magical-markers asked: What does prolonged exposure mean in the context of PTSD? Relaxation training + repeated visualization of the trauma?
Based on the protocols I’ve read, I don’t think I would ever utilize relaxation for basically anything anxiety-related. It doesn’t provide any incremental benefit based on component analyses, and once more studies are done to assess for new learning rather than strict symptom reduction as the mediator/main outcome variable, it’s possible we’ll see that relaxation interferes with the mechanism of change associated with therapy, especially for exposure (i.e., new learning). I could go on for a while about that, so I’ll leave it there for now!
Now, exposure for PTSD completely depends on the individual and the nature of the trauma. Exposure for PTSD is usually seen as the most controversial because it involves inducing anxiety surrounding situations which were life-threatening, or invasive to an intense degree. You can think of situations that induce PTSD. Typically, they are among the most awful things you can imagine. People fear “re-traumatization,” which has never actually been documented despite many who commonly echo it as a concern despite no foundation in the literature.
"You’re going to force someone to relive their <trauma>?!"
On the surface, yes, but really it’s much more than that. It is learning that memories, no matter how horrible and traumatic, do not have to cage our present and future life. Most individuals with PTSD are suffering to an inexplicable degree. Avoidance does not work long-term, as pretty much anyone can attest to. As such, we need to move in the opposite direction by bringing the trauma closer so we can learn from it.
(I would also like to note at this juncture of my response that the dropout rates in exposure studies, a measure typically associated with the tolerability of an intervention, are no worse than for treatment studies looking at standard cognitive therapy without exposure, and are FAR BETTER than drug trials. So despite the sentiment that exposure is “cruel,” thousands of participants spanning dozens of RCTs might disagree.)
PE will pretty much always incorporate visualization. Typically that is where it will start. Eventually, the more intense you can make it, the better. If you can find physical images, video clips, sounds, locations where traumatic events occurred, etc. that can trigger the anxiety, then that would be useful beyond just visualization. Obviously this would be at the top of the fear hierarchy and not something you would do within the first few sessions of treatment. When creating a fear hierarchy, we are finding that having the individual list their most anxiety-provoking situation and then going beyond that may lead to a reduction in relapse months or years later.
For example: someone with OCD regarding contamination might fear touching a table top and then licking their hand more than anything, and then when they reach that level, you have them reach their hands into a garbage can and then eat their lunch. Or touch dog poop. Seriously.
This is tougher to do for PTSD because you do not have control over the anxious event as that happened in the past. So naturally you are limited by the stimuli available to you, and can only work with stimuli which serve as reminders rather than stimuli that are the actual fear situations themselves (compared to contamination in OCD, or an increased heart rate in panic, etc.)
So, like all exposure, it is getting them anxious and engaged in the situations/contexts which once induced avoidance, and then allowing new learning to take place. All in the absence of safety behaviors. So yes there is visualization, but there can be much more than that depending on the individual’s specific trauma event. It could involve talking with strangers, or going to a restaurant with your back to the door, or walking alone outside, or looking at images which are similar to the situation the client endured, etc.
Hope that helps!