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PTSD Questions & Answers
Joyce Boaz & Dr. Frank Ochberg, M.D.

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Recovery: Exposure Therapy

Q: Dear Frank, Can you explain exposure therapy? A support pal is considering doing EMDR with a therapist and wants to know more about it.

A: Dear Joyce, Exposure therapy refers to many different techniques that mental health professionals use to help people overcome symptoms of PTSD and related conditions. The symptoms include anxiety, avoidance, flashbacks, and phobias. In some cases, the client has been afraid of objects or conditions that never caused them physical harm - like spiders or heights or public speaking. In other cases, the client is terrified of her or his own memory, usually of an event that occurred and that re-occurs in dreams or in vivid recollection.

Exposure means that the therapist gains the client's confidence and manages to have them encounter the object or the situation that they dread, but this is done in ways that enable the person to experience mastery, overcoming the emotion of terror or disgust. Usually it requires lessons in "self-soothing" so that relaxation is achieved and sustained while fearful stimuli are experienced. There are two radically different schools of thought about experiencing dreaded stimuli. One school recommends creating a hierarchy from minimal to maximal stimulation, taking small steps to advance from mild to major stressors. A woman who was mauled by a large dog and who cannot go near a German Shepherd without collapsing in a state of terror begins looking at pictures of puppies. She does this with a trusted therapist near by. She breathes slowly and steadily. She is congratulated and encouraged. A week later, she looks at pictures of a medium sized dog. Eventually, she spends 20 minutes near a barking dog behind an electronic fence. In this approach, she never experiences terror or horror. She moves through successive approximations from tolerable exposure to major confrontation. The psychologist Joseph Wolpe emphasized pairing relaxation training with this climb up a ladder of carefully arranged rungs, one small step at a time. He called it "reciprocal inhibition," since relaxation was paired with stressful stimulation. It worked for phobias and fears - but it didn't always last very long. Psychiatrist Isaac Marks discovered that staying in the presence of a dreaded stimulus for 40 to 45 minutes caused great anxiety, but eventually the fear response ended on its own. That was called "flooding." If you didn't drown in the flood of fear, you came out of the session with a cure that lasted. But this technique required considerable courage - courage on the part of the patient and the doctor! To prepare for a session of living with your worst fear, you needed to trust the therapist and you needed to learn ways to reduce the physical and mental components of anxiety.

In the 30 years following the creation of the PTSD diagnosis, and the recognition that millions of survivors were not only anxious, but were also prone to unwanted memories of dangerous, deadly and degrading encounters, several new techniques of exposure were invented. EMDR requires the client to follow a moving finger while holding a fearful image in the mind. Ochberg's Counting Method requires the client to silently recall a dreadful event while the therapist counts to 100. Virtual reality techniques take the client to scenes of war or disaster, while in the sanctuary of a safe place. The exposure in these situations is to a memory or an image of something fearful, but that exposure is coupled with something that is soothing or comforting or predictable. The client tolerates stress and fear is extinguished.

Exposure is NOT psychoanalysis - in which unconscious fears are brought to the surface and exposed. Exposure is NOT cognitive behavioral therapy - in which thoughts are modified from self-stigmatizing references to self-confident references. Exposure IS an encounter with an object or an image or a memory that evokes powerful negative emotion, but that encounter is made tolerable. And once a person can tolerate a trigger, the trigger loses its power to deliver a bullet. The stress response is disarmed.

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