Prolonged Exposure Therapy (PE) Metaphor Bank

Prolonged Exposure Therapy (PE) is an evidenced-based, manualized protocol effective for the treatment of posttraumatic stress disorder (PTSD). 

The use of metaphors in PE can assist providers by presenting information and concepts without using jargon, which may be easier for patients to understand. The CDP has created a series of videos featuring our subject matter experts delivering a selection of  metaphors which are commonly used in PE.

Jump to: SESSION 2 SESSION 3 SESSION 6
SESSION 1

Coach & Athlete:  Dr. Holloway describes the relationship between therapist and patient using the example of a coach and athlete relationship, highlighting the collaborative nature of the relationship but having different roles. Both bring expertise to the relationship. And much like the athlete, the patient does a lion’s share of the actual work and effort in treatment, while the therapist guides the patient’s efforts so they are maximally beneficial, helping the patient to go just a little further than they think they can go and to perform beyond their own perceptions of competence. This example can be very useful in session 1 when describing the overview of treatment and rationale for exposure therapy.

Debriding a Wound: Some clients considering PE treatment worry that it might be aversive or uncomfortable. Dr. Holloway addresses this concern using the example of cleaning or debriding a wound. The important point is that proper healing is fostered by setting the right conditions for healing, such as by cleaning and debriding a physical wound. Similarly the procedures of PE help set the conditions necessary for proper healing from PTSD, and that while at time, like cleaning a physical wound, it may be unpleasant or uncomfortable in the short run, they are what is necessary for proper healing. This example may be appropriate when discussing the overview for treatment by PE in session 1, when discussing the rationale for imaginal exposure in session 3, or at any time when clients express concerns that they are worried that PE will make them worse, not better.

Setting a Bone: Some clients considering PE treatment worry that it might be aversive or uncomfortable. Dr. Holloway addresses this concern using the example of setting a bone. The important point is that proper healing is fostered by setting the right conditions for healing, such as by setting a broken bone. Similarly the procedures of PE help set the conditions necessary for proper healing from PTSD, and that while at times, like setting a bone, it may be unpleasant or uncomfortable in the short run, they are what is necessary for proper healing. This example may be appropriate when discussing the overview for treatment by PE in session 1, when discussing the rationale for imaginal exposure in session 3, or at any time when clients express concerns that they are worried that PE will make them worse, not better.

Sensitive Alarm: Dr. David Riggs describes how the experience of a trauma can increase one’s sensitivity to perceived danger and threat by using the example of an alarm set too sensitively and reacting to all stimuli whether objectively dangerous or not. He describes how exposure therapy helps to decrease the sensitivity to perceived danger—not eliminate it—such that the person can better distinguish actual threats from those that feel dangerous but are not objectively dangerous. Or, as the sensitivity of the alarm goes down, it is only activated by those things that are truly dangerous. This example may be useful when discussing unhelpful thoughts that the world is a much more dangerous place than previously thought, or when discussing a patients hesitation to engaging in exposure therapy because they believe they need to maintain high levels of alertness or avoidance in order to be prepared for all possible threats.

Clutching the Brake:  Dr Holloway explains how some “symptoms” of PTSD can be thought of as simply skillset mismatch with a context, and that treatment of PTSD can be thought of as learning a new skill set that better matches the current context. The example of learning to drive vehicles of standard and automatic transmissions is used to illustrate new skills acquisition, and that even when older, less fitting skills emerge from time to time, e.g. “clutching the break”, that doesn’t mean new skill acquisition was unsuccessful, or that progress is lost, but rather is a natural part of learning. This example can be useful when discussing the overview of exposure therapy in session 1, describing the rationale for in vivo exposure in session 2, or even discussing “inoculation” against relapse during the final session.

 

SESSION 2

Pool Temperature: Dr. Kelly Chrestman describes the process of habituation, or “getting used to something,” using the example of getting used to the water in a swimming pool. She explains that some people enter a swimming pool slowly and others jump right in, but the difference is only a difference in the speed at which one becomes used to the water temperature. She also explains that it is not the water tempterature that changes, but it is the person that changes in getting used to the water. Dr. Chrestman also explains how some people avoid swimming at all because they may believe it is too uncomfortable to get used to the water, or they may be waiting for the water to get warmer first, similar to how many people avoid engaging in many aspects of their life because they are waiting to first feel comfortable or not anxious about these situations rather than getting into them and getting used to them. This example may be very useful when discussing the rational for exposure therapy in session 1, discussing the rationale for in vivo exposure in session 2, or any time the when a review of the concept of habituation may help the patient to stay engaged in exposure when feeling uncomfortable.

