Exposure Therapy and Journal Writing

There is an evidence-based intervention that is used in the treatment of anxiety disorders, including PTSD.  It is called "exposure therapy" and it is the most researched and empirically supported intervention there is.  Exposure studies date back to the 70s and 80s. 

Exposure therapy, (also referred to as imaginal exposure or the trauma narrative) for the treatment of traumatic stress, involves the client telling the story of the traumatic event to a therapist, over and over, until habituation occurs.  That is, until the memory of the event is "digested" and is no longer upsetting and distressing.  Telling about what happened "there and then" in the safer "here and now."  Until then, thinking or talking about the event has produced painful emotions and physiological responses (increased heart rate, sweaty palms, etc.).  Trying not to think about it (avoidance as coping) is thought to cause and perpetuate the traumatic stress symptoms (nightmares, intrusive thoughts and memories, etc.) even though it appears to relieve the pain in the short-term. After the current fear of the old memory is faced and overcome, the client feels a "sense of relief and calm."  The memory can be filed away without the distressing emotions and physiological arousal attached to it - without the emotions and sensations that the memory was encoded with in the first place.

Edna Foa, a trauma researcher, describes the approach in her book, Prolonged Exposure Therapy for Adolescents with PTSD: Emotional Processing of Traumatic Experiences:

• The overall aim of Prolonged Exposure (PE) is to help trauma survivors emotionally process their traumatic experiences in order to diminish PTSD and other trauma-related symptoms. The name “prolonged exposure” reflects the fact that the treatment program emerged from the long tradition of exposure therapy for anxiety disorders, in which clients are helped to confront safe but anxiety-evoking situations in order to overcome their excessive fear and anxiety. At the same time, PE has emerged from the emotional processing theory of PTSD, which emphasizes the central role of successful processing of the traumatic memory in the amelioration of PTSD symptoms. Emotional processing is the mechanism underlying successful reduction of PTSD symptoms.

As a clinician,  I have conducted several sessions to review the trauma narrative with children and adolescents.  I listen and bear witness.  I ask questions only to facilitate the telling of the story with details about events, people and feelings.  I try to create a safe environment (warm and empathic) so the story can be told until the child reaches a sense of calm and relief.  I ask the student to rate their fear when telling the story now.  I watch as the ratings go up (more fear) and then go down (less fear) with each successive re-telling.  The first time I conducted a session, I felt the tension rise in my own body, my muscles ached after a few re-tellings.  I asked the student if she wanted to stretch between tellings and she said yes.  We giggled as we stretched - hands to the ceiling and hands to the floor.  I felt better after laughing and stretching.  At the end of treatment, she remembered the stretching was helpful, too.


I train other social workers to use this technique as part of an evidence-based trauma treatment.  Social workers remark about how tired they feel after doing one to three sessions in one day.  I wonder about the transfer of energy.  I think about how one masseuse said that she sets an intention to help clients release toxins without taking them on herself.  I think about how vicarious traumatization in the course of therapy has been described:

• As the emotional needs and distresses of people in difficulty were presented to me, I not only felt them through the process of empathy, but I also found I tended to absorb them within myself as well (English, 1976).
• Conditions of depression and despair in one's clients (which he calls 'soul sadness') can be contagious (Chessick, 1978).
• Research supports the notion that doing psychotherapy can be dangerous to the psyche of the therapist (Guy, 1987). 
• The notion of vicarious traumatization...implies that much of the therapist's cognitive world will be altered by hearing traumatic client material (McCann, 1990).  
• Secondary traumatic stress and compassion fatigue is a reaction from indirect exposure to a traumatic event...as a result of the therapist's own empathy towards a traumatized client in addition to the therapist's own secondary experience to the traumatic material (Figley, 1999).

Then I come across Pennebaker's finding that writing stories about emotional events is healing, upsetting while doing it, but with a positive impact on physical health in the end.  Writing the stories that healed included certain elements, namely:

• Writing about both facts and feelings surrounding the traumas - linking cognitive and affective aspects of the story.
• Use of positive emotion words.
• Use of a moderate number of negative emotion words.
• Very high and very low levels of negative emotion words were related to poorer health.
• Most important, an increase in both causal and insight words over the course of writing.  That is, people who benefited from writing began with poorly organized descriptions and progressed to coherent stories by the last day of writing.

Now the "use of positive emotion words" and the number of negative and positive emotion words reminds me of the flourishing ratio that Friedrickson (2004) talks about in her "Broaden-and-Build Theory of Positive Emotions" and Losada’s model of team performance.   These researchers found that a ratio of positive to negative affect at or above 3 to 1 will characterize individuals in flourishing mental health.

Fortunately, we can feel all our feelings - the so-called positive and negative ones - and still flourish.  Their balance just has to be 3 to 1 - three positive emotions to one negative emotion.  We don't have to be perfect or false.  Three to one will do nicely.  By the way, this turns out to be true for individual flourishing, couple relationships, and work teams.

The idea of writing about emotional or traumatic events, even if no one provides feedback, as was done in Pennebaker's study with college students, intrigued me.  Healing for students without the risk of vicarious trauma for mental health clinicians?   Hmm.