ramps up the anxiety even more.

This is why the preferred treatment pathway for trauma-related disorders is about tackling things in stages – the three ‘phases’ or ‘stages’ of treatment, and the first of these focuses around safety and stabilisation. It’s really important to build up your confidence in your ability to cope and to manage anxiety and stress by learning some skills and strategies, before you delve into the traumatic memories that ended up with you in this stressed-out state. Otherwise, looking at the past, looking at the awfulness of the ‘what happened’ that led to a dissociative disorder, will inevitably increase your emotional baseline of distress and will send difficult feelings flying around your brain and body day and night. And you’ll be left feeling that you can’t cope with all these feelings that are flooding in … so you must be defective … so life must be totally unmanageable … so you can’t cope with therapy … so without therapy you can’t cope with life … and before you know it, you’re in a dead-end, hopeless, even suicidal ‘crisis’.

Of course I don’t just work with people who experience high levels of anxiety, but I live with someone too! As we have written and talked about in many previous contexts, several years ago and almost literally overnight Carolyn went from being a highly competent ‘professional’ to having what we then termed a ‘breakdown’. She was beset for months on end with unbearable levels of anxiety and distress. It was through all of that that memories of her abuse began to flood back and the dissociative nature of her personality became clear, and she’s been on a journey of recovery ever since, which is ongoing. But a major thing which has helped Carolyn ‘cope’ better, which has enabled her to return to full-time work (in a role that is somewhat demanding, to say the least!), has been work on ‘safety and stabilisation’ and learning to manage anxiety, distress and crisis. So I know from firsthand just how important this is.

In talking about this subject with her, Carolyn identified three bundles of groupings of thoughts which she would experience (and still does) during periods of high anxiety. These are:

  • catastrophic thoughts
  • self-berating thoughts
  • and paranoid thoughts.

Her ‘catastrophic’ thoughts all revolved around the premise that everything was going to go wrong. Rather than it being just one unpleasant email she had received, or just the washing machine that needed fixing, in this kind of state of mind, it was as if everything was about to explode. If the washing machine had stopped working, then how did we know that the oven wasn’t about to pack in too? If one person had gossiped something unpleasant about us via Facebook, how did we know that all our friends wouldn’t suddenly turn against us? Who was to say that the noise that the car was making wasn’t terminal, and shouldn’t we just get rid of it now before we found out that it was a worthless deathtrap-in-the-making? In this state of mind, everything was everything and nothing was nothing – there was little space in between for grayscales. Hope and optimism were squeezed out; danger and risk were everywhere; there was little or no ability to step back and take in the broad perspective of the past and the future – it was all just what was being felt right here, right now, and with an eerie glow of ‘doom’ around it all.

It has always been tricky for me to fully empathise with Carolyn when she has been in this state of mind, to realise that the overwhelming blackness feels so incredibly real to her – because to me, outside the situation, and outside her state of mind, this supposed catastrophe looks awfully like a temporary blip … and I want to say so! But I have learned, and perhaps am still learning, that agreeing with her emotions whilst verytactfully offering an alternative to her catastrophic appraisal of truth, is the best way forwards. Saying, “Don’t be so stupid!” in a frustrated-beyond-reason tone of voice rarely helped.

Many trauma survivors will likewise be familiar with the ‘self-berating’ state of mind that comes to the fore at certain times of difficulty or high anxiety. This is the I hate me, I’m useless, I can’t get anything right, everything I do is rubbish, I can’t cope, I can’t DO ANYTHING stream of self-directed verbal abuse. Unfortunately, feeling and thinking and voicing these beliefs just increases Carolyn’s sense of incapacity and overwhelmedness, and it’s been as she’s learned to counteract these thought processes and not taken on board these harsh, critical accusations (many of them projections of her abusers from childhood) that she has been able to manage her anxiety better. After all, anxiety is telling her that something bad is going to happen. These voices tell her that she can’t handle whatever is going to happen, because she’s defective and useless. So it’s no wonder that believing these attacks further increases her anxiety.

And sometimes as a combination of the catastrophic and the self-berating, and sometimes as a state of mind of all its own, she has experienced the ‘paranoid’ stream of thoughts which again many trauma survivors will be familiar with. Once more, it has been helpful for Carolyn to recognise that this state of mind has come about as an attempt by her brain to foresee threat and have the maximum possible advance warning so that she can escape or survive: if someone has it in for you, better to know sooner rather than later so that you can be over the horizon before they actually act out their malicious intent! Previously, these ‘paranoid’ thoughts were just further evidence to Carolyn of her own insanity, even though the degree of her fear was never such that she falsely attributed to her sense of anxiety ‘unusual beliefs’ such as that she was being followed or tapped or hacked by the CIA. But the paranoia that she lives with is every bit as real, despite being in a more ‘usual’ range of expression: “No-one likes me” and “Everyone is against me” are paranoid-flavoured thoughts that lots of people will have had at one point or another during life.

So it’s been helpful for Carolyn to realise that her brain is over-wired to see ‘threat’ when there is ‘no threat’ or at least ‘big threat’ when there is ‘small threat’. That has enabled her to tackle some of her anxiety-inducing suspicions that people have malicious motives towards her when they are merely tired, or distracted, or feel unwell. It really does ramp up anxiety levels when you go around thinking all the time that everyone is going to harm you. So one of the best ways to reduce the overwhelming, nebulous sense of dread that anxiety brings is to start to think through some of these ways that the brain overreacts – the catastrophising, the self-berating, the paranoid – and talk yourself back down to a more realistic, and evidence-based, level.

