Graduated exposure valuable in addressing trauma

Many times survivors of trauma present as angry, depressed, anxious, passive, or otherwise unlikeable. Counselors too often dismiss them as uncooperative or unmotivated, when these behaviors most often are not conscious choices. Rather, the unwanted behavior results from the clients' “survival brain” responding to cues of previous traumatic experiences. As in my previous column, I am avoiding the more precise terminology used by brain scientists and am instead using language that is easy for clients to understand.

Therapeutic techniques that help the “intellectual” brain are often less helpful to the survival brain. Suggesting that clients are making a conscious choice to engage in offensive behavior, when they are not, can irreparably harm the therapeutic relationship. This column will discuss a therapeutic technique that has proven helpful in these situations.

Our intellectual brain responds well to cognitive therapy, narrative therapy, solution-focused therapy, and a host of other talk therapies, because our intellectual brain thinks in words. But talk therapy is of less direct use to our survival brain, since the actions that it drives are often unchosen and without conscious thought. The most helpful interventions here are often behavioral.

Our survival brain needs to “learn” more helpful choices through experience. While a wide range of considerations influence our intellectual brain, our survival brain has only two goals: to pursue pleasure and to avoid pain. Any behavior that provides a reward likely will be repeated. Any behavior that provides an immediate punishment likely will be avoided.

The survival brain has no long-term memory, or sense of reason. When injecting heroin helps increase pleasure or decrease pain, the survival brain encourages repetition of that behavior. The long-term consequences of this choice stand outside the scope of the survival brain’s functioning. (That’s why the intellectual brain is equally important to our survival.)

The survival brain can “learn” to make more appropriate choices, but since the choices are not made consciously, the survival brain can’t be “talked” into anything. Graduated exposure therapy offers one of the best ways to accomplish more helpful survival brain behavior. It is based on the principle that inappropriate responses to stimuli (tendency to fight/flee/freeze) decrease with each non-problematic exposure.

Veterans' experience

To offer an example, veterans of the battlefield are often most comfortable sitting in a restaurant seat positioned against a wall, looking out over the entire room. Many of the rest of us prefer the same seat, from which we can see what is going on, but it is much more uncomfortable for people whose lives depended on awareness of their surroundings to have their backs to the action.

Once the veteran returns home, the same behavior that protected during combat may cause practical problems. If the veteran arrives at a business meeting and a preferred seat is already occupied, this may affect the quality of the person's presentation. Depending on the survival brain’s experience, the person may be so distracted and uncomfortable that he/she is unable to give the presentation at all.

If the veteran has an awareness of the cause of the discomfort, one option is to explain the situation and ask for the preferred seating. But prejudice and stigma still exist in the business world, and this request could easily be misunderstood. A behavior that may have saved the veteran’s life was reinforced on the battlefield, but that same behavior now poses an obstacle to the client’s success in business. The survival brain’s attachment to the behavior is certainly understandable.

One way to ameliorate this particular symptom would involve gradual exposure to the situation causing the extreme discomfort. This exposure could be in vivo (real) or imaginal (in the person’s mind). Depending on the strength of the survival brain’s response, imaginal tasks might work better at first. In session, and in between, the client might decide to imagine himself at a table in a restaurant in a less-than-preferred seat. Once the client is comfortable with this, he may try eating out with people with whom he is comfortable, then sitting in a less-than-preferred seat, and so on. The tasks are gradually changed until the client is comfortable in any seat in front of any audience for any purpose.

For individuals with post-traumatic stress disorder (PTSD), this gradual exposure is preferable to an older intervention known as flooding. This technique would expose the client to his/her worst fears with no escape, until the client was comfortable. So someone with arachnophobia would be locked in a room with 500 spiders, until the fear subsided. Believe it or not, this technique often worked. But clients and counselors are more comfortable with graduated exposure. Moreover, when flooding doesn’t work, it often backfires badly.

A how-to guide

Here is a step-by-step recipe for trying graduated exposure with your clients:

• First, agree on the target behavior your client would like to change. It may be responding angrily in certain situations, fear of heights, or any other obstacle to comfortable daily living.

• Next, discuss a goal—the new behavior your client would prefer in this specific situation.

• Then brainstorm with your client to form a list of all cues that trigger the unwanted behavior. The cues could be internal (heart racing) or external (sight of a spider). Be sure to consider all five senses. Sights and sounds are most often considered, but sensations, aromas and even tastes can serve as triggers.

• Help your client imagine the least threatening, smallest step forward that would be the least bit meaningful—one both of you are certain can be accomplished. Use that task as the first assignment. For example, for someone afraid of spiders, the task might involve looking at a picture of a spider online.

• Once that task is no longer the least bit uncomfortable, imagine again the least threatening, smallest step forward that would be the least bit meaningful, and make that the next task. Continuing with the same example, this task might involve being in the room with a rubber spider.

• Use that task as the next assignment, and so on, until your client reaches the desired behavior goal.

Graduated exposure offers a relatively simple, non-threatening way to make major changes in behavior for those who struggle with symptoms of PTSD, anxiety and many other problems.

Nicholas A. Roes, PhD, author of Solutions for the 'Treatment-Resistant' Addicted Client (Haworth Press) is Executive Director of the New Hope Manor residential treatment facility in upstate New York. His e-mail address is NickARoes@aol.com and his website is www.nickroes.com.