Imaginal Exposure Protocol for PTSD: Processing Hot Spots in Trauma Memories

Barbara Rothbaum, Ph.D.

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

Highlights

  • Focus on only 1 hot spot per session.
  • Instruct the patient to recount that hot spot repeatedly.
  • Ask probing questions.
  • Work on hot spots until the final session.

 

Transcript

Video 4: the Hot Spots Procedure, Imaginal Exposure.
Remember we only work on 1 hot spot in each session. After we determine the beginning and the end of the hot spot we select, we can begin the 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.

Ask your patient to repeat the hot spot without pause between repetitions and to recount as many details as possible.

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.

Help your patient focus on the feelings, thoughts, senses—all the stimuli. This is the time for the therapist to ask probing questions to get all of the details. We want to dig deep into this slice of the trauma. Prior to this, I’d advise if your patient seems to be doing well with the exposure, get out of their way. Just let them talk if they’re doing fine. Now is the time to ask the probing questions to really get at every aspect of this memory. Have the patient describe every bit of relevant stimuli, every thought, every response, the fears.

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.

Examples: For childhood sexual abuse, ask for details, including “How big are you?” ”How big is he?” If it’s a combat trauma, describe every detail. For example, “Tell me exactly what position you were in.” I remember one example of a patient and as we were working on the hot spot, he had felt very guilty that two of his men had died and it was, he felt, his responsibility since he was the commanding officer. And in going through the detail, he said that, let’s say, Jones had been shot right away by a sniper. And even though he told Smith not to go out, Smith went to try to help Jones and then Smith was picked off. He was shot immediately. And my patient wanted to go and help them but he knew at this point, now, that there were two snipers and they were firing from different directions. And he was covered and that if he had gone out in any direction that he would’ve been shot. And by going over it and over it, he realized that there was nothing he could do, that he had told Smith not to go out and he had and he had gotten shot. And even though he wanted to go and try to help that it would’ve just meant he would’ve been shot, too. And as hard as that is, it does finally help relieve some of the guilt that there was something he should’ve done that he didn’t do.

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.

In processing, when patients are struggling—especially with feeling guilty or blaming themselves or I wish I had done this—once we’ve gone through it a lot and I feel like I pretty much know the answer, I will ask them, “Why didn’t you?” And then they can go through it in detail and, for example, the soldier in combat can say, “Because I would’ve been killed, too, and part of me realized that.” And as sad as that is, it does help relieve some of the guilt.

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.

Focus on the patient’s hot spots until each one has been sufficiently processed. Don’t get impatient and move on to another trauma memory until there’s a sufficient reduction of anxiety and distress in the first memory. The processing is where issues of guilt and blame and “I wish I would have,” etc. can really be discussed and worked on. We often refer to it as wearing it out, wearing out the memory. And you really want to wear it out before moving on to the next hot spot.

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.

This may take several sessions depending on the number of hot spots, the patient’s pace, the amount of time he spends listening to exposure recordings as homework, and the intensity of the trauma, how avoidant he is—all of this. Allow it to take the time that it takes. Just like we ask patients can they be patient with themselves, that it’s a process, and give themselves the time and space it takes, therapists need to be patient as well.

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.

Sometimes, the patient will give low SUDS ratings and they might appear minimally distressed even when focusing on a very distressing part of the memory. Usually, this is due to under-engagement in the trauma memory. In these cases, focusing in on the hot spot and asking the patient to describe this focused portion of the event in detail may increase the engagement in the SUDS, allowing finally for a reduction of the SUDS to occur.

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.

Focus on the hot spots until the final session, when you’re going to ask the patient to put the whole memory back together—to recount the entire memory again. When the anxiety associated with the hot spots has sufficiently reduced, then the hot spots work is completed. You’re going to have the patient return to focusing on and recounting the entire memory again, putting it all back together, like my patient who said it was like playing a long-playing record and those parts didn’t skip anymore.

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.

The key points from this video that we’ll focus on only 1 hot spot per session, starting with the most difficult. We’ll instruct the patient that he or she will recount that hot spot repeatedly without pause. This is the time for the therapist to ask probing questions to get all of the details. We want to dig deep into this slice of the trauma and continue to work on hot spots in all sessions until the final session. And ask the patient to recount the entire memory again in the final session.

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