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Narrative Exposure Therapy: A Case Study

Image habituation
We were akin then to try to help give him means of overcoming the trauma associated with this event and regain control of his life. He was paralysed by anxiety to the extent he was unable to leave his home address with significant support from others to do so. The idea of revisiting the site where this trauma happened was inconceivable to him. As a consequence, we decided that we would utilise exposure therapy, but in an imaginable way to allow him to engage with the traumatic memories that were so distressing, but do so from within his house. We embarked on a form of narrative exposure therapy called MH habituation training.
To do this, we had to create a script quite detailed to the events around the trauma. Working slowly and methodically, we pieced together what happened on that day, how it happened, what he could see and hear and feel and went through this with a fine tooth comb. We then were able to break the script down into component parts and use it as a form of exposure therapy. We recorded his script into a Dictaphone, and then broke this into small chunks. We then advised that instructed him to lesson repeatedly to those small chunks over and over again until he became inured or habituated to those descriptions.
A common challenge with people who have been through a traumatic event is convincing them of the merits of exposure therapy. Many traumatic events, such as assaults, rape, torture, or some of the things that people witness within the military or fire brigade are obviously hugely distressing. Often, the last thing that people want to do is revisit those memories and thoughts that provoke so much distress. A huge feature of PTSD is avoiding any aspect of those traumas. To suggest that the treatment to overcome it is to do exactly that feels counterintuitive, and often, people are resistant or reluctant to embark on a treatment in which they will have to revisit memories and images that they have for so long suppressed.
Before embarking on exposure therapy, people have to be able to control their anxiety that we are going to deliberately provoke. We know that anxiety is associated with a range of physiological symptoms. Fortunately, many of those symptoms are under our control. We often spent considerable time ensuring that patients are well versed on how to regulate their breathing, how to minimise the amount of tension within their body, and how to get the level of physiological arousal at its lowest before embarking on exposure therapy, which we know will provoke mood or anxiety.
A common mantra that I will say to patients to convince them of this is that it’s impossible for them to be physiologically completely relaxed and feel anxious at the same time. So if they can control themselves physically, they, in turn, control themselves emotional. First treatment was exceptionally efficient. He was advised to listen to these sentences over and over again on an hourly, daily basis, which meant that, within one week of this intense exposure to these images, audio recordings, memories, and thoughts, he was able to shift the amount of anxiety associated with them from significant and distressing to very mild indeed.
As a trainee, working for the first time with a significant case of trauma and having so much success so quickly was hugely encouraging to me as a trainee at that time. It really showed the value and potential for psychological therapy and helping people overcome trauma. Most encouragingly of all, the patient himself has gone on to thrive. He recommends his academic studies, kept in touch with me through this, and has gone on to gain employment within the voluntary sector, helping people with mental health problems along the way.

In week 1 Dr John Sharp described a patient he had worked with who had experienced a horrendous assault which had resulted in him struggling to cope with day-to-day life.

In this video, Dr Sharp discusses the application of NET to the care for this individual who suffered a traumatic event. Specifically, he discusses the technique of image habituation. Identify examples of exposure in the treatment plan of this patient.

Dr Sharp describes the common challenges implicated in