Pine Log: Dr. Holloway uses an example from parenting to illustrate how habituation is a process with which clients are already familiar—specifically helping children overcome unrealistic fears through gradual exposure. This example may be useful during a discussion of the overall rationale for exposure therapy in session 1, during a discussion of the rationale for in vivo exposure in session 2, or anytime a review of the rationale for exposure is needed. This example is provided with much thanks to Dr Greg Reger, who first described it to us.

Rogue Wave: Dr. Hembree explains how in vivo exposure is not specific to Prolonged Exposure therapy, but is in fact the same process by which all people, especially children, learn not to be afraid of many things in their life. She uses the example of a wise mother helping her child learn that playing at the beach can be safe after he has previously been hit by a rogue wave. She then elicits examples from the patient’s own life to help her see in vivo exposure as another example of process with which she is already familiar. This example may be especially useful when discussing the rationale for in vivo exposure in session 2.

Riding a Bike: Dr. Chrestman discusses parts of the rationale for exposure by comparing the process to learning to ride a bicycle—a very common experience for many patients. She describes how confronting feared situations, such as those targeted in in vivo exposure, helps the patient to develop mastery and confidence in their abilities for those feared situations, which is a process most patients have already experienced in their own lives. This example can be useful during a discussion of the rationale for trauma in session 1, during a discussion of the rationale for in vivo exposure in session 2, or at times when reviewing in vivo exercises.

Car Alarm: Dr. David Riggs describes how the experience of a trauma can increase one’s sensitivity to perceived danger and threat by using the example of an alarm set too sensitively and reacting to all stimuli whether objectively dangerous or not. He describes how exposure therapy helps to decrease the sensitivity to perceived danger—not eliminate it—such that the person can better distinguish actual threats from those that feel dangerous but are not objectively dangerous. Or, as the sensitivity of the alarm goes down, it is only activated by those things that are truly dangerous. This example may be useful when discussing unhelpful thoughts that the world is a much more dangerous place than previously thought, or when discussing a patients hesitation to engaging in exposure therapy because they believe they need to maintain high levels of alertness or avoidance in order to be prepared for all possible threats.

Cologne: Dr. Holloway uses an example of olfactory habituation to describe the process of “getting used to” a stimulus, and relates that to the process of habituation to anxiety-provoking situations. The main points of this example are that exposure to a stimulus over a prolonged period of time, and over repeated exposures, reduces the intensity of response to the stimulus. This example may be most useful when discussing the overall rationale for treatment by Prolonged Exposure in session 1, and may also be useful when discussing the rationale for in vivo exposure in session 2 or discussing the rationale for imaginal exposure in session 3.

 

SESSION 3

Cleaning the Closet: Dr. Jenna Ermold describes parts of the rationale for imaginal exposure using the example of a staple of Saturday morning cartoons—the stuffed closet that bursts open at the wrong times. She describes how imaginal exposure allows for processing and organizing trauma memories by carefully going through details much like going through the items shoved into a closet, and thereby allowing the patient more control over the memory and when they confront it instead of memory details intruding into the person’s functioning at the most inopportune times. This example may be useful when discussing the rational for imaginal exposure in session three, or any time the patient questions how thinking about or talking about their trauma in treatment can be helpful, especially when they consider how much energy they have already expended trying NOT to think about trauma memories.

Slamming the Book Shut: Dr. David Riggs uses the example of “slamming the book shut” while reading an intense passage to explain how many people suffering from PTSD think about their trauma memories—and by extention how intrusive thoughts of the trauma do not have the same therapeutic effect as repeated, prolonged exposure to trauma memories. In essence, many PTSD sufferers interrupt or distract their thinking at the most difficult or critical part of the memory without allowing themselves to process the entire memory from beginning to end. This example may be useful when discussing the rational for exposure therapy in session one or the rational for imaginal exposure in session three, or any time the patient questions how thinking about or talking about their trauma in treatment can be helpful when what they want is to be able to think about the memory less.

