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.
- Deborah linked the lowest level of anxiety with the attempted rape when she was a teenager.
- The next highest was the distressing things she was exposed to as she traveled with her combat unit.
- Higher still was the recent attempted assault by her supervisor.
- 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.
Looking for practical everyday tools? This print-friendly handout is just what you need. Click on the following link to download the PDF:
Exposure Work on Trauma Memories
This handout is a summary for therapists who choose to use exposure therapy to help clients process and reduce the impact of traumatic experiences. It provides an overview of the exposure work approach and offers key considerations for therapists. Exposure work involves systematically confronting and engaging with traumatic memories safely and carefully. Therapists are encouraged to collaborate with clients in developing a prioritized exposure hierarchy, working toward events with the highest levels of distress and significance. The handout highlights different exposure methods, such as written exposure, oral communication, or recordings, and emphasizes the process of written exposure in detail. Therapists guide clients through writing, reading, revising, and increasing emotional engagement in their accounts of their experiences. The importance of creating a supportive and nonjudgmental environment and recognizing differences between traditional and ACT-based exposure are also emphasized. Therapists are reminded to adapt approaches to meet each client’s unique needs and provide a safe and supportive environment throughout the process.
Instructions
This handout provides an overview for therapists who aim to use written exposure work for trauma memories with clients. Start by explaining the purpose and benefits of exposure work in processing and reducing the impact of traumatic experiences. Collaborate with the client to develop an exposure hierarchy based on distress levels and prioritize events for discussion. Consider the client’s preferences and strengths when selecting the exposure method, such as written, oral, or recorded. Describe the process of written exposure, including writing in detail about the traumatic event, reading it aloud, and revising it for increased emotional engagement. Progress through the exposure hierarchy, ensuring a supportive environment and guiding the client through intense emotions. Differentiate traditional exposure from ACT-based exposure, emphasizing acceptance and living meaningfully. Adapt the approach to meet each client’s unique needs, providing a safe and supportive environment throughout.