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Exposure Therapy Advice/ Tips?

Thread starter #1
I've had 2 "little t" traumatic incidents that happened 4 years ago and 6 months ago really mess with my PTSD again and am currently in maximum possible avoidance mode.

I need to start doing exposure therapy again. Cos just trying to "force" myself to keep doing daily tasks is absolutely not working. I put off tasks for as long as humanly possible, then rush through them feeling miserable and then go back to avoiding everything asap.

So given that forcing myself isn't working, I need to do the therapeutic bit of exposure therapy.

I did exposure therapy with a T once, right at the beginning of my therapy journey. I wasn't diagnosed with PTSD yet, he wasn't a trauma T and I was told to "just try" exposure therapy.

It was an unmitigated disaster and I was acutely suicidal by the end of it. The therapist didn't realise that with PTSD you can just expose yourself to situations you find painful or traumatic and just dissociate completely, and experience zero "exposure effect" in terms of lowering stress levels over time. Those rules that you can only feel panic for so and so many minutes and then it starts abating... Those rules were made for normal people who don't have dissociative super-powers honed by years of childhood trauma.

At the time, I ended up walking away from it with the opinion that "exposure therapy is a nightmare and doesn't work". But years later, I realised what had happened and that exposure therapy for PTSD needs to be approached differently, with dissociation in mind.

I'll talk to my T about this when I see him next (in about 4 weeks) but I need to start doing some DIY practical exposure therapy at home re simple crap like "doing the dishes" and "not hiding in bed half the day".

I'm going to do a quick refresher course on exposure therapy and read up on the essentials to make sure I'm not approaching it wrong...

I'd be interested to hear people's advice/ tips re how to make exposure therapy work with PTSD tho. Any advice on how to get best results and avoid common pitfalls?

Thanks!
 
#2
I’m confused. Are you saying, that for you, exposure therapy is doing household tasks and forcing yourself out of bed? I don’t think that is exposure therapy.

However, I am struggling with that same thing. The way I am trying to stay afloat, is to do something that HAS to be done right away. (Such as fill out forms or pay for stuff related to school) The other stuff... Is not getting done.

I am working on therapy stuff as well, but we are focusing on attachment and developmental trauma at the moment. Using flash emdr. This sometimes makes getting other stuff done even harder because my younger parts just want to hide and take naps. And current me gets obsessed with research.
 

joeylittle

Administrator
#3
I'd be interested to hear people's advice/ tips re how to make exposure therapy work with PTSD tho. Any advice on how to get best results and avoid common pitfalls?
Something people often get mixed up: there's exposure therapy for actions/objects/places that create a fear response - and then there's exposure therapy as it applies to trauma narrative.

Both are useful.

If you haven't (or aren't sure if you have) really dealt with the narrative aspect of the little-t traumas that you're referring to, you'd want to start with that. And so long as you are confident with your symptom management tools (which I believe you are) - so that you can manage/diffuse a certain amount of emotional discomfort during the process, without ending up in a crisis - it's a fairly straightforward thing to DIY.

Dunno if that's helpful, let me know if you have questions about anything I've written.
 
Thread starter #4
Sorry if I've explained it muddled!

So, I wasn't thinking the specific PTSD type of exposure therapy... Where you try and expose yourself to the emotions connected to trauma.

I was thinking more of the classic exposure therapy for phobias and stuff like that. But with "PTSD awareness" so that it doesn't just end up as exposure-dissociation-exposure-dissociation with no actual shift in the anxiety or avoidance levels cos the dissociation is just blanking out the whole process.

And no, I don't think stuff like "getting out of bed" is classic exposure therapy content. But my brain is so hyper-avoidant atm... I'm basically actively avoiding anything other than sleeping all day. And having to force myself to do "anything" to try and cut through the avoidance. So I want to apply the classic exposure therapy techniques to those things. Cos I need to get out of bed and DO stuff.

I've been trying to use "sheer willpower" but it's just not working... or barely working... to a basically useless degree. So I figure using exposure therapy approaches is a bit more likely to yield useful results than the willpower method.

Just wondering if there is anything specific I should be doing to "process" the exposure events? Making sure I lean into the emotions? Journalling about it? Making a conscious effort to relax during exposure? Doing something soothing after each exposure?
 
