Imaginal Exposure Script: An Example
Barbara Rothbaum, Ph.D.
This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.
- The patient included information about the stimuli, her responses, and the meaning.
- She speaks in the present tense to help with engagement.
- She describes many points that will be important to discuss in the processing.
In video 7, I want to give you an example of an imaginal exposure transcript.
This is the case of an adult female sexual assault survivor that I treated a number of years ago. When she presented for treatment, she was 31 years old, married, Caucasian. She had a master’s degree. She presented for treatment about 1 year after a rape in her townhouse.
Her complaints were of nightmares, fear of being alone, avoidance of sex with her husband, hypervigilance, jumpiness, checking locks, decreased concentration, which was causing difficulties in school, and she was avoiding taking her dogs for walks after dark, being downstairs alone, or discussing the assault with anyone.
So, this is a transcript of her imaginal exposure narrative. I should warn you, it does have some upsetting material in it.
I see this person in the doorway of the stairwell and he seems to be rushing at me. And my heart’s pounding. I’m really surprised and I know I’m really in trouble. He has this thing at my head and he says if I scream—which I don’t because I’ve got fingers practically down my throat—that he’ll shoot me. He says, “Where did your husband go?” And I say, “Just out to do something very quickly. He’ll be right back.” And he says, “I’ve got my buddy waiting for him.” And that really scares me because it seems like now this is some type of horror story or something that we’re both going to be hurt. He says, “Get on the bed,” which again scares me. I didn’t expect that. It’s the first time I suspect rape. So, I get on the bed. I don’t see any choice, any way to escape. I think there’s somebody downstairs. He whacks me across the face and he says, “Don’t scream anymore.” I think this man is really dangerous. He can really hurt me and I have to be careful. So, I have to figure out how much anything I try to do is going to provoke him and not let it get that far. He’s pushing too low and I feel burning, sharp cutting, and then it goes in. And I don’t really feel it after that. Just like movement. He says, “When I’m done with you, my buddy is coming up.” That’s just another terrifying moment. I want to get out. I can’t have that, another person going to hit me. I’m saying, “No, no. Please don’t hurt me. No, no.” And I hate it. I hate whining. I hate myself, hearing myself say it. I wish I would stop. It’s like I can’t make myself stop. He comes off of me and says, “Kiss it,” which I don’t want to do. My mouth’s bleeding and it hurts. It just looks evil and I think it’s dirty. And I don’t want to do it. But he pushes me down and I’m afraid I’m going to be hurt. So, I just do it. I’m shaking now. It’s cold and I’m embarrassed. It’s very peculiar. It’s like I’m again suspended and I’m new to my bedroom with someone I don’t know. It’s like the same feeling when you dream you’re at work but you’re not dressed correctly like you wore your pajamas to work or something, sort of a little panic and embarrassed, and you don’t want anyone to see you.
Those were excerpts from her imaginal exposure. And you can hear that it’s got a lot of the information we want included.
We want information about the stimuli and she includes that. You want information about responses and she includes that. I think she says, “my heart’s pounding” at one point. And you want information about the meaning. And she has a lot of information about the meaning. “Now, I think it’s really dangerous.” “There’s someone downstairs.” “They’re going to attack my husband, too.” “We’re both going to be hurt.”
And again, in therapy, we’re going to repeat this over and over again every session. These were just excerpts from her narrative and we’re going to repeat it session after session.
Some key points from this video. In this example of an imaginal exposure narrative, the patient included information about the stimuli. “It looked dirty.” “It looked evil.” Her responses: “I could hear myself screaming.” And the meaning: “Now, I think this is really dangerous.” She speaks in the present tense to help engagement. She describes many points that will be important to discuss in the processing.
More PE presentations
- 8 Myths About Exposure Therapy
- Addressing PTSD Emotional Avoidance and Anxiety Sensitivity: Tips for Therapists
- Assessing PTSD: Measurement-Based Therapy
- Breathing Retraining in PTSD: A Practical Exercise
- CBT for PTSD: Basics and Rationale
- CBT for PTSD: Summary
- Constructing the In Vivo Exposure Hierarchy for PTSD Therapy
- Imaginal Exposure for PTSD: Emotional Processing Preparation and Rationale
- Imaginal Exposure Protocol for PTSD: Processing Hot Spots in Trauma Memories
- Implementing Imaginal Exposure: Revisiting the Trauma Memory
- In Vivo Exposure Therapy for PTSD: The Essentials
- Increasing Emotional Engagement in PE Therapy for PTSD: Addressing Under-Engagement and Homework
- Managing Comorbidities in PE Therapy for PTSD
- Mechanisms of PE in PTSD: Emotional Processing and Cognition Modification
- PE Therapy Sessions: Structure and Main Components
- Preparing Clients for PE: First Steps
- Processing Emotional Hot Spots for PTSD: Introduction
- PTSD from a PE View: The Fear Structure, Trauma, and Recovery
- PTSD Treatment with Exposure Therapy and Virtual Reality: Tips for Therapists
- Self-Care for PTSD Therapists: Developing Tolerance for Patient Distress
- Understanding DSM-5 Criteria for PTSD: A Disorder of Extinction
- Using PE to Overcome Fear: 4 Cornerstones