Useful exercises and strategies
We all benefit from developing an understanding of our emotional responses and utilising strategies that help us better manage difficult situations. Mindfulness has much to offer us in this work.
Mindfulness is defined as being aware of one’s thoughts, feelings and bodily states in the present moment. It allows men to anchor themselves in the here and now, and be able to process memories of the PAST in the PRESENT.
- Mindfulness exercises can help us to develop an ‘observing self’, that allows us to notice intense thoughts and feelings, and to watch as they appear and pass by.
- Trauma often influences individuals to be in a constant state of hypervigilance, involuntarily drawing the individual’s attention to their past. Mindfulness provides an opportunity to be fully aware in the present moment.
- Rather than focusing on the thoughts and issues that present, the individual is encouraged to acknowledge the thought rather than attempt to ‘fix it’ or resolve it.
- Men are encouraged to keep their eyes open to avoid dissociation, feeling unsafe or triggering flashbacks.
- Mindfulness activities include: Mindfulness sitting, walking, sultana eating or tea drinking exercises are useful exercises men can engage with. Book in quiet time every day.
- It is important to note to clients that mindfulness should not be used solely for relaxation. Rather, it is an opportunity to be aware of your thoughts, feelings and physiological reactions without utilising avoidance.
Learning area: Using mindfulness with men
A supplementary learning area for clinicians in relation to using mindfulness with men who have experienced childhood sexual abuse or sexual assault is presented.
While men may hold some reservations about engaging in yoga, the positive effects are often linked to increased awareness of body sensations and emotion regulation. The mindful aspects of yoga that increase insight into the physiological and cognitive processes may influence men’s experience of trauma related symptoms (Van der Kolk et al., 2014).
Yoga can have a significant influence in the improvement of the mind-body connection for men. Similar to relaxation, safety considerations may include avoidance of some poses (downward dog, child’s pose or corpse pose) that may trigger trauma related flashbacks. Van der Kolk (2014) has found yoga is a successful activity in (a) improving arousal problems in PTSD, and (b) improving individual’s relationships to their bodies.
- The Trauma Centre has a number of articles on the relationship between yoga and trauma and can be accessed via their Publications page.
Some people have noted how this acknowledgement and expression of distress can at times leave them feeling tired or agitated, and that for them it is useful to reengage with life and with their bodies, to purposefully involve themselves in activities where they feel fully physically and emotionally present. In this process, distress tolerance is not about managing distress, but about creating a rich, emotionally engaged life.
While distress tolerance is a necessary component of living an emotionally engaged life, not all emotions simply need to be tolerated and accepted. Grounding recognises that by reducing the intensity of the distress, the individual may be better able to sit with the distressed feelings rather than avoiding the distress completely. Grounding strategies invite men to redirect their attention to the immediate environment in the here and now in order to reduce the intensity of distress experienced in response to flashbacks, sudden panic, negative intrusive thoughts or dissociative states (Briere & Scott, 2006). In order to remedy acute trauma responses, regain control and avoid the attention of others, men often engage in a number of habitual behaviours to self-soothe and avoid further distress. Learning to tolerate distress by temporarily reducing distress allows an opportunity to reset their level of distress before recommencing therapeutic work. Grounding should:
- Focus the individual’s attention to the therapist through altering voice and posture.
- Assist the client to identify current internal experiences (thoughts, emotions, physiological states).
- Orient the client to the present immediate external environment focusing on items in the room, date and time etc.
- Introduce breathing and relaxation exercises if necessary.
- Recommence with therapy topic if possible (Briere & Lanktree, 2013).
- Follette, V & Pistorello, J. (2007). Finding life beyond trauma.
- Hayes, S. (2005). Get out of your mind and into your life.
- Living Well App
- My Calm Beat
- Living Well. Mindfulness exercises
Relaxation and deep breathing
Relaxation continues to be one of the most basic and successful ways to reduce hyperarousal and anxiety for individuals, and is strongly linked to positive outcomes for individuals who have experienced trauma (Briere & Lanktree, 2012). Men may express some reservations about engaging in relaxation interventions, and may express some confusion about how strategies may improve their ability to regulate their emotions. For some men who have experienced sexual abuse and complex trauma, engaging in structured relaxation and deep breathing exercises can be challenging. Some men have become so accustomed to being hypervigilant and in a state of hyper arousal that their body being in a state of relaxation may feel foreign and uncomfortable. In addition to the Mindfulness, Yoga and Grounding Exercises mentioned above, additional useful strategies to consider and introduce to men include:
- Deep breathing
- Progressive muscle relaxation
- Guided visual relaxation
- Simple breath hold and release, or muscle tension/release strategies
Safety remains a priority when introducing relaxation and breathing exercises with any individual who has experienced sexual trauma. It is important to take time to:
- Invite the client to keep their eyes open to reduce risk of dissociation and flashbacks
- Discuss instructions and purpose clearly to avoid any unexpected responses
- Provide an environment the individual perceives as safe
- Identify sensations associated with progressive muscle relaxation in order to reduce the risk of possible association with their trauma.
- Living Well. Relaxation Exercises
- Please refer to Supplementary Module previously presented within the Mindfulness section
Attention shifting is grounded in moving the individual’s attention away from thoughts associated with overwhelming emotions and the triggering event, in order to return to homeostasis (Clotire et al., 2006).