File Cabinet: Part of the rationale for imaginal exposure is that exposure allows the client to process the trauma memory more completely and fully than they have previously allowed himself or herself to do. Processing trauma memories can be difficult because doing so elicits the distressing emotions attached to these memories, and because it is often difficult to make sense of these events within the context of one’s previous experience. Dr. Holloway describes this difficulty using the example of a file drawer, and that processing the trauma memory can be thought of as fitting the memory into the system of knowledge and memories the person already has, or having to create a new space within that structure for memories that don’t easily fit. This example may be appropriate when discussing the rationale for imaginal exposure in session 3.

Digesting Spoiled Food: Some clients considering PE treatment worry that it might be too aversive or uncomfortable. Dr. Hembree addresses this concern using the example of digesting spoiled food. The important point is that while a person may feel uncomfortable or ill after consuming food, over time that discomfort reduces as the spoiled food is processed or digested. Similarly, trauma memories are like spoiled food in that they must be processed or digested in order for the discomfort they elicit to dissipate. This example may be appropriate when discussing the overview for treatment by PE in session 1, when discussing the rationale for imaginal exposure in session 3.

 

SESSION 6/HOT SPOTS

Learning to Play a Song: The procedures and rationale for focusing on “hotspots” is described using the example of learning to play a song on a musical instrument, beginning first on developing general skill on the entire song, then focusing on specific parts of the song that still give the musician trouble. This example can be effective with clients with a music background, connecting with a process with which they are already familiar. It may be best suited for the first hotspots session (around session 6) while discussing the rationale and procedures for hotspots, or anytime when revisiting the rationale for hotspots may be required.
HYPERVIGILENCE PROCESSING THE TRAUMA EXPOSURE
RATIONALE		 LEARNING NEW SKILLS
THERAPEUTIC RELATIONSHIP HABITUATION UNCOMFORTABLE,
BUT NECESSARY		 HOTSPOTS
HYPERVIGILENCE, NOT PROTECTIVE

Sensitive Alarm: Dr. David Riggs describes how the experience of a trauma can increase one’s sensitivity to perceived danger and threat by using the example of an alarm set too sensitively and reacting to all stimuli whether objectively dangerous or not. He describes how exposure therapy helps to decrease the sensitivity to perceived danger—not eliminate it—such that the person can better distinguish actual threats from those that feel dangerous but are not objectively dangerous. Or, as the sensitivity of the alarm goes down, it is only activated by those things that are truly dangerous. This example may be useful when discussing unhelpful thoughts that the world is a much more dangerous place than previously thought, or when discussing a patients hesitation to engaging in exposure therapy because they believe they need to maintain high levels of alertness or avoidance in order to be prepared for all possible threats.

Car Alarm: Dr. David Riggs describes how the experience of a trauma can increase one’s sensitivity to perceived danger and threat by using the example of an alarm set too sensitively and reacting to all stimuli whether objectively dangerous or not. He describes how exposure therapy helps to decrease the sensitivity to perceived danger—not eliminate it—such that the person can better distinguish actual threats from those that feel dangerous but are not objectively dangerous. Or, as the sensitivity of the alarm goes down, it is only activated by those things that are truly dangerous. This example may be useful when discussing unhelpful thoughts that the world is a much more dangerous place than previously thought, or when discussing a patients hesitation to engaging in exposure therapy because they believe they need to maintain high levels of alertness or avoidance in order to be prepared for all possible threats.

 

PROCESSING THE TRAUMA

Slamming the Book Shut: Dr. David Riggs uses the example of “slamming the book shut” while reading an intense passage to explain how many people suffering from PTSD think about their trauma memories—and by extention how intrusive thoughts of the trauma do not have the same therapeutic effect as repeated, prolonged exposure to trauma memories. In essence, many PTSD sufferers interrupt or distract their thinking at the most difficult or critical part of the memory without allowing themselves to process the entire memory from beginning to end. This example may be useful when discussing the rational for exposure therapy in session one or the rational for imaginal exposure in session three, or any time the patient questions how thinking about or talking about their trauma in treatment can be helpful when what they want is to be able to think about the memory less.

