Exposure Strategies for PTSD Treatment

Although Posttraumatic Stress Disorder (PTSD) was originally codified in the DSM-III as an anxiety disorder, clinicians working with survivors know that the shame and guilt experienced by these clients are some of the most toxic and difficult emotions to work with. While it can be expected that following a horrifying trauma a survivor would experience terror, the shame or guilt associated with self-blame for the event entangles the mind.

In a recent study, Langkaas and colleagues (2017) hypothesized that in individuals with PTSD, the presence of these non-fear-based emotions would interfere with and predict poor response to exposure therapy for PTSD. These researchers compared exposure procedures with imagery rescripting, a procedure believed to be better suited for non-fear-based emotions. In exposure, the individual repeatedly and for a prolonged period revisits the trauma memory using imagery. In imagery rescripting, the individual revisits the trauma memory but rewrites the ending of the traumatic event by having the present version of the survivor enter the memory and correct his perceived culpability in the traumatic event. None of the hypotheses were supported. Exposure strategies were just as effective as imagery rescripting. The same level of impact on fear and non-fear emotions was observed. How could that be?  How could exposure help emotions like shame and guilt?

Cognitive Formulation of PTSD

PTSD can be thought of as a phobia to a memory that develops after a traumatic event. As a result, the individual avoids:

  1. the memory itself (thought suppression), and
  2. reminders or cues of the memory (internal or external).

When an individual avoids a memory, any attempt to review, organize, or recall details are halted. The memory becomes unavailable for the individual to gather meaningful information for the purposes of cognitive restructuring.

Emotions like shame and guilt are nourished by thoughts attributing responsibility, culpability, and agency to the individual.

  • In guilt, the individual believes he should have acted differently (e.g., said “No,” stopped the massacre, avoided the party).
  • In shame, the individual asserts that he should have physically reacted differently (not frozen, not had a sexual reaction, not given up) and that something unique to him brought about the trauma. (For example, he might have the thought, “I should have been able to stop the trauma,” or “The perpetrator chose me because I was different.”)
Strategy for Change: Exposure

To reduce or eliminate the experiences of non-fear emotions, such as shame and guilt, the individual needs to correct these unhelpful and inaccurate cognitions. The difficulty with using a Socratic approach to testing the cognitions is the inaccessibility of corrective data or evidence. For example, a man traumatized as a young child harbors the belief “I should have stopped the perpetrator.” This belief leads to guilt for not stopping the trauma that occurred. For years, family, friends, and professionals told him that it wasn’t his fault; he was a little boy. However, these kinds of words never led to meaningful relief and often led to further guilt.

To gain lasting relief, the man needs to consider the basic Socratic questions, “What is the evidence that it was your fault? What is the evidence it was not your fault?” The confounding factor in PTSD is that the evidence needed to correct the belief is found through deliberately considering the events of the trauma–the same memory the individual phobicly avoids. Further, meaningful correction of a belief requires extended review of this evidence and the ability to process the information. Logical thinking is paralyzed during extreme anxiety and the individual relies on avoidance as a coping strategy. Avoidance of the memory explains why the man does not come to the most logical conclusions: He was just a boy and had no power in the moment.  Because he avoids the memory, he has no evidence on which to develop a new conclusion.

The memory elicits such intense anxiety that the individual cannot systematically review and integrate data from the event. As long as the individual has the phobic reaction to the memory, correcting the belief will be difficult. Therefore, exposure can be a straightforward and efficient strategy for resolving PTSD symptoms and non-fear-based emotions.

Exposure Strategies
  • Habituation to the trauma memory allows for organization of the memory and extended time for reviewing the details of the event.
  • The extended time reviewing the memory, for the purposes of habituation, provides the individual exposure to the corrective information. In some cases, individuals return after the second or third exposure to the trauma memory and tell the therapist, “I was only five; there was nothing I could do!”

Without the phobic reaction to the memory, the individual can look at the cognitions associated with shame and guilt and correct them with the available evidence. In cases where the shame and guilt cognitions do not correct through the repetition of the memory alone, the therapist can draw the individual’s attention to the newly available data or ask well placed questions to correct the unhelpful and inaccurate belief.

Posttraumatic Stress Disorder brings chaos into a survivor’s life. A clinician can easily feel overwhelmed and confused by a survivor’s presentation, which is often complicated by shame and guilt. This reaction to the complexities of PTSD can lead the clinician to make unhelpful hypotheses and interventions. With an individualized cognitive formulation, the clinician can make sense of the chaos and collaboratively select a coherent, long-term strategy for change.

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CBT for PTSD