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Exposure and Visualization Therapies

Jamie Marich, Ph.D., LPCC-S, LICDC-CS, RMT, edited by C. E. Zupanick, Psy.D.

Many approaches for healing trauma incorporate an element of exposure therapy. Exposure therapy has been around for many years. It has been successfully used to treat fear-based disorders such as phobias, and PTSD. Exposure therapy involves the gradual exposure to the feared object, memory, or other stimulus, simultaneously paired with deliberate relaxation. A well-trained, trauma-informed practitioner will make sure that you are sufficiently stable and well-prepared before attempting such an approach.

therapy sessionVisualization techniques and imaginal exposure exercises, sometimes called guided imageries, have been used for many purposes. With respect to trauma, stress inoculation training (SIT) and systematic desensitization are well-known approaches that have withstood the test of time. The SAMHSA registry lists numerous, manualized treatment models that incorporate some elements of guided imagery or visualization. Here we highlight just a few.

Prolonged Exposure (PE) Therapy

Prolonged exposure therapy (PE) is form of cognitive-behavioral therapy. It is a modern day version of a well-established type of therapy called exposure therapy. On the SAMHSA registry, PE is described:

Prolonged Exposure (PE) Therapy for Posttraumatic Stress Disorders is a cognitive-behavioral treatment program for adult men and women (ages 18-65+) who have experienced single or multiple/continuous traumas and have posttraumatic stress disorder (PTSD). PE has three components: (1) psychoeducation about common reactions to trauma and the cause of chronic post-trauma difficulties, (2) imaginal exposure (also called revisiting the trauma memory in imagination), repeated recounting of the traumatic memory, and (3) in vivo exposure, gradually approaching trauma reminders (e.g., situations, objects) that are feared and avoided despite being safe. Standard treatment consists of 8-15 sessions conducted once or twice weekly for 90 minutes each. The duration of treatment can be shortened or lengthened depending on the needs of the client and his or her rate of progress.

PE has enabled people to confront the source of their trauma-related symptoms. However, some people find PE to be too intense and uncomfortable. An alternative is Traumatic Incident Reduction, which is discussed next.

Traumatic Incident Reduction (TIR)

A newer version of exposure therapy on SAMHSA's registry is Traumatic Incident Reduction (TIR). TIR harnesses the power of visualization. In other words, exposure to the feared stimulus is done in the mind's imagination. The summary of TIR as offered on the SAMHSA registry explains:

Through sessions that usually run between 90 and 120 minutes, the practitioner facilitates the client's examination and resolution of a past trauma. Depending on the incident and the symptoms experienced by the client, resolution may be achieved in one or two sessions, or it may take repeated sessions for clients who experience residual distress related to the incident. Each TIR session begins with an assessment step, in which the client identifies the most significant item to be addressed during the session. This item can be a descriptive item, which describes a particular traumatic incident, or a thematic item, which describes a particular negative feeling, attitude, or thought. If a thematic item is selected, the negative feeling, attitude, or thought is used to identify specific incidents for resolution. This step is followed by a viewing step, in which the client examines the incident, including aspects such as the time and duration of an incident, awareness of and connectedness to each incident, and a verbal report of the incident. At the completion of the session, it is expected that the client will be able to talk calmly about the traumatic incident with a sense of autonomy and without a return of the symptoms caused by the incident.

Narrative Therapy

Narrative therapy is rapidly gaining popularity. It is considered to be an emerging approach by SAMHSA. Narrative therapy incorporates both cognitive and exposure principles. In narrative therapy, clients are guided through a process of retelling their stories in order to process the negative memories. The use of storytelling as a healing mechanism has been used throughout history in cultures around the world. Interestingly, the most popular folktales, across different cultures, typically contain an element of recovery from some trauma or injury. The effectiveness of narrative therapy, when considered within this historical and multicultural context, can certainly be appreciated.