Cleaning the Closet: Dr. Jenna Ermold describes parts of the rationale for imaginal exposure using the example of a staple of Saturday morning cartoons—the stuffed closet that bursts open at the wrong times. She describes how imaginal exposure allows for processing and organizing trauma memories by carefully going through details much like going through the items shoved into a closet, and thereby allowing the patient more control over the memory and when they confront it instead of memory details intruding into the person’s functioning at the most inopportune times. This example may be useful when discussing the rational for imaginal exposure in session three, or any time the patient questions how thinking about or talking about their trauma in treatment can be helpful, especially when they consider how much energy they have already expended trying NOT to think about trauma memories.

File Cabinet: Part of the rationale for imaginal exposure is that exposure allows the client to process the trauma memory more completely and fully than they have previously allowed himself or herself to do. Processing trauma memories can be difficult because doing so elicits the distressing emotions attached to these memories, and because it is often difficult to make sense of these events within the context of one’s previous experience. Dr. Holloway describes this difficulty using the example of a file drawer, and that processing the trauma memory can be thought of as fitting the memory into the system of knowledge and memories the person already has, or having to create a new space within that structure for memories that don’t easily fit. This example may be appropriate when discussing the rationale for imaginal exposure in session 3.

Digesting Spoiled Food: Some clients considering PE treatment worry that it might be too aversive or uncomfortable. Dr. Hembree addresses this concern using the example of digesting spoiled food. The important point is that while a person may feel uncomfortable or ill after consuming food, over time that discomfort reduces as the spoiled food is processed or digested. Similarly, trauma memories are like spoiled food in that they must be processed or digested in order for the discomfort they elicit to dissipate. This example may be appropriate when discussing the overview for treatment by PE in session 1, when discussing the rationale for imaginal exposure in session 3.

 

EXPOSURE RATIONAL

Riding a Bike: Dr. Chrestman discusses parts of the rationale for exposure by comparing the process to learning to ride a bicycle—a very common experience for many patients. She describes how confronting feared situations, such as those targeted in in vivo exposure, helps the patient to develop mastery and confidence in their abilities for those feared situations, which is a process most patients have already experienced in their own lives. This example can be useful during a discussion of the rationale for trauma in session 1, during a discussion of the rationale for in vivo exposure in session 2, or at times when reviewing in vivo exercises.

Pine Log: Dr. Holloway uses an example from parenting to illustrate how habituation is a process with which clients are already familiar—specifically helping children overcome unrealistic fears through gradual exposure. This example may be useful during a discussion of the overall rationale for exposure therapy in session 1, during a discussion of the rationale for in vivo exposure in session 2, or anytime a review of the rationale for exposure is needed. This example is provided with much thanks to Dr Greg Reger, who first described it to us.

Rogue Wave: Dr. Hembree explains how in vivo exposure is not specific to Prolonged Exposure therapy, but is in fact the same process by which all people, especially children, learn not to be afraid of many things in their life. She uses the example of a wise mother helping her child learn that playing at the beach can be safe after he has previously been hit by a rogue wave. She then elicits examples from the patient’s own life to help her see in vivo exposure as another example of process with which she is already familiar. This example may be especially useful when discussing the rationale for in vivo exposure in session 2.

 

LEARNING NEW SKILLS

Clutching the Brake:  Dr Holloway explains how some “symptoms” of PTSD can be thought of as simply skillset mismatch with a context, and that treatment of PTSD can be thought of as learning a new skill set that better matches the current context. The example of learning to drive vehicles of standard and automatic transmissions is used to illustrate new skills acquisition, and that even when older, less fitting skills emerge from time to time, e.g. “clutching the break”, that doesn’t mean new skill acquisition was unsuccessful, or that progress is lost, but rather is a natural part of learning. This example can be useful when discussing the overview of exposure therapy in session 1, describing the rationale for in vivo exposure in session 2, or even discussing “inoculation” against relapse during the final session.

 

THERAPEUTIC RELATIONSHIP

Coach & Athlete:  Dr. Holloway describes the relationship between therapist and patient using the example of a coach and athlete relationship, highlighting the collaborative nature of the relationship but having different roles. Both bring expertise to the relationship. And much like the athlete, the patient does a lion’s share of the actual work and effort in treatment, while the therapist guides the patient’s efforts so they are maximally beneficial, helping the patient to go just a little further than they think they can go and to perform beyond their own perceptions of competence. This example can be very useful in session 1 when describing the overview of treatment and rationale for exposure therapy.

