A form of exposure therapy is also used to treat distressing memories of the trauma. We call it “imaginal exposure”. In Section 5, we talked about confronting feared situations such as places, people, and activities. In cases of Posttraumatic stress disorder, however, the most “feared situation” is actually the painful memories of your experience. These memories are so frightening, and cause so much distress, that the person tries to avoid or escape from them by blocking them out. Imaginal exposure treatments are used to assist in confronting the memories. Exposure is only one term used to describe this process. Some people talk about “trauma focus work”, “working through the trauma”, “coming to terms with the experience” or simply “confronting the memories”.
What is imaginal exposure?
There are many analogies used to explain this process to Posttraumatic stress disorder sufferers before treatment commences. The following examples from our clinical practice may help you to understand what will happen and why it is important.
After a trauma, we often try to file away our memory of what happened, putting it to the back of our mind. It’s as if we are trying to pack the event away into a box. We then use a little strength to keep the lid tightly closed and try to leave it undisturbed. However, over time, two things happen. Firstly, our strength begins to wane and it becomes more of an effort to keep it sealed (that is, to stop the memories from coming back). Secondly, due to the pressure, the box begins to lose its shape and small cracks begin to appear. What we experience as symptoms (such as memories of the trauma, and having nightmares and disturbed sleep) is like the content of the box spilling out through these cracks. This is usually very frightening, so we try to avoid anything that reminds us of the trauma. We try to stop thinking and talking about what happened and how we felt. In this way, the content of the box becomes a “ghost” which we have learned to fear and which we are terrified of confronting. As part of therapy, we are going to open the box and inspect the content for what it really is. We will talk through what happened and how you felt. We will be inspecting the “ghosts” that have been created and throwing away any maladaptive and distressing beliefs you may have about the event. We find that once the trauma has been dealt with in this manner the symptoms become much less severe and less frequent.
Another analogy talks about the dentist:
When dentists work on a decayed tooth, they don’t just slap the filling on top of the decay. If they did, it might be fine for a few weeks or months, but the problems would keep coming back as the tooth continued to deteriorate. Instead, they spend some time drilling and scraping, cleaning out all the decay before putting the tooth back together. This is a very unpleasant and painful process, but we know it is worth going through this short-term pain for the long-term gain. Traumatic memories are a bit like tooth decay. We need to make sure that we have confronted all aspects of the trauma before we try to put the event behind us. We need to give ourselves time to face up to even the worst parts of the experience so that there are no skeletons in the closet to come and haunt us in the future. Like the dentist’s drilling, it is a painful process but an important part of recovery.
A final analogy comes from the work of Edna Foa, one of the leading experts in the treatment of Posttraumatic stress disorder:
Suppose you have eaten a very large and heavy meal that you are unable to digest. This is an uncomfortable feeling. But when you have digested the food, you feel a great sense of relief.
Flashbacks, nightmares, and troublesome thoughts continue to occur because the traumatic event has not been adequately digested. Treatment will help you to start digesting your heavy memories so that they will stop interfering with your daily life.
Exposure-based treatments are not for everybody. In some cases, if the trauma occurred many years ago and the memories are not causing too much of a problem, it may be best not to drag everything up again. Talk to your therapist about whether this approach would be beneficial for you.
Therapist-assisted imaginal exposure
Confronting the traumatic memories is a very difficult and painful process, and is best done with the help of an experienced therapist. There are several steps that your therapist will take you through. First, the therapist will provide an explanation of the process, including what you will be doing, why you are doing it, and a reminder on the SUD scale, as well as answering any questions you may have. Next, the therapist will work with you to develop a hierarchy of painful memories in much the same way as you developed a list of goals for your in vivo exposure above. If you have experienced several traumatic events, this may be simple enough. You will need to think about each event and rank them in order of how distressing they are for you to remember. If you have only experienced one event that is causing you problems, you will not need to generate a hierarchy.
The therapist will then ask you to go through the selected event or experience in great detail, starting at the beginning and continuing through to the end, to a point where you felt relatively safe. In order to keep the distress manageable, you may initially be allowed to keep your eyes open, to talk in the past tense (e.g., “I was walking along the path when I saw him coming towards me”), and to skip some of the worst details. For the procedure to be fully effective, however, you will need to build up (perhaps over several sessions) to making your account as vivid and detailed as possible. You will need to talk through the whole event with your eyes closed and in the present tense (e.g., “I am walking along the path and I can see him coming towards me”), since this makes it much more real for you. You will need to be careful that you do not miss any of the details, even (or perhaps especially) the worst ones. Remember that we do not want to leave any skeletons in the closet to come out and worry you in the future. Your therapist will repeat this process many times in the same session and/or in subsequent sessions. However, the more often you go through it the quicker you will recover, so your therapist may tape the session and ask you to listen to the tape every day at home. Again, this is not an easy process, but sticking to the following steps will help you through it and help to ensure that it provides the maximum benefit.
