Prolonged exposure t couldn't answer a simple question

[Dana1010]

I just completed my second session in a 12 week prolonged exposure trauma therapy program.
We were discussing the in-session, imaginal exposure and the real life (in vivo) exposure "homework" I would be doing.

So I said: Going to the supermarket and waiting in line is somewhat triggering. Though I "expose" myself to this everyday, the anxiety it produces never seems to go down. So if this continual exposure does not work to reduce triggering, how are these exposure assignments you are giving me any different?

She basically went in circles and couldn't give me a straight answer.

Another thing: She has me doing in vivo homework already before doing any imaginal exposure in session. I said I found this odd, since I would think that in vivo would be more intense, and I would need imaginal training first. She said not everyone feels that way (really???), which I found odd.

So I am basically asking if anyone here can explain: (a) If exposure works to lessen triggers, why has it not worked already for me, like with the supermarket example?

And (b) What is up with the in vivo before imaginal exposure?

 

[Deleted member 37474]

I was having triggers at a school that I go into three times a week for work. What I found is that you have to face the triggers not just experience them. One day, when it was really bad, my friend from here, coached me through it. She made me describe the differences between the hallway and the hallway from my trauma. We discussed the wooden door and what its function is in a school. The temperature.. just needed to expect that. Since that day, the school hasn't been nearly as bad of a problem for me.

 

[Justmehere]

It has to be graduated exposure.

In vivio or imaginal, doesn't actually matter that much. She's right about that. What matters is that it's graduated exposure.

For example, with the grocery store, it would start with perhaps the process of getting ready to go to the store. In vivi or imaginal.

Not actually being totally physically at the store where symptoms and exposure is the highest. Or imagining being at the store. It starts where any sign of anxiety or symptoms starts and works from there.

What you have been doing on your own isn't likely graduated exposure therapy. That's probably why it's not working.

 

[Friday]

It has to be graduated exposure.

This.

The trick is that your SUDS level never gets to the point of being triggered. Ever. So it's very much a frog boiling in water. It matter if you throw the frog into boiling water 10,000 times. It will hop right out every time. Put the frog in cold water and gradually increase the heat so that they acclimatize? Voila. They don't hop out.

She said not everyone feels that way (really???), which I found odd.

Very much true for me. Here's why: It's easier to control my physical environment than my thoughts.

I can get up and physically walk away, or even before that, note that I'm starting to spike sooner than expected & back off before I've even gotten to the level I'd planned on. The control facet is far easier for me to manage.

The only time I do imaginary stuff is when I can't even think about XYZ (the furthest point from ABC, the actual trigger or stressor) without my distress spiking uncontrollably. So I DO think about it. In bare flickers, with great distance in between them, and coping mechanisms up the wazoo employed before and after. Until I can manage XYZ, and then I start there. Flirting along the edges of a thing, only needing to monitor my reactions.

Imaginable things are infinitely more painful & more difficult for me to manage than physical exposure. Although they a stellar way to kick off several hours of flashbacks & ruminations. So I use them very sparingly, and with great caution.

 

[EveHarrington]

I'm glad @Justmehere and @Friday mentioned graduated exposure.... I've done self-exposure therapy myself and by chance (luck?) it was graduated...I'm guessing this is why (in part) it was successful. (Even if I didn't have the benefit of therapist guidance.)

 

[Dana1010]

What I found is that you have to face the triggers not just experience them.

Can you describe in more detail what you mean by "face" them? In what way does this differ from experiencing them?

Imaginable things are infinitely more painful & more difficult for me to manage than physical exposure. Although they a stellar way to kick off several hours of flashbacks & ruminations. So I use them very sparingly, and with great caution.

I just don't see how, for one example, personal contact with someone who looks and acts like "you-know-who" in real life could ever fail to kickoff the several hours of flashbacks and ruminations. That is the whole reason I avoid real life exposure, so I don't really get this.