 

HABITUATION

Cologne: Dr. Holloway uses an example of olfactory habituation to describe the process of “getting used to” a stimulus, and relates that to the process of habituation to anxiety-provoking situations. The main points of this example are that exposure to a stimulus over a prolonged period of time, and over repeated exposures, reduces the intensity of response to the stimulus. This example may be most useful when discussing the overall rationale for treatment by Prolonged Exposure in session 1, and may also be useful when discussing the rationale for in vivo exposure in session 2 or discussing the rationale for imaginal exposure in session 3.

Pool Temperature: Dr. Kelly Chrestman describes the process of habituation, or “getting used to something,” using the example of getting used to the water in a swimming pool. She explains that some people enter a swimming pool slowly and others jump right in, but the difference is only a difference in the speed at which one becomes used to the water temperature. She also explains that it is not the water tempterature that changes, but it is the person that changes in getting used to the water. Dr. Chrestman also explains how some people avoid swimming at all because they may believe it is too uncomfortable to get used to the water, or they may be waiting for the water to get warmer first, similar to how many people avoid engaging in many aspects of their life because they are waiting to first feel comfortable or not anxious about these situations rather than getting into them and getting used to them. This example may be very useful when discussing the rational for exposure therapy in session 1, discussing the rationale for in vivo exposure in session 2, or any time the when a review of the concept of habituation may help the patient to stay engaged in exposure when feeling uncomfortable.

 

UNCOMFORTABLE, BUT NECESSARY

Debriding a Wound: Some clients considering PE treatment worry that it might be aversive or uncomfortable. Dr. Holloway addresses this concern using the example of cleaning or debriding a wound. The important point is that proper healing is fostered by setting the right conditions for healing, such as by cleaning and debriding a physical wound. Similarly the procedures of PE help set the conditions necessary for proper healing from PTSD, and that while at time, like cleaning a physical wound, it may be unpleasant or uncomfortable in the short run, they are what is necessary for proper healing. This example may be appropriate when discussing the overview for treatment by PE in session 1, when discussing the rationale for imaginal exposure in session 3, or at any time when clients express concerns that they are worried that PE will make them worse, not better.

Setting a Bone: Some clients considering PE treatment worry that it might be aversive or uncomfortable. Dr. Holloway addresses this concern using the example of setting a bone. The important point is that proper healing is fostered by setting the right conditions for healing, such as by setting a broken bone. Similarly the procedures of PE help set the conditions necessary for proper healing from PTSD, and that while at times, like setting a bone, it may be unpleasant or uncomfortable in the short run, they are what is necessary for proper healing. This example may be appropriate when discussing the overview for treatment by PE in session 1, when discussing the rationale for imaginal exposure in session 3, or at any time when clients express concerns that they are worried that PE will make them worse, not better.

 

HOTSPOTS

Learning to Play a Song: The procedures and rationale for focusing on “hotspots” is described using the example of learning to play a song on a musical instrument, beginning first on developing general skill on the entire song, then focusing on specific parts of the song that still give the musician trouble. This example can be effective with clients with a music background, connecting with a process with which they are already familiar. It may be best suited for the first hotspots session (around session 6) while discussing the rationale and procedures for hotspots, or anytime when revisiting the rationale for hotspots may be required.
ALL METAPHORS

Sensitive Alarm: Dr. David Riggs describes how the experience of a trauma can increase one’s sensitivity to perceived danger and threat by using the example of an alarm set too sensitively and reacting to all stimuli whether objectively dangerous or not. He describes how exposure therapy helps to decrease the sensitivity to perceived danger—not eliminate it—such that the person can better distinguish actual threats from those that feel dangerous but are not objectively dangerous. Or, as the sensitivity of the alarm goes down, it is only activated by those things that are truly dangerous. This example may be useful when discussing unhelpful thoughts that the world is a much more dangerous place than previously thought, or when discussing a patients hesitation to engaging in exposure therapy because they believe they need to maintain high levels of alertness or avoidance in order to be prepared for all possible threats.

