Exposure Therapy

Exposure therapy addresses the heart of PTSD symptoms by going directly to the trauma memory with the guidance of a therapist. In exposure therapy, the client revisits the memory of the trauma in her mind, describing the event repeatedly in the therapist's office. The goal of exposure therapy is to help the woman experience and process emotions that occurred during the trauma but were not allowed out because of the danger of the situation. Many therapies help manage specific PTSD symptoms, such as medications to help with sleep and nightmares or relaxation/breathing to help with anxiety, but exposure therapy directly addresses the link between the trauma and the symptoms. As noted earlier, traumas are life-threatening events, where the individual experiences the most intense emotions of her life. An important part of survival during the trauma event requires the individual to "shut down" or numb these intense emotions. The logical time to process these emotions would be soon after the trauma has ceased and the individual is safe once again. However, most often the community surrounding the woman does not support talking about the experience or only encourages the woman to provide factual information as in a police report, if she reports it at all. The "police report" narrative typically discourages the expression of emotions and is technical in nature. An important part of healing is experiencing the painful, fearful emotions of the trauma in a safe manner. Unfortunately, family members also discourage victims of sexual assault from expressing emotions after a rape, primarily because of their own discomfort. For example, the husband does not want to hear details of his wife being raped because of his own sense of helplessness and inability to protect her. Sometimes in an attempt to support the woman, family members and friends will suggest the woman "try not to think about it," which only serves to further invalidate her experience rather than helping her heal. The result is the woman reacts to memories and triggers of the rape by continuing to shut down the intense emotions, as she still does not feel safe. The woman may also suppress emotions because of time or family commitments, such as her responsibilities as a parent or the need to return to work. She may not have the benefit of therapy or support or be afforded the time to heal.

The consequence of "pushing down" or numbing of emotions is PTSD. As noted earlier, most people experience PTSD symptoms after a trauma, but most individuals' symptoms resolve within a year. It is believed that those people with natural support systems who talk about their experiences afterward are less likely to continue to have symptoms.2 Those that continue to hold in the emotions by avoiding thinking or talking about the rape or avoiding places that remind them of the rape are those that continue to be bothered by PTSD, which can last a lifetime. Additionally, women who blame themselves or think negatively about themselves or their symptoms also continue to have symptoms. PTSD symptoms, most obviously nightmares and flashbacks, are signs that the emotions of the trauma have not been processed. Revisiting the trauma memory in exposure therapy allows the individual to process the emotions of the life-threatening event. Here is an example of how exposure works with a fearful event. Let's say a young boy, age four, is taken to the beach by his mother every day. The little boy loves visiting the beach and playing in the sand and water. One day a strong wave catches him by surprise and knocks him over. He is frightened and may even swallow a little water, but his mother is close by to ensure his safety. The next day, when his mother prepares him for the beach, he begins to cry and fuss, not wanting to go. The mother, in all her wisdom, insists on taking him; however, on the first day she walks with him far away from the water. The next day he fusses, but she again insists on taking him and continues to do so daily despite his protests. Each day his protests lessen and she also takes him closer and closer to the water until he eventually returns to his normal state and once again loves going to the beach. Now let's rewind this example and the next day after the incident the mother gives in to his protests, feeling badly for him after the difficult experience, and doesn't take him back. The third day, his protests worsen, and the fourth his protests escalate further. The mother, thinking she is saving him from an uncomfortable situation, never takes him back to the beach. The result is, while the little boy feels better in the moment in not going back, in the long run, he grows into an adult with a fear of water and dislike of the beach. The example shows the philosophy behind exposure therapy. The example is taken from everyday life and the way we use exposure to face challenges, such as going to job interviews, giving speeches, and going to the dentist. In other words, we have all engaged in one type of exposure or another.

Prolonged Exposure

Prolonged Exposure (PE; see client manual Reclaiming Your Life from a Traumatic Experience—Workbook for details)13,14 is the most developed model of exposure therapy for PTSD and is considered the standard of care in providing exposure therapy. Therapists across the country are being trained in PE15 because of the positive results found in its application with all types of trauma, even traumas that occurred years ago. Like CPT, PE therapy is a time-limited treatment. It consists of ten, ninety-minute individual sessions with a therapist trained specifically in the PE protocol. PE consists of education, breathing retraining, and two types of exposure therapy—imaginal and in vivo, or real life.

