Imaginal Exposure for PTSD: Emotional Processing Preparation and Rationale

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.

Highlights

  • Imaginal exposure begins in session 3.
  • Ask the patient to go back in her mind’s eye to the time of the trauma and recount it out loud, repeatedly.
  • Record it for homework practice.
  • After the imaginal exposure, process the experience with the patient.
  • Make new learning that occurred in the exposure explicit to the patient.

 

Transcript

Video 4. Imaginal Exposure: The Essentials.
In this video, we’re going to get into the meat of PE. In imaginal exposure, we ask the patient to go back in her mind’s eye to the time of the trauma and recount it out loud, repeatedly, several times per session. And we record it for homework practice.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

We ask the patient to revisit the trauma memory in imagination to visualize it and emotionally connect with the traumatic event while recounting the experience aloud in the present tense.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

The standard procedure is designed to do a number of things to enhance the patient’s ability to access all of the salient aspects of the trauma memory, details about the event, thoughts, emotions, sensory experiences. Remember, from our discussion of emotional processing theory, we need to make sure we include information about the stimuli, the responses, and the meaning. It helps to promote emotional engagement with the trauma memory. Eyes closed and speaking in the present tense help emotional engagement. It invites a narration of the memory in the patient’s own words with minimal direction and prompting by the therapist.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Allow the patient to approach the trauma memory gradually the first time she revisits it and recounts the trauma memory. We gradually ask for more detail.
In the second session of imaginal exposure, which would be session 4, we ask them to include a little bit more detail. By the third session of exposure, which is session 5, I tell them, “If it’s in your memory, say it out loud.” I don’t want to leave any stone unturned. Sometimes I’ll use the dental analogy. “If you have decayed tooth, you want the dentist to clear out all the decay before they put the filling in. So anything that’s there, I want you to say it out loud.”

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

In general, the therapist should not be too directive when the patient describes the trauma experience. It’s important that the patient be in control of the process of remembering the trauma and the feelings associated with it. Therefore, give the patient permission to approach the memories at her own pace and provide a calm and supportive presence. Imaginal exposure is not a conversation between you and the patient. Patients are sometimes reluctant to engage fully with the emotional aspects of recounting the trauma memory. Sometimes I’ve had people describe it in a lot of detail and it seems like it’s fine. And I realize they have cut themselves off from their emotions. It’s almost like they’re giving you the police blotters report, but without any emotion.
Remember that while anxiety is often a focus in PTSD treatment, any negative affect that the patient experienced at the time of the trauma, or subsequently, should be included.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

During the first imaginal exposure, the first revisiting of the trauma memory, the patient should be allowed to determine the level of detail with which she recounts the narrative of her trauma with minimal interruption from you. In subsequent repetitions in sessions, encourage her to provide more details about the trauma and to engage with the emotional content of the memory more fully through probes for more details about the event as well as emotional, cognitive, and physiological reactions that occurred during the trauma. And we’re going to discuss this in a lot more detail in later modules when we talk about hotspots.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

We explain to the patient that we’ll ask her to do an imaginal exposure—just what we described—and we’ll present the rationale for imaginal exposure.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Imaginal exposure will help in a number of ways. Repeated revisiting of the trauma helps process or digest the trauma. It helps organize it and make sense of it. I like the filing analogy. If you think about it, in our memories, we have files for different kinds of experiences or different memories. For example, we probably have a file for restaurant experiences. So, we have so much information in that file that we know when we walk through the door of a restaurant if we should seat ourselves or if we should wait to be seated or if we should go to a counter and order. We figure out if we should pay the server or pay at the counter or pay as we leave. We’ve got a number of experiences. So, it’s easy to file a new experience, walk into a new restaurant, and figure out what to do.
We don’t have files for traumatic experiences and so we don’t know how to file it. And when we avoid thinking about it, then that prohibits us from filing it. And so think about a real file cabinet. If you have papers on top that you haven’t filed, they’re going to be intrusive. Every time you open it, they’re going to fly out. They’re going to fall out. You’re going to have to go back to them. And so what we’re trying to do with this, by going over and over and over it—sometimes, they’ll say we’re making sense of a senseless situation and it helps us file it away. And when we have something appropriately filed, we can access it when we want to, but it doesn’t intrude when we’re trying to access something else.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Imaginal exposure will also help distinguish between thinking about the trauma and actually re-encountering it. Many survivors avoid anything that brings up feelings like those they felt at the time of the trauma. And if anything makes them feel that way, they feel like they’re in danger if they feel those feelings. So, for a lot of people, it really does almost feel dangerous to think about the trauma because it brings up those feelings. So, we’ll need to teach them to distinguish that thinking about it and even having those feelings is not dangerous. It’s not re-encountering the trauma.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Imaginal exposure will help with habituation so that the trauma can be remembered without intense disruptive anxiety. We need them to learn that thinking about it is not dangerous. And the longer and more often they stay with it, the more those feelings decrease. Imaginal exposure helps foster the realization that engaging in the trauma memory does not result in loss of control or going crazy. For example, some of my patients have felt like if they let themselves cry that they would never stop crying. Or some people describe, if you remember, in kid’s cartoons when the thermometer goes up and up and up until it bursts out the top. They almost think that their anxiety or distress is like that; that if they go there, it’s just going to go out the top and something terrible will happen.
And lastly, imaginal exposure enhances a sense of self-control and personal competence. When they feel that there is so much they can’t do or they need to avoid, they feel incompetent. And by doing it, even though it’s hard and maybe even especially because it’s hard, it helps enhance their sense of competence.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

