Re:Exposure and retraumatization

Sandra:

I did forget to mention that there is something of a graduated hierarchy built into doing exposure therapy by our method. We start with a first easy (well, medium difficult is a better descriptor) in vivo exposure as homework, usually assigned in session 2. In vivo exposure at this level is so reliable that, if the patient does it the way they are instructed,it almost never fails to result in noticable within-session and across session fear reduction. So, they usually have an initial "success experience" with exposure before beginning the imaginal exposure.

The first time we do imaginal exposure, we give them standard instructions about present tense, first person, etc., etc., but in fact we give them control of where they start, when it ends, how much detail, etc. Once patients have gotten their feet wet, we then start helping them to focus more on greater engagement with memory, recounting details, probing for thoughts and feelings that occurred during the trauma etc. After about four sessions of telling the story from beginning to end, we usually shift to working on specific segments of the memory that are particularly distressing. This is termed working on "hot spots." By this point, patients can usually tell most aspects of the story without extreme levels of distress, until they hit one of these hot spots. So we then conduct repetitions just on the hotspot segment until distress reduces and then tackle the next one and the next one.

If the person has a history of multiple traumas, we start with the one that they describe as being the most distressing to them at the time. This is usually gaged in terms of which trauma is most recurrently represented in the re-experiencing symptoms. After completing work on that memory, we will then pick a second memory following similar criteria. In other words, now that we've reduced re-experiencing symptoms and distress related to memory 1, what event (if any) continues to bother you the most currently. Usually, we find that tackeling the top one of two, maybe even three, is usually enough.

Now, here I'm going to make the "clinical disclaimer." I can't say with any confidence that these kind of details make any difference at all. These are the procedures we use and we know that these procedures work. We haven't done the kind of parametric and dismantling research that would need to be done to establish whether or not such things make any real difference. Other research groups do it slightly differently. For example, Issac Marks' group starts with the imaginal exposure for about four sessions and then shifts exclusively to in vivo exposure, which is done in session and as homework, whereas we rely almost exclusively on homework for completing in vivo expousre. It is a rare case of PTSD where we actually assist patients with in vivo exposure. With PTSD, we've just not yet found a significant need for this. Whereas with OCD and phobias it is a substantial part of the treatment. Again, I don't know how much difference these procedural variations make in the big picture. I suspect some of these things are a bit more important than others, but I doubt any of them would either make or break the therapy.

As for eye movements being a way to keep the therapist from interfering with the patient's processing the memory, that's an interesting hypothesis. If that's the case, then I personally have no need for learning EMDR. I'm usually so intensely involved in hearing the story that I don't really have a lot to say. It is usually the case that anything I might have to say can easily be delayed until after we have completed the exposure. And even then, patients more often then not come up with far better insights than I have to offer. I know that empirically exposure therapy works and, theoretically, this approach to makes the most sense. So from my frame of reference, my therapeutic task is help the patient stay on task. Given that mind set, it's usually pretty easy to stay out of the way of the patient's processing of the memory.

Replies:

Re:Exposure and retraumatization, by Sandra Paulsen Inobe, PhD, 02/10/03 Disseminating exposure therapy, by Cahill, 02/10/03 Retelling the Story, by Sandra Paulsen Inobe, PhD, 02/10/03 Re:Retelling the Story, by Cahill, 02/10/03 Re:Retelling the Story, by Sandra Paulsen Inobe PhD, 02/10/03

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