Education and breathing retraining. Education and breathing retraining are provided in the first two sessions. Education on how exposure therapy works is essential, as understanding the therapy will help an individual complete it. There may be times when the individual may want to stop the therapy. Education starts with an explanation of habituation, which simply means "to get used to something," particularly an uncomfortable something. An example of habituation is going to the same scary movie multiple times. The first time a scary movie is watched, it creates the feeling of fear, possibly a fun kind of fear, as we have chosen to watch it. However, if the same scary movie is watched twenty times in two weeks, by the twentieth time there would no longer be fear, but rather boredom. The fear would have progressively decreased with each viewing of the movie. This is called habituation. The same thing happens with a trauma memory. In the original rape, the emotions were overwhelming and terrifying, and the woman could have died. When the memory of the rape returns, women experience similarly intense, fearful emotions, but going back to the memory repeatedly, like the movie, will allow habituation of these feelings.

Education is also provided about the role of avoidance in keeping PTSD symptoms alive. While avoidance is one of the symptoms of PTSD, it is a strategy used to lessen uncomfortable anxiety. When avoidance is examined more closely, essentially it works in the short run but not the long run. Just as with the little boy on the beach, immediate avoidance after the incident lessened his anxiety but had long-term negative consequences. In another example, say a woman's child needs milk for cereal the next morning, and she must go to the store, but going to the store makes her quite anxious. She thinks, "I'll go this afternoon at 2," and as 2 o'clock gets closer, her anxiety starts to build. It continues to build until 2 o'clock arrives; she makes the decision not to go to the store. Immediately after her decision, her anxiety drops and she feels better. So avoidance worked to reduce her anxiety, but only in the short run. In the long run, she feels badly because her child has no milk for his cereal and she feels like a bad parent. Another long-term consequence is that it is harder to go to the store later when she has no alternative and must go. In the example, the woman felt the immediate positive effects of deciding to avoid but then experienced the longer-term negative effects of avoidance. In therapy, it is also noted that while avoidance has been used as a strategy by the individual over the many years since the trauma, it has not been successful in eliminating the PTSD.

Another part of education is teaching the woman to "measure" her anxiety using a scale called the subjective unit of distress (or discomfort) scale or SUDS. The SUDS is a rating scale that ranges from 0, which is without any anxiety, to 100, which is the highest anxiety/fear, such as that experienced during the rape. A middle event is identified and rated a 50 (which will always remain a 50), such as going to the accountant to get income taxes done. The main value of using a SUDS measure is that it marks improvement during the imaginal and in-vivo activities and demonstrates the gains during therapy for the woman.

Finally, breathing retraining is a relaxation method used to help manage anxiety but is discouraged during exposure sessions. It is used at different times during the week between sessions. While relaxation methods, including breathing retraining, are helpful with the anxiety symptoms of PTSD, the goal of in-vivo and imaginal exposure is to allow anxiety to increase and lower on its own. Engaging in breathing or any other exercise during the imaginal or in-vivo exposures may create the message that the memory is truly dangerous and a coping strategy like relaxation must be used.

Imaginal and in-vivo exposure. PE is based on the theory that intense emotions are created during a rape or trauma, and these intense emotions require processing. PTSD symptoms are natural responses until processing occurs. The two factors that cause PTSD to persist are avoidance of trauma reminders and negative beliefs associated with the trauma. There are two types of avoidance, and they are easily recognizable: (1) avoidance of memories or thoughts of the trauma and (2) avoidance of people, places, or things that are reminders of the rape. The reason avoidance is so common is that avoidance is a natural response to pain. For example, when we touch a hot stove, we immediately pull our hand away. This type of avoidance is useful in keeping damage to a minimum. However, avoidance of emotional pain associated with the memory of a rape causes more problems in the future, as it does not allow for the emotional processing necessary for such a significant event. The two main treatment components of PE—imaginal and in-vivo exposure—allow experiencing of the emotional pain in systematic ways that promote healing of the trauma memory. The second factor that maintains PTSD symptoms is negative thinking around the trauma memory. Thoughts such as "It's my fault this happened. If only I would have said no. Why can't I just let it go? I must be going crazy. Nobody else has these problems" are common, inaccurate thoughts and serve to keep the PTSD symptoms active.