#5
I think what you maaaaaaay actually be talking about isn’t exposure therapy but stress inoculation.

Doing something that’s stressful to you, which then causes you to dissociate... so you’re looking for a means to learn to do the stressful thing without dissociating as an end result, or worse, dissociation leading to dysreg, leading to rapid decomensation/suicidal ideation, etc.? Which means adding that stressful thing into your life in small quantities growing larger, each time -or- over time, improving your tolerance to it?

Exposure Therapy & Stress Inoculation are closely related... BUT exposure therapy actually removes the stress entirely, no more reaction to deal with, by chipping away at the trigger/stressor; rather than improving your tolerance to the stress that’s there.

Think of it like not having an anxiety attack at all, versus learning to be functional during an anxiety attack. Exposure therapy makes it so the anxiety never happens, whilst stress inoculation trains you to handle the anxiety better.

But my brain is so hyper-avoidant atm... I'm basically actively avoiding anything other than sleeping all day.
So if we’re looking at this from a PTSD perspective? Think StressCup. Avoidance as a coping mechanism for too much stress right now = sleep. Which means, if you don’t want to sleep all day? BEFORE adding more stress to your life, you’re going to have to find a handful of other coping mechanisms to deal with the existing stress. Lower the stress levels in your cup, before adding more stress. <<< Which is NEITHER exposure therapy, nor stress innoculation, but stress management. IE the core & ongoing issue when you have a stress-disorder.

A depression perspective, meanwhile, has the same end result (all day in bed), but a different cause/different means of dealing with. I can’t help with that one, at all, as I’ve never managed it.
 
#6
I was thinking more of the classic exposure therapy for phobias and stuff like that. But with "PTSD awareness" so that it doesn't just end up as exposure-dissociation-exposure-dissociation with no actual shift in the anxiety or avoidance levels cos the dissociation is just blanking out the whole process.
There are ways to manage this. As you know, exposure therapy is not about just jumping into the deep end and drowning the fog or other symptoms. This includes classic fears/phobias. The point is to dose out the exposure and gradually titrate up. It's also not just exposure to the trigger of the fear, but also the symptoms. In classic gradual exposure therapy the first thing that will often be worked on is symptom experience and management. One might be told to spin in a chair, breathe really fast, on purpose, with no trigger, to feel something like a panic attack and be ok with it. Then for the trigger exposure, it's gradual. Take a fear of flying. Going and hoping on a plane isn't the path. The first step might be imagining going to the airport, feeling a spike in symptoms, managing it, and then gradually increasing exposure. Next step might be watching planes in the sky. Then driving by the airport. Then driving by and parking. Then driving by parking and walking inside... you get the idea.

There is also a imaginal desensitization technique that I have tried. Basically, it's imagining the exposure (getting on a plane) and feeling symptoms and then imagining using tools to cope and those tools working and staying calm. Really seems to work for some people.
Systematic Desensitization to Stop Panic Attacks
I've been trying to use "sheer willpower" but it's just not working... or barely working... to a basically useless degree. So I figure using exposure therapy approaches is a bit more likely to yield useful results than the willpower method.
I'd suggest a different approach. Rather than focusing on the anxiety of the task, instead focus on the positive. Maybe breaking it down into small goals and rewarding yourself for reaching them. Give yourself permission to stay in your room for x amount of time if you wash 1 dish. Some people will focus on visualizing the goal and how good that will feel.

Another thing that helps me is a habit calander or even log on my phone. It works on a similar idea as fit bits. It gamifies a good habit. Over time, I will sometimes do a good habit just out of desire to not break the chain and pattern. It was developed by writers procrastinating their work. It works for some for other things too.

I'm fighting depression/avoidance/general symptom spike myself. Keep up the good fight to get through!
 
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Thread starter #7
So if we’re looking at this from a PTSD perspective? Think StressCup. Avoidance as a coping mechanism for too much stress right now = sleep. Which means, if you don’t want to sleep all day? BEFORE adding more stress to your life, you’re going to have to find a handful of other coping mechanisms to deal with the existing stress. Lower the stress levels in your cup, before adding more stress. <<< Which is NEITHER exposure therapy, nor stress innoculation, but stress management. IE the core & ongoing issue when you have a stress-disorder.
Yeah... I've been wondering about this... 😕
Cos if my brain is just sheer protecting itself using avoidance, then it makes sense that I can't cut through the avoidance. 😬

But, I think (hope) that my brain is actually doing this on auto-pilot from decades of ingrained PTSD avoidance and that by using the exposure therapy approach my brain will notice that it's actually making mountains out of molehills and that by dealing with the molehills that'll help stress levels drop.

