Implementing Imaginal Exposure: Revisiting the Trauma Memory

Barbara Rothbaum, Ph.D.

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

Highlights

  • Review the start and end points of the narrative with the patient before you start imaginal exposure.
  • Remind the patient that once they go through the memory, you’ll ask them to start again.
  • If the patient is doing fine, let them talk. Only interrupt for a SUDS rating.
  • You can offer encouragement at that point.
  • Asking “What’s happening now?” gets them back into the exposure.

 

Transcript

Video 5: How to Implement Imaginal Exposure.
The standard instructions for imaginal exposure are to go back in your mind’s eye to the time of the trauma. And I refer to the trauma, but as we’ve said before, always use their words. So, go back in your mind to the time of the attack or the assault or the accident—whatever they call it. Recall the memory with your eyes closed. Describe the trauma as if it is happening now. I will often tell people, “We want you to have a foot there in the memory and a foot here, in the present, in my office.” Engage in the feelings that the memory elicits.

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.

Describe the trauma memory in the present tense. Recount as many details as you can, including events and thoughts and feelings. Repeat the narrative as many times as necessary in the allotted 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.

Explain the imaginal exposure procedure to the patient. It’s typical for a patient to have some trepidation. If they weren’t nervous about it, they wouldn’t have PTSD. Reassure her and continue to present the following explanation: “I’m going to ask you to recall the memories of the trauma.” You should have already determined the start and the end points of the narrative. So, review those with the patient.

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 best to start the revisiting at a point in the memory that’s a little bit before the trauma actually occurred so that you have a chance to enter the image and get connected to it. So, I want you to begin your recounting of the trauma at a point that’s at least a minute or two before you realize the situation is getting bad or frightening. You will then go through recounting the trauma up until the danger is over or you feel safe again or you’re out of the situation. Remind the patient what was decided as the beginning and end of the trauma and adjust those points slightly if she asks for these adjustments.

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 best for you to close your eyes while you do this, so you wouldn’t be distracted. I’ll ask you to recall these memories as vividly as possible and to picture them in your mind’s eye. We call this revisiting the trauma memory.

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.

What I would like you to do is describe the experience in the present tense as if it were happening now, right here. I’d like you to recount aloud what happened during the trauma in as much detail as you can today. And we’ll work on this together.

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 you start to feel uncomfortable and want to stop or avoid the memory by leaving the image, I’m going to help you stay with it. It’s important to stay with it. From time to time while you’re revisiting the trauma, I’ll ask for your SUDS level on the 0 to 100 scale we described previously. Please just try to answer quickly with the first number that comes to mind and describe how you feel here today sitting in this chair and don’t leave the image.

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.

Because it’s important that we stay in the imaginal exposure for a lengthy period of time, when you finish recounting the trauma, I’m going to ask you to start all over again from the beginning without any pause. We may do this several times today within the session and how many times depends on how long it takes to go through the memory. The more, the better. It’s important that you don’t push the memories away—even if they’re painful. Remember memories are not dangerous—even if they feel bad. This is not a conversation between us. It’s you revisiting and recounting aloud your own memory. So, I wouldn’t say much in response to you until your imaginal exposure is over. But we’ll have time afterward to talk about it and process your experience with it.

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 therapist’s involvement during the imaginal exposure partly depends on how the patient is doing.

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 doing fine, let them talk and stay out of their way. The best thing to do is just let them go if they’re doing well. Only interrupt them every 5 minutes for a SUDS rating. It’s fine to offer encouragement at that point with something like “You’re doing great. What’s happening now?” That gets them right back into the exposure.
Express empathy with the client’s distress, but keep your comments to a minimum.

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 client is very distressed and crying, you may want to periodically reassure them with something like “You’re doing great,” “Stay with it,” or “This is exactly what you need to be doing.”
If the client becomes too distressed to the point that they’re not learning, you may conduct the revisiting with the client’s eyes open and/or use the past tense. We’re going to talk about under-engagement and over-engagement in future modules.

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 therapist can titrate the client’s emotional response if it’s really necessary, but it probably isn’t in most cases. You can probe for thoughts and feelings to encourage emotional engagement if they need more engagement.

If they get stuck, you can always ask “What’s happening now?” to keep them moving.

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.

Always allow sufficient time after the revisiting to discuss and process the experience.

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.

Some therapeutic comments during imaginal exposure include: You’re doing fine. Stay with it. You’re doing very well. It takes courage to stick it out. Stay with your feelings. Stay with it. You’re doing exactly what you need to do. I know this is difficult. You’re doing a good job.

Stay with the image. You’re safe here. It’s okay to let go of the feelings. My favorites that I use most often: “Good job,” “Stay with it,” and “What’s happening now?” That keeps them moving.

Key points from this video: You should have already determined the start and end points of the narrative. So, review those with the patient before you start imaginal exposure. Remind the patient that once they go through the memory, you’ll ask them to go immediately back to the beginning and start again.

If the patient is doing fine, let them talk and stay out of their way. Only interrupt every 5 minutes for a SUDS rating. It is fine if you want to offer encouragement at that point with something like “You’re doing great. What’s happening now?” That gets them right back into the exposure.

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