For patients with a prolonged trauma, for example, that it’s a period of torture or several days of captivity or days’ long battle or multiple incident traumas, for example, repeated assaults, recurring childhood sexual abuse, multiple incidents of combat, you’ll need to establish which of the traumatic memories will be the focus of imaginal exposure. We call that the index trauma. Typically, the index trauma are the memories that are most intrusive and distressing at the present time.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

So, we will use our assessment of their PTSD symptoms and their current re-experiencing symptoms, for example, if you’re having flashbacks to what event, if you’re having intrusive thoughts to what event. Choosing a memory to focus on should begin during session 1 when you ask about the trauma history and continue in session 3 prior to beginning imaginal exposure. You want to make sure you’ve got the right event, you’ve got the index trauma.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

To ensure that the memory chosen is the one that’s most upsetting for the patient, ask her which memory is haunting her the most through intrusive distressing thoughts, flashbacks, or nightmares. In most cases, successful processing of the most disturbing memory will generalize to less distressing memories so that they, too, will become less distressing.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

If the patient is extremely anxious and uncertain about whether she can manage the worst memory, you can have her first choose a trauma memory that she feels she can manage. Then move up to the most distressing memory after the first memory ceases to elicit high distress. But I want to tell you that this is rare. They’re going to be apprehensive. They’re not going to want to go there. But almost all of our patients can. So I wouldn’t jump to this unless your patient absolutely refuses and say they’re not going to go through with therapy.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Sometimes, even after processing the most distressing memory, another traumatic experience continues to trigger high levels of distress. And in that case, proceed to using imaginal exposure with that memory after the first memory is much less distressing.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Once we start a memory, I want to finish that memory before we go to another one. So, even if in, say, the second session of exposure therapy, they say, “You know what? This one doesn’t bother me as much as this one.” At that point, I’m still going to want to finish. Since we started it, I want to finish this memory before we move on to another one.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

As soon as the patient opens her eyes after the imaginal exposure, we engage in processing. After the imaginal revisiting of the trauma memory, you’ll process the experience with the patient for approximately 15 to 20 minutes. The first question I ask when they open their eyes is, “How is that for you?” or “What did you notice today in going through the memory?” So, you want to ask an open-ended question to get their observations before you say anything.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

In brief, processing involves encouraging the patient to talk about her reactions to revisiting the trauma memory and to discuss feelings and thoughts that she may have about the trauma or its meaning in her life.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

The process of imaginal recounting of the trauma memory creates powerful opportunities for learning. It’s common for patients to emerge from imaginal and in vivo exposure with new awarenesses and insights. And in fact, that’s the goal of therapy.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

But sometimes, what’s obvious to the therapist is not obvious to the patient. So, we want to ask questions and make reflective statements to get the patient to see what we see. It’s not helpful to tell them. We want them to arrive at it. Asking the patient to describe and expand on these insights makes them more explicit. And she often begins to reevaluate and modify unrealistic views or expectations.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

It’s important that the patient not leave the session in great distress or with high anxiety. Treatment sessions should be planned so there’ll be sufficient time at the end of the session to help the patient alleviate her distress level.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

In cases where the patient remains very distressed, breathing retraining after the imaginal exposure may be helpful. But I’ve got to tell you again, this is very rare. I don’t think I have ever done it. So, don’t resort to it. We really want to work on an exposure paradigm for the patient. It’s also helpful to tell the patient that she may temporarily feel more upset after some imaginal exposure sessions, especially the early ones, and then relief after others.
Finally, it may be helpful to tell the patient that anxiety and distress during the imaginal recounting of the trauma memory reflect the beginning of emotional processing of the distressing memories, the beginning of healing from the trauma. Sometimes, I’ll use the analogy and, especially for women who have borne children, it’s just like they tell you in the early months of pregnancy: if you’re nauseous, that’s good. It means your hormones are in good shape. I’ll tell them if this is upsetting, that’s good. It means we’re working with the right memory and you’re accessing your emotions. So, that’s exactly what we want to happen.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

If the patient is very apprehensive about her reaction to early sessions of imaginal exposure, it’s fine if she brings a support person with her to wait and drive home with her after the session, although that’s generally unnecessary. I’ll also tell patients if they want to hang out in the waiting room—and I’ll point out a couple of different waiting rooms—to make sure that they feel okay before they drive home, that that’s fine.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Key points from session 3. Session 3 is where we begin imaginal exposure. In imaginal exposure, we ask the patient to go back in her mind’s eye to the time of the trauma and recount it out loud repeatedly, several times per session. And we’ll record it for homework practice.

After the imaginal exposure, you’ll process the experience with the patient for about 15 to 20 minutes. And in processing, we want to make new learning that occurred in the exposure explicit to the patient.

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