Slamming the Book Shut: Dr. David Riggs uses the example of “slamming the book shut” while reading an intense passage to explain how many people suffering from PTSD think about their trauma memories—and by extention how intrusive thoughts of the trauma do not have the same therapeutic effect as repeated, prolonged exposure to trauma memories. In essence, many PTSD sufferers interrupt or distract their thinking at the most difficult or critical part of the memory without allowing themselves to process the entire memory from beginning to end. This example may be useful when discussing the rational for exposure therapy in session one or the rational for imaginal exposure in session three, or any time the patient questions how thinking about or talking about their trauma in treatment can be helpful when what they want is to be able to think about the memory less.

Riding a Bike: Dr. Chrestman discusses parts of the rationale for exposure by comparing the process to learning to ride a bicycle—a very common experience for many patients. She describes how confronting feared situations, such as those targeted in in vivo exposure, helps the patient to develop mastery and confidence in their abilities for those feared situations, which is a process most patients have already experienced in their own lives. This example can be useful during a discussion of the rationale for trauma in session 1, during a discussion of the rationale for in vivo exposure in session 2, or at times when reviewing in vivo exercises.

Car Alarm: Dr. David Riggs describes how the experience of a trauma can increase one’s sensitivity to perceived danger and threat by using the example of an alarm set too sensitively and reacting to all stimuli whether objectively dangerous or not. He describes how exposure therapy helps to decrease the sensitivity to perceived danger—not eliminate it—such that the person can better distinguish actual threats from those that feel dangerous but are not objectively dangerous. Or, as the sensitivity of the alarm goes down, it is only activated by those things that are truly dangerous. This example may be useful when discussing unhelpful thoughts that the world is a much more dangerous place than previously thought, or when discussing a patients hesitation to engaging in exposure therapy because they believe they need to maintain high levels of alertness or avoidance in order to be prepared for all possible threats.

Clutching the Brake:  Dr Holloway explains how some “symptoms” of PTSD can be thought of as simply skillset mismatch with a context, and that treatment of PTSD can be thought of as learning a new skill set that better matches the current context. The example of learning to drive vehicles of standard and automatic transmissions is used to illustrate new skills acquisition, and that even when older, less fitting skills emerge from time to time, e.g. “clutching the break”, that doesn’t mean new skill acquisition was unsuccessful, or that progress is lost, but rather is a natural part of learning. This example can be useful when discussing the overview of exposure therapy in session 1, describing the rationale for in vivo exposure in session 2, or even discussing “inoculation” against relapse during the final session.

Coach & Athlete:  Dr. Holloway describes the relationship between therapist and patient using the example of a coach and athlete relationship, highlighting the collaborative nature of the relationship but having different roles. Both bring expertise to the relationship. And much like the athlete, the patient does a lion’s share of the actual work and effort in treatment, while the therapist guides the patient’s efforts so they are maximally beneficial, helping the patient to go just a little further than they think they can go and to perform beyond their own perceptions of competence. This example can be very useful in session 1 when describing the overview of treatment and rationale for exposure therapy.

Cologne: Dr. Holloway uses an example of olfactory habituation to describe the process of “getting used to” a stimulus, and relates that to the process of habituation to anxiety-provoking situations. The main points of this example are that exposure to a stimulus over a prolonged period of time, and over repeated exposures, reduces the intensity of response to the stimulus. This example may be most useful when discussing the overall rationale for treatment by Prolonged Exposure in session 1, and may also be useful when discussing the rationale for in vivo exposure in session 2 or discussing the rationale for imaginal exposure in session 3.

Debriding a Wound: Some clients considering PE treatment worry that it might be aversive or uncomfortable. Dr. Holloway addresses this concern using the example of cleaning or debriding a wound. The important point is that proper healing is fostered by setting the right conditions for healing, such as by cleaning and debriding a physical wound. Similarly the procedures of PE help set the conditions necessary for proper healing from PTSD, and that while at time, like cleaning a physical wound, it may be unpleasant or uncomfortable in the short run, they are what is necessary for proper healing. This example may be appropriate when discussing the overview for treatment by PE in session 1, when discussing the rationale for imaginal exposure in session 3, or at any time when clients express concerns that they are worried that PE will make them worse, not better.

Pine Log: Dr. Holloway uses an example from parenting to illustrate how habituation is a process with which clients are already familiar—specifically helping children overcome unrealistic fears through gradual exposure. This example may be useful during a discussion of the overall rationale for exposure therapy in session 1, during a discussion of the rationale for in vivo exposure in session 2, or anytime a review of the rationale for exposure is needed. This example is provided with much thanks to Dr Greg Reger, who first described it to us.