Plus, by doing so much avoidance, tasks are just piling up and up and up, which is also creating massive stress/ filling stress cup, so just by reducing the avoidance and getting the basics done, I think that'll actually contribute to lowering stress cup levels.

Which I'm aware is kind of circular logic/ chicken and egg stuff. But I do think that the avoidance and tasks piling up is a large factor in what's causing problems with stress cup levels.

So I'm just going to have to gently try and ease myself out of that circular logic and hope my stress cup doesn't spill over while I'm doing it.

Exposure therapy makes it so the anxiety never happens, whilst stress inoculation trains you to handle the anxiety better.
And yeah, not sure which one I mean...

According to this: What Is Exposure Therapy?

Exposure therapy can include:
  • Graded exposure
  • Flooding
  • Systematic desensitization
And is thought to help in several ways, including:
  • Habituation
  • Extinction
  • Self-efficacy
  • Emotional processing
(I've removed the details/ explanations cos of copyright, but they're in the link)
So I'm not sure about where stress innoculation ends and where exposure therapy starts?

It's also not just exposure to the trigger of the fear, but also the symptoms. In classic gradual exposure therapy the first thing that will often be worked on is symptom experience and management.
That's a really good point, thank you!

Another thing that helps me is a habit calander or even log on my phone. It works on a similar idea as fit bits. It gamifies a good habit.
Thanks, I'll look into this. The "habit" part of my brain seems to have well and truly broken during trauma, but I've found the gamification element of new app approaches surprisingly helpful where other things haven't worked at all, so worth a try!
 
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#8
This article outlines how stress inoculation and exposure therapy can work in tandem: How to Manage PTSD Stress With Stress Inoculation Training

I look at it this way:
Stress inoculation lowers the stress cup levels so that more stress can go in without the cup overflowing and experiencing stress related symptoms. If my stress cup level is low, I can face crappy weather or as pile of dishes and it doesn't bother me so much. If my baseline stress level is high, YET another thing like crappy weather and a pile of dishes becomes harder, more stressful, so I am more likely to avoid it. One way to lower stress is re-framing, and there is some of that already occurring in your posts.

Exposure therapy lowers the likelihood over the long run that an event will cause stress in the first place, but can cause the stress cup to fill up in the short run.

You are at the place where your stress cup is overflowing, so that stress inocculation may work better to free you up to do more.
I've found the gamification element of new app
There are some cool habit calander apps out there that can be fun to "play." I hope you find the tools work well for you!
 
Thread starter #9
If my stress cup level is low, I can face crappy weather or as pile of dishes and it doesn't bother me so much. If my baseline stress level is high, YET another thing like crappy weather and a pile of dishes becomes harder, more stressful, so I am more likely to avoid it. One way to lower stress is re-framing, and there is some of that already occurring in your posts.
Yeah, I agree.

One interesting and counter-intuitive thing I've been finding is that cos I've been off sick from work since February, normal tasks are taking on a different stress load than they usually do. And it's not in the cummulative way ^^ stress cup stuff usually works.

For example, when I was working, something like doing the dishes was just 1% of my daily tasks/ daily stress load. So doing the dishes was an annoying chore, but I just did it and got on with the other 99% of tasks I had to do.

Since I've been home, tasks like doing the dishes might now be 20% of my daily to-do list... And somehow in my head they've now become THE DISHES.

And I think the same is true of a lot of worries/ fears/ anxieties/ etc. When I was working, there just wasn't time or headspace to deal with them... So I'd brush them in passing and that would be it. Now, there's more room for those issues and they're expanding to fill the available space.

So weirdly, some stressors (like work) can actually "shrink" other stressors (like dishes) in size and vice-versa.

Which is also why I'm hoping exposure therapy/ stress innoculation might work. Cos stress cup levels aren't quite as simple as 2 +2 = 4. So if I use exposure therapy to get at some of the core issues/ triggers underlying my avoidance, maybe my brain will focus on these and stop over-reacting to tasks which *should* be minor.
 