There are a variety of measures in therapeutic and healthcare settings that are used to tackle anxiety, some more effective than others, but it’s a good idea to take a broad-stroke approach to reducing anxiety rather than just trying one approach and then giving up because it didn’t ‘work’. This strategies include, amongst others:

  • Cognitive Behaviour Therapy (CBT) – especially useful for tackling some of the distorted thinking (eg catastrophising) that can lead to and increase anxiety, as well as result from it
  • medication (although beware of side effects and the addictive nature of certain drugs eg benzodiazepines)
  • mindfulness, including MBSR (Mindfulness-Based Stress Reduction)
  • relaxation techniques
  • tackling insomnia (the vicious cycle of sleep deprivation leading to reduced coping capacity, which increases anxiety, which increases insomnia) – apart from medication, there are a variety of ways to improve sleep including exercise, diet, ‘sleep hygiene’ (routines and environment etc), exposure to daylight and so on
  • soothing strategies (ie finding ways to reduce anxiety and distress once it starts to build eg by going to a ‘safe place’, either literal or imagined, or anticipating upcoming stressful events and planning to manage them as well as possible)
  • increased social support (eg a better network of friends, supportive family, counselling/therapy, and engaging in social groups or activities)
  • ‘boxing’, ie putting anxiety or the things causing it into a metaphorical ‘box’ and then allowing a ‘controlled explosion’ or exploration at a more supported and appropriate time, eg during a therapy session
  • self-care (includes diet, exercise, self-talk, positive and pleasurable experiences)
  • dealing with underlying causes of anxiety in therapy
  • learning to manage the physiological (bodily) symptoms of anxiety, eg breathing exercises, stretching, ‘tracking’ internal sensations as part of Sensorimotor Psychotherapy).

There are many more ways that I could mention and in much more depth, but the point that I am trying to make is that anxiety is not something that just has to be put up with. It’s something that can be dealt with on a number of levels in a number of ways, rather than being impossible to tackle. And that’s very much what I believe about recovery: that trauma is primarily about loss of control and ‘self-agency’. It’s about being in overwhelming situations of threat and harm where you were powerless to do anything. And recovery from that trauma has got to be based therefore in being re-empowered, in getting back some control of your situation, and feeling able to live your own life and manage what goes on in it. This is why it’s so important to learn to manage feelings in general, and anxiety in particular, because that constant, humming sense of foreboding and dread has such a negative effect on your self-confidence to go out and conquer the world.

And it can be a revelation to people to realise that they can learn to start to take control of their thoughts, their feelings and even their bodies. For many trauma survivors, all their life things have just happened to them, outside their control, and especially where their bodies are concerned. So not only is getting in control of anxiety helpful in and of itself, but it can be a really positive stepping stone towards changing your view of yourself: that you’re not a helpless victim of whatever thoughts or feelings or bodily sensations come your way, but that you can manage them, and control them, and even start to change them. That is one of the many reasons why mindfulness can be so helpful in the recovery from trauma and dissociative disorders – because it teaches skills that directly impact your control of your mind, emotions and body.

So ‘affect regulation’, learning to manage your feelings, is not just a casualty resulting from early life traumatisation, but it can be a barometer for measuring recovery – for how well you’re starting to get back in control, after a lifetime of powerlessness and victimhood. And in many ways that is a balancing act of two factors. Firstly, the process of recovery involves learning to manage anxiety and feelings in general, which is a bit like mopping up overflowing bathwater that is flooding the bathroom floor. It’s a case of responding to the emergency-in-process, and getting better and better at having the towels and buckets to hand, so that the flood doesn’t spread to the rest of the house and start to drip through the floorboards onto the ceiling above. And secondly it’s a case of starting to figure out what is causing the anxiety, and the distress, in the first place – the trauma, the relational difficulties in childhood, all the abuse and difficult life circumstances that led to the bath filling up and overflowing. And this latter work, which is often done in therapy and takes time, is like the process of turning the bath taps off, so that the bath stops filling up. As you learn skills for safety and stabilisation, the bathroom floods less in the first place. As you work through the underlying trauma, the taps get turned down gradually. And some of the blockages – the dissociated memories, or unfelt feelings that were too distressing and overwhelming to be expressed – are removed from the plughole so that ‘emotions’ flow away more readily in future without risking flooding the floor.

In conclusion, there is hope. High anxiety is something that plagues almost all trauma survivors, and learning to manage it is an essential skill. It is the first and possibly most essential part of the three phases of treatment: safety and stabilisation. Anxiety left unsoothed can quickly escalate to a crisis. But anxiety understood and responded to, with skills such as mindfulness and relaxation, and then processed at a deep level by understanding what led to it in the first place (the dissociated trauma) does dissipate over time. And life becomes more bearable, without that sense of doom or dread, without the frantic, skin-picking agitation that needs alcohol or food or work or sex or drugs or medication to assuage.

Don’t worry, be happy … It’s a promise, not a command!

© PODS 2013