Imaginal exposure. Imaginal exposure directly addresses avoidance by having the woman face the memories and release the emotional pain. The symptoms of nightmares, flashbacks, and/or intrusive thoughts are signals that the emotional pain, fear, and anxiety associated with rape have not been processed. Avoidance is defined as any type of distraction used by the woman when a memory of the rape comes up, with or without reminders. Avoidance can occur in any number of ways, such as leaving the room, turning on the TV, or even drinking alcohol. Facing the memory or permitting the memory of the rape allows her to experience the unprocessed feelings of fear and pain. A useful metaphor is the book example. It is used here to highlight how the trauma emotions are not processed. Let's say our life experiences are represented in a book, with each chapter consisting of different times in our life. The first few chapters might represent all our childhood experiences, the next our teens, the next college, and so on. You can easily read through (remember) the chapters in all parts of your life before and after the rape. However, when you reach the chapter on the rape, you quickly slam the book closed. This occurs each time the book opens to the rape chapter; the chapter cannot be read through, and the memory is never processed. Exposure therapy is opening up the chapter and reading through each painful experience of the trauma over and over, so eventually the rape chapter becomes like all the other chapters in the book. While the rape memory will always produce significant feelings, these feelings are approachable and not overwhelming. The book metaphor helps demonstrate how, in people with PTSD, the memory of the rape is set apart from all other life experiences.

In an imaginal therapy session, the therapist helps the woman identify her worst trauma, if there is more than one. Next, the woman is asked to close her eyes and describe the memory of the rape in the present tense, recalling as many details as possible. A specific starting and ending point are identified, and when she completes the description, or narrative, she is asked to return to the beginning and repeat it. She is instructed to include sights, sounds, smells, thoughts, and feelings as she describes the rape. The repetitions of the same trauma narrative continue for forty-five to sixty minutes in the therapy session. The effect of imaginally repeating the trauma, in the present tense, in the therapist's office, week after week, essentially allows all the feelings the woman experienced in the rape to come out. All the feelings of fear, terror, betrayal, pain, and anger, as well as others, emerge. The emergence of these feelings may result in tears, but most important they emerge, are released, and are processed. Another effect of imaginal exposure is allowing for corrective information. While most trauma survivors believe they remember all the details of the rape or trauma, particularly because the nightmares and flashbacks are recalled so vividly, individuals tend to store the memory away with self-blame labels, among other cognitive distortions. As the memory is repeated, and the variety of emotions arise, greater details of the rape are also remembered, which allow for corrective information. The inaccurate thoughts become corrected simply by a repeated imaginal review of the trauma narrative (not cognitive restructuring, as in the previous section). For example, the woman who initially blamed herself for a gang rape when she was eleven years old realizes she did nothing to cause the rape and could not have been to blame only after she visits the memory repeatedly. The imaginal exposure is conducted in sessions three through ten, and during each imaginal session, the SUDS ratings are taken by the therapist every five minutes. Additionally, the session is tape-recorded, and the woman is instructed to listen to the tape daily, rating her pre-, peak, and postanxiety levels using the SUDS measure. This repetition of imaginal review each week and listening to the rape daily allows the woman to fully engage the memory with all the painful details and all the difficult emotions surrounding the event and thus allows healing of the traumatic memory. The description of imaginal exposure may sound terrifying to someone who has been through a trauma like rape; however, it is important to keep in mind that while there may be a temporary increase in nightmares or anxiety, the overall symptoms will improve. The woman is reminded that the imaginal exposure is just bringing back a memory, and while the actual trauma was life threatening, recalling the memory will not hurt her. The uncomfortable feelings are real, but the image is a memory.

In-vivo exposure. The in-vivo exposure also consists of facing one's fears, but it is done in real-life situations. The in-vivo exposure involves going to places or engaging in activities that have been avoided since the trauma. Most people who have experienced a trauma avoid crowded places because they feel unsafe due to the unpredictability of a large crowd. Other avoided situations are those that remind the woman of the rape. In our earlier example where the woman was raped by a coworker at a company party, the woman would avoid interacting with coworkers including her rapist, going to parties, and going out during the night. The biggest problem with avoided situations is that they multiply. In other words, the number and types of avoided situations increase over time. Years after the rape, she may now avoid restaurants, convenience and grocery stores, and athletic events, none of which were directly related to the trauma. This is called generalization, and the way it happens is illustrated by the following example. Let's say the woman who was raped by a coworker at a party happens to be at a convenience store when she has a flashback of the rape. She escapes from the store, isolates, and never returns to the convenience store because the convenience store has now become a reminder of her rape. As time goes on, more situations become associated or connected with the memory of the rape, and they too are avoided. The woman's world continues to shrink, and she is less able to function in these everyday situations because they too have become reminders of the rape.

In-vivo exposure involves creating a list of all these avoided situations. The situations are specific to each individual and should include a range of anxiety-producing events from mild to high. Once the list is complete, each item is rated with the SUDS measure. With the guidance of the therapist, two or three situations in the 40 to 60 anxiety range are selected for practice from daily to a few times during the week. For example, the woman might rate going to the grocery store at 2 in the afternoon as a 55. She would then be asked to go the grocery store every day and stay in the store for a minimum of thirty minutes or until her anxiety drops to half of its peak, whichever comes first. She would rate her anxiety with the SUDS before going into the store for pre levels, then again when she completed the activity for peak and post levels. While the activity itself is important, the rating is also important because it will eventually provide concrete evidence of her anxiety lowering. While the numbers may not seem lower from day to day, they do lower with continued practice over a two-week period of time. The lower numbers provide self-confidence and confidence in the process. When her anxiety has dropped sufficiently and is no longer problematic for that particular situation, she selects a different avoided activity in which to engage. The more often the activity is done, the more quickly her anxiety lowers. Remember that avoidance is a PTSD symptom and individuals will tend to avoid doing the homework exercises, and it is important not to extend the in-vivo activities over long periods, but rather to do them daily and frequently. The grocery store example illustrates the importance of daily in-vivo exposures. If the woman goes daily for two weeks, her anxiety may start at 40, go up to 60, and come down to 55 on the first day. Each day these numbers will continue to lower until after two weeks or fourteen days, her numbers may be 10 pre, 20 peak, and 10 post. If she did the same activity every other day, she would achieve the same results in one month; if she did the exercise once a week, it would take fourteen weeks or 3 1/2 months to improve. Not only does stretching the exercise out slow improvement, but it also encourages the person to continue to use avoidance as a coping strategy. Therefore, doing the in-vivo activities as frequently as possible (at least daily) will result in improvement more quickly. Once one activity is completed, another is assigned from the list.

Practical suggestions. This section on exposure therapy and PE is intended to provide a general description of how this therapy works and is not intended as a guide to use this therapy on your own. It is extremely important not to jump into your trauma memories based only on the direction in this chapter. While exposure therapy seems intuitively appealing and straightforward, traumatic memories should only be brought back with a trained therapist, because unforeseen problems can arise. The therapist has training and skill in dealing with potential problems and can help you get through the traumatic memories in a successful manner. Having said that, it is likely you can recall having done some minor levels of exposure in your life at various times with nontraumatic experiences. It is important to recognize that you have already done lower levels of "in-vivo" exposure, even though it was not technically therapy. Think back to situations where you forced yourself to do something uncomfortable, like giving a speech or taking a test. The more often you did it, the easier it became and the less anxiety you experienced. Therefore, you can set goals and tackle relatively easy activities that can be completed on your own with the understanding that you must seek professional help should you get overwhelmed. Another very easy activity to implement is using the SUDS measure. It takes little effort and can give you tremendous payoff. You can check your own SUDS numbers at almost any time of the day. Getting your SUDS levels throughout the day or when you go to an activity (pre/peak/post) will help you start the process of healing and lay a useful foundation when you begin therapy.

Anxiety and Panic Attacks

Anxiety and Panic Attacks

Suffering from Anxiety or Panic Attacks? Discover The Secrets to Stop Attacks in Their Tracks! Your heart is racing so fast and you don’t know why, at least not at first. Then your chest tightens and you feel like you are having a heart attack. All of a sudden, you start sweating and getting jittery.

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