• Step 1: Preparation.
• Plan an activity to do immediately afterwards (e.g., go for a walk, visit or ring a friend; do an enjoyable absorbing activity, not an addictive activity like watching TV or drinking, or an emotional shutdown like hiding away on your own).
• Choose a private place with no interruptions (take the phone off the hook, let others know you are not to be disturbed).
• Identify two people you can contact immediately if you need help: keep their phone numbers handy.
• Briefly relax yourself and try to clear your mind of other thoughts and worries: note down your Subjective units of distress level on a piece of paper.
• Step 2: Confront the memory safely.
• Listen to the tape and try to focus on what is being said: try not to imagine other, more frightening parts – just concentrate on the tape.
• Equally, try to imagine it happening as if you were experiencing it again. What can you see, hear, smell, touch, taste? What are you feeling and thinking?
• When reminded to do so on the tape, note your Subjective units of distress level. If it is above 90, take a moment to remind yourself where you are; you are safe here and now; you can feel as upset as you need to in the memory.
• Don’t stop the tape in the middle: stick with the memory through to the end.
• Step 3: At the end of the tape, pause and open your eyes.
• Look around, feel the chair, remind yourself where you are and that you are safe.
• Note your Subjective units of distress level and use an arousal management strategy if necessary (such as breathing control or relaxation).
• Step 4: Process the memory by writing down some or all of:
• What new (or old) pieces of the memory did you discover or became clearer?
• Are you now thinking differently about any aspects?
• What feelings or thoughts are going through your mind right now?
• What parts of the memory are still too upsetting to remember or accept?
• What do you still want to change about the event or its aftermath? How can you achieve that?
• What did you do that you should be able to feel good about?
• Step 5: Relax and do your planned activity.
Self-directed imaginal exposure
Many people find it difficult to do imaginal exposure to traumatic memories on their own. The process is too painful and they need the support and structure provided by a therapist. However, it is not impossible. Indeed, many people who recover from trauma without professional help are doing just that. They are thinking about the trauma often enough, for long enough, and in enough detail for the memory to lose the worst of its associated distress and for it to become modified and “sorted out” in their own mind. If you are going to attempt the process without a therapist, writing down the memory is often a useful way of doing it. (Indeed, it may be helpful to do this even if you are working with a therapist, although we suggest that you discuss it with him or her first.)
The assignment described below is adapted from the work of two American psychologists, Patricia Resick and Monica SchnickeMake sure you read through those steps carefully and prepare yourself properly before attempting the assignment. Select a suitable time and place so that you have enough privacy and sufficient time to do the task properly.
This task is important in helping you to sort out exactly what happened. The process of “putting the pieces of the jigsaw puzzle together” seems to be very important in getting over the incident. It also works in a similar way to the imaginal exposure described above – the more you confront the painful memories and the bad feelings associated with them, the less powerful and distressing they will become.
The task is to take a sheet of paper – an exercise book would be ideal – and write out a detailed account of exactly what happened. (Interestingly, research suggests that it is much more effective if you write it out by hand rather than using a word processor.) Include as many sensory details as possible (sights, sounds, smells, and so on). Also try to include all the thoughts and feelings that you had during the event. Do not stop yourself from feeling the emotions – although it is painful, that is part of the recovery process. If you become too distressed, you can stop writing for a while but try to continue again as soon as possible. It is important to keep writing until you reach the end (and a point of relative safety), even if that takes a long while. Make a note of your Subjective units of distress level in the margin every few minutes – this is important to compare your levels when you reread or rewrite the account. You can rewrite the account as often as you like, putting in more details or different perspectives as they come to you. On days when you do not rewrite the account, read it to yourself at least once. Again, stick to the steps outlined above when you do this. If you have kept a note of the Subjective units of distress levels in the margin, you will notice them dropping over time as you repeat the process. You will need to repeat the task until your Subjective units of distress are reasonably low throughout (say, a maximum of about 30).
Exposure: can I cope with it?
Exposure is a very difficult and painful process, but it is the only way to recovery. As we noted above, it is usually not as difficult as you fear it will be and most people get an enormous sense of achievement when they have confronted the memory or other feared situation. If you have read (and practiced) the sections above, you now have several strategies that will help you to manage your anxiety and distress. These are very useful to use both before and after the exposure exercises. If necessary, you can use them during the exposure exercises also, although we recommend that you do this only if you really need to. It is better to confront the full anxiety and allow it to reduce of its own accord than it is to use other strategies to bring it down. However, it is important that you do not feel overwhelmed at any time. Despite the best of intentions (in terms of preparing your hierarchies and confronting only situations or memories that you feel ready for) the anxiety will, sometimes, be greater than you expect. On those occasions, by all means use your coping strategies if necessary.