Setting a Bone: Some clients considering PE treatment worry that it might be aversive or uncomfortable. Dr. Holloway addresses this concern using the example of setting a bone. The important point is that proper healing is fostered by setting the right conditions for healing, such as by setting a broken bone. Similarly the procedures of PE help set the conditions necessary for proper healing from PTSD, and that while at times, like setting a bone, it may be unpleasant or uncomfortable in the short run, they are what is necessary for proper healing. This example may be appropriate when discussing the overview for treatment by PE in session 1, when discussing the rationale for imaginal exposure in session 3, or at any time when clients express concerns that they are worried that PE will make them worse, not better.

Digesting Spoiled Food: Some clients considering PE treatment worry that it might be too aversive or uncomfortable. Dr. Hembree addresses this concern using the example of digesting spoiled food. The important point is that while a person may feel uncomfortable or ill after consuming food, over time that discomfort reduces as the spoiled food is processed or digested. Similarly, trauma memories are like spoiled food in that they must be processed or digested in order for the discomfort they elicit to dissipate. This example may be appropriate when discussing the overview for treatment by PE in session 1, when discussing the rationale for imaginal exposure in session 3.

Pool Temperature: Dr. Kelly Chrestman describes the process of habituation, or “getting used to something,” using the example of getting used to the water in a swimming pool. She explains that some people enter a swimming pool slowly and others jump right in, but the difference is only a difference in the speed at which one becomes used to the water temperature. She also explains that it is not the water tempterature that changes, but it is the person that changes in getting used to the water. Dr. Chrestman also explains how some people avoid swimming at all because they may believe it is too uncomfortable to get used to the water, or they may be waiting for the water to get warmer first, similar to how many people avoid engaging in many aspects of their life because they are waiting to first feel comfortable or not anxious about these situations rather than getting into them and getting used to them. This example may be very useful when discussing the rational for exposure therapy in session 1, discussing the rationale for in vivo exposure in session 2, or any time the when a review of the concept of habituation may help the patient to stay engaged in exposure when feeling uncomfortable.

Rogue Wave: Dr. Hembree explains how in vivo exposure is not specific to Prolonged Exposure therapy, but is in fact the same process by which all people, especially children, learn not to be afraid of many things in their life. She uses the example of a wise mother helping her child learn that playing at the beach can be safe after he has previously been hit by a rogue wave. She then elicits examples from the patient’s own life to help her see in vivo exposure as another example of process with which she is already familiar. This example may be especially useful when discussing the rationale for in vivo exposure in session 2.

Cleaning the Closet: Dr. Jenna Ermold describes parts of the rationale for imaginal exposure using the example of a staple of Saturday morning cartoons—the stuffed closet that bursts open at the wrong times. She describes how imaginal exposure allows for processing and organizing trauma memories by carefully going through details much like going through the items shoved into a closet, and thereby allowing the patient more control over the memory and when they confront it instead of memory details intruding into the person’s functioning at the most inopportune times. This example may be useful when discussing the rational for imaginal exposure in session three, or any time the patient questions how thinking about or talking about their trauma in treatment can be helpful, especially when they consider how much energy they have already expended trying NOT to think about trauma memories.

File Cabinet: Part of the rationale for imaginal exposure is that exposure allows the client to process the trauma memory more completely and fully than they have previously allowed himself or herself to do. Processing trauma memories can be difficult because doing so elicits the distressing emotions attached to these memories, and because it is often difficult to make sense of these events within the context of one’s previous experience. Dr. Holloway describes this difficulty using the example of a file drawer, and that processing the trauma memory can be thought of as fitting the memory into the system of knowledge and memories the person already has, or having to create a new space within that structure for memories that don’t easily fit. This example may be appropriate when discussing the rationale for imaginal exposure in session 3.

Learning to Play a Song: The procedures and rationale for focusing on “hotspots” is described using the example of learning to play a song on a musical instrument, beginning first on developing general skill on the entire song, then focusing on specific parts of the song that still give the musician trouble. This example can be effective with clients with a music background, connecting with a process with which they are already familiar. It may be best suited for the first hotspots session (around session 6) while discussing the rationale and procedures for hotspots, or anytime when revisiting the rationale for hotspots may be required.