 

[kilted]

The SUDS scale etc is a crude attempt to look at stress hormone levels. THe reason for this is that there's an optimum level f these hormones that stimulates neurogenesis (brain rewiring). If there's no stress (ie complete avoidance of the stress trigger) then there's no stimulus for new brain development (learning). Too much stress and neural connectivity reduces so no new learning there either.

This is why SOME stress is a good thing for us, unfortunately that level of stress is much lower than many people experience in normal life.

If you keep exposing yourself to a situation that your body perceives as highly stressful, then the high levels of stress hormones mean the body doesn't learn that the situation isn't stressful......the response doesn't reduce. This is where other techniques using calming mantras, visualisations, cognitive messaging etc work.... one exposes to the stimulus using NEW ways of "being" in the situation. This is different to just going into the situation again and again.


It sounds like your therapist doesn't understand the neuroscience behind exposure therapy.

 

[joeylittle]

I don't know if this will be useful - but exposure therapy in trauma work generally addresses the trauma narrative, first. Working on associated experiences that may be triggering would then follow.

Have you done any exposure work using your trauma narrative, @Dana1010?

 

[Friday]

I just don't see how, for one example, personal contact with someone who looks and acts like "you-know-who" in real life could ever fail to kickoff the several hours of flashbacks and ruminations. That is the whole reason I avoid real life exposure, so I don't really get this.

Because that's not what you do. That's just throwing the frog in boiling water. You step back many many many steps, and come at the all the individual pieces that make up the stressor, first.

Let's just use the triggered while standing in line example for a moment. How many aspects of that could you come up with? Maybe a few dozen parts that suck about it? Some that aren't even directly related to the line, but definitely go into why lines suck? Each and every single one of those parts would get chipped away at, first. Some of those parts? Are actually going to have a solid dozen pieces of their own to break down. So that's what you do. You just keep working your way down the list of badness. Chipping away.

Sounds like it might take a long time? It can. Some of my hardest stressors and triggers took years to sort out. Others? Had just as many pieces, but the whole process was done inside of a few weeks. My average length of time, is generally a few months. Everyone is different. And, IME, every stressor & trigger is different. But it's the same process.

 

[Suzetig]

Very simply, what you're doing when you go to the supermarket isn't therapy, exposure or otherwise. Exposure therapy works by helping you process your experience which means physically, emotionally and psychologically feeling the impact, understanding the ways it affects you and being able to reset your pattern in that situation to know that you are in fact safe there.

In going to the supermarket I'm guessing you go, fight the panic or anxiety and get the hell out of there as soon as possible? Exposure therapy might have you stay in the supermarket line for longer, identify the sensation in your body etc and do some grounding or visualisation to expand your zone of tolerance there. It's not just about putting yourself through the situation over and over again - all that does is keep triggering you.

 

[Rumors]

I have found that as I have learned to look at it, sit with it, and then process it is when I am most successful. If all I do is spew the the trauma story from the lens of the victim and then run from it, all I am doing is reliving it with the same fear I felt when it happened. I have to be mindful of the process and see what happened through my adult perspective and not through a 4 year old perspective. That is sitting with it. Then, once I can see it for what it is, I am able to process it. It sucks, it's hard, it has taken me a very long time to learn to be mindful and stay present.... it takes practice and work.
Best wishes! I hope you are able to work through this.

 

[Deleted member 37474]

Can you describe in more detail what you mean by "face" them? In what way does this differ from experi...

I haven't been in therapy as long as some of these other posters, so I don't know the correct wording involved and my triggers in my example may not be as strong as what you are experiencing, but what I meant is instead of just seeing the hallway and feeling a sense of panic and running through it to get to the room (experiencing it), I would take a moment (actually took a picture on my phone and sent it to my friend) and she messaged with me about it ("facing" it). She helped me realize why it was not that hallway from 1992 by having me state the differences and this pulled me back into reality. Then the next day I went to the school, I would start in my head about how and why this is just a school hallway before I got to it.