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Thread starter #11
Another aspect you might look at is ...something to liven up the day?
Heh, yup. I guess if I intentionally add in nice things that aren't survival-related, maybe my brain will realise that survival isn't all I'm doing atm.

So, I think I need to do exposure therapy/ stress innoculation around the depression thoughts and self-talk. Because I've been observing something weird:

When I'm in avoidance mode (hiding under the covers in bed) I can more or less actually get my brain to "shut up" for a while.

But if I get up to say, feed the cats or do the dishes, my depression brain doesn't say "Well done Sophy, that's the cats fed/ the dishes done!" Instead, it seems to get confronted with the topics cats/ animals and dishes/ housework and does a reverse thing of "So you fed the cats... Have you done anything else for them today?? Have you fed all the other animals?? You're being so useless and you should be doing so much more. What a waste of space you are." And similar thoughts for the dishes "What about all the other housework? And you realise that housework is just the easy stuff right? There's so many errands and chores you need to be doing and the heating in the kitchen needs to be fixed before autumn sets in, when are you going to do that?!"

So by doing tasks (cat food/ dishes) I'm not getting ANY positive feedback from my brain, instead I'm getting a deluge of scathing depression self-talk triggered by the sight/ thought of the cat food and dishes. So I end up trying to avoid these tasks because I know that horrible self-talk will follow.

So, I think one of the things that I need to do exposure therapy/ stress innoculation on atm are simply the depression thoughts and self-talk and the depression feelings.

Instinctively, I've just been trying to "push those things away". So when ever a depression thought arises, I try and make it go away, try and distract myself, whatever. And for a minor bout of depression, I think that approach works fine, because if you just shove it aside a bit, life usually takes over again and the bout of depression has passed.

But in a major bout of depression, there's too many of the depression thoughts, self-talk and feelings to be pushed "aside" anywhere. They're just everywhere, there's a flood of them. And the usual avoid/ distract/ move on technique isn't helping at all.

I think I need to really *sit with* all those shitty depression core beliefs (I'm useless, I'm incompetent, This will go on forever, Bad things will keep happening, I deserve to feel crap, etc) and stare them down. I have to stop running from them internally.

I think *this* is what I keep avoiding. Not the cat food and the dishes as such. But the barrage of negative thoughts and feelings that depression spews at me in connection to *anything*.

By running and avoiding, I'm giving the depression monster ten times more power over me than if I just sit still and mutter resignedly "Gimme all you've got... throw it at me... I'm a horrible person and everything's awful and always will be and we're all going to die and life is pointless and yadayadayada... Heard it all before... Haven't you got anything more impressive than that? Come on up the ante, let's settle this once and for all..."

Edit to add: I think this is why the "positive reinforcement" of habit creation hasn't been working for me. Because by taking an action (feeding cats/ doing dishes) I'm NOT getting any positive feedback - instead, I'm getting an onslaught of depression self-talk. With my brain in that pattern, habit creation can't possibly work. The only habit I'm forming is avoiding those things and going back to bed to hide.
 
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#12
But if I get up to say, feed the cats or do the dishes, my depression brain doesn't say "Well done Sophy, that's the cats fed/ the dishes done!" Instead, it seems to get confronted with the topics cats/ animals and dishes/ housework and does a reverse thing of "So you fed the cats... Have you done anything else for them today?? Have you fed all the other animals?? You're being so useless and you should be doing so much more. What a waste of space you are." And similar thoughts for the dishes "What about all the other housework? And you realise that housework is just the easy stuff right? There's so many errands and chores you need to be doing and the heating in the kitchen needs to be fixed before autumn setsin, when are you going to do that?!"
Ooooooh... you’re going to love (or hate ;) these! (Below)

I think I need to really *sit with* all those shitty depression core beliefs (I'm useless, I'm incompetent, This will go on forever, Bad things will keep happening, I deserve to feel crap, etc) and stare them down. I have to stop running from them internally.
Because one better than just flooding yourself with negative thinking and miserable feelings? You can actually go on the offensive with them.

Solving the problem: reframing negative thoughts
Negative thinking styles part ii: reframing negative thoughts


Primary cognitive distortions (negative thinking styles)
 
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