- Attention shifting should not be confused with avoidance. It is more akin to mindfulness strategies in encouraging the client to acknowledge the emotion provoking thoughts and make a conscious decision to shift their attention to a more productive thought.
- The act of acknowledging and interpreting the thought as unhelpful distinguishes this from avoidance.
- It may prove helpful to schedule an appropriate time for the client to reflect on their thoughts and feelings when they are in a frame of mind more conducive to challenging the thought.
As an extension to relaxation, deep breathing and attention shifting, positive visualisation involves imagining a safe, peaceful or pleasant place with as much detail as possible (Briere & Lanktree, 2012). There are a number of ways this may be facilitated:
- Guided imagery – The clinician or a guided CD verbalises a relaxing scene (beach, rainforest etc.) with descriptions centring on the 5 senses, while the client sits in a comfortable position. Note: it is important to let the client choose the scene to be imagined, because sometimes seemingly peaceful places (eg. rainforest, the beach) may have been the site of the abuse.
- Client directed – The clinician prompts the client to describe a scene utilising questions that encourage detail in the scene. Alternatively, the client may choose to verbalise the scene to the clinician directing the flow of the visualisation with few prompts from the clinician. This provides an opportunity for the client to assume control and to personalise their visualisation.
- Client directed with drawing – The clinician prompts the client to describe and draw a relaxing picture or place, providing an option for the client to identify details as they are drawing. This process may assist clients who find it difficult to engage their imagination and provides a prompt for when the client is utilising this skill alone. Alternatively, the client may choose an object which represents the relaxing, safe scene/image. (Note: There are now many mindful drawing books available).
Whichever process is used to direct attention to the positive visual image, it is often helpful to invite the client to periodically check in and notice what impact (if any) this image has on their body (physiological sensations).
Note: Resources available via the Living Well website – Relaxation Exercises. Please observe the same safety behaviours and variations as outlined in relaxation, mindfulness and yoga sections (i.e. Eyes open, no corpse pose etc).
The use of time outs can be a successful strategy for emotion regulation, by encouraging the individual to leave the environment that is influencing the emotion dysregulation for a period of time (Cloitre et al., 2006). This strategy may not initially sit well with men and be interpreted as ‘running away’. Therefore, the client is encouraged to return to the environment when they have reached a state of stabilisation within their trauma responses, rather than avoiding the specific environment. This should be highlighted to the client.
Scaling questions may be useful in conjunction with this strategy, by rating their experience or intensity of the emotion and predetermining they will leave the environment if it reaches a specific number.
Similar to time outs, the use of distractions removes the individual’s attention from the influence of dysregulated emotions. Providing a distraction from the overwhelming emotion provides a break for the individual to re-establish stability, before later examining the triggers and identification of emotions. For successful application, these behaviours need to be behaviourally based, with a fixed pattern of outcomes such as cleaning house, jogging a circuit, washing the car, working out at the gym etc. (if I do A than B will result, influencing me to feel C). Clear boundaries should be drawn regarding:
- What existing behaviours are being replaced.
- What are the new replacement behaviours and an assessment of the risk of new behaviours becoming compulsive and therefore problematic.
- When should replacement behaviours be implemented.
Practical problem-solving skills
Everyone benefits from possession of practical problem solving skills - structured ways of evaluating and responding to difficult situations, thoughts and emotions. Given societal expectations that men are ‘meant to be’ skilled problem solvers, it is not surprising that men can be interested and welcome conversations that increases their problem solving skill set. Practitioners might therefore take this opportunity to introduce and carefully step men through a structured problem solving framework (that includes acknowledging and managing emotions). In so doing, there is no suggestion that the particular man is ‘deficit’ in problem solving skills - it is more a checking in that recognises that men who have been sexually abused can face profound and intense difficulties, and our intent is to ensure his life skills tool box is stocked with the latest information and problem solving framework.
Pleasurable and positive activities
Introducing skills for the better management of emotions and tolerating distress can risk being drawn into focusing on the reduction of negative behaviours and thoughts, losing sight of the goal to enhance the individual’s wellbeing, resiliency resources and hope. During skill development around emotion regulation, men may become preoccupied with ‘fixing’ the behaviours that are influenced by trauma related symptoms, and feel overwhelmed by the impact of the trauma to their lives. Work during stabilisation should reflect on not just minimising the influence of trauma related symptoms, but also provide the individual with the opportunity to shift attention toward their ability to engage fully in the life they want for themselves.
Encouraging work to promote skill enhancement is often overlooked or considered trivial, however it is linked to significantly positive effects for individuals who have experienced complex trauma:
- Exercise, hobby development, learning, sports, socialising, diet, sleep hygiene etc. all have strong evidence highlighting the advantageous nature of an increase in these types of activities.
- For men, this may provide a tangible or goal oriented skill that increases confidence in their ability to cope and regulate their emotions, as well as providing a discussion point about building experiences of pleasure in their lives.
- In some instances, the increase in positive strategies may assist in prompting discussion about deserving to live a happy and fulfilling life, rather than one that continues as a testament to the pain and suffering they may have experienced as a result of their childhood sexual abuse or sexual assault.
- Identification of positive or pleasurable activities should be directed by the client, and it may be helpful to provide a list of activities for the client to select their desired behaviours from.
This focus on encouraging and supporting individuals to become engaged in pleasurable and positive activities, and to more fully integrate these in their lives, might be seen as the work of Phase III of the Trauma Therapy Framework - something to aim for and reach in due course.
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