ACT Work on Trauma Memories: Exposure Hierarchy


Booz Allen
Department of Veterans Affairs
Yale University
University of Nevada, Reno

Key Points

  1. Use an exposure hierarchy to prioritize a client’s traumatic events by level of distress from lowest to highest.
  2. Deborah chose to use written exposure due to her journalism background, rather than oral or via recordings.
  3. Traditional exposure is based on habituation and attenuation of distress, whereas ACT-based exposure focuses on awareness and mindfulness.
Earn 1.25 CE Credits

Exposure Work on Trauma Memories

Deborah agreed to try working on trauma memories, and collaborated in prioritizing them as an exposure hierarchy. You can read about exposure from a behavioral perspective through cognitive processing therapy or prolonged exposure therapy. Exposure can be done through writing, orally, or by the client listening to recordings. Because of her journalism and communications background, Deborah preferred to approach it through writing.

Deborah’s Exposure Hierarchy

It was agreed that the written exposure would be time-limited so Deborah didn’t feel like it would go on forever: two weeks for each traumatic event. She was asked to rate the level of distress each traumatic event created for her.

  1. Deborah linked the lowest level of anxiety with the attempted rape when she was a teenager.
  2. The next highest was the distressing things she was exposed to as she traveled with her combat unit.
  3. Higher still was the recent attempted assault by her supervisor.
  4. The most distressing trauma for Deborah was the rape she experienced in Afghanistan.

She was given a prompt, based on cognitive processing therapy prompts, for writing about the traumatic event with as many details as possible, including how she felt this experience affected her thoughts about herself, others, and the world. The plan was that she would write it outside of session, then read the account out loud in session.

Written Exposure

At the first session following this assignment, Deborah had not followed through with doing it which, again, is very common with trauma survivors. Whatever had gotten in the way of her doing it was explored in a nonjudgmental way, then the process of writing about the event was started in session to create some momentum.

In the sessions that followed, Deborah would read her account out loud. The therapist would validate her experience and emotions. After her emotions had settled, Deborah would be asked questions, or given feedback about elements that seemed to be missing or lacked emotional description. She would be given the homework of rewriting that narrative with more emotional engagement, and reading it aloud to herself once daily.

This process was followed for all four events in her hierarchy. You don’t necessarily have to talk about every trauma, especially with clients who have multiple events. With Deborah, eight or nine weeks was a sufficiently time-limited approach for focus on exposure. With some clients, there can be a purposeful choice not to go into every event because there are so many. Some benefit enough working through the hierarchy that they don’t need to keep going.

Traditional and ACT-Based Exposure

Traditional exposure is based more on anxiety habituation and attenuation. In an ACT model, the main difference is that we can use subjective units of distress, for example, as part of exposure, but we’re doing it for awareness and mindfulness rather than with the goal of seeing measures go down over time.

From an ACT perspective, we don’t believe people necessarily have control over the level of their emotional response. Guilt, shame, grief, or other feelings may not really reduce, and that’s seen as okay. What we want is for a client to be able to live meaningfully and move forward even in the presence of those experiences and emotions.

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ACT Work on Trauma Memories: Exposure Hierarchy

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ACT for Trauma: PTSD and Beyond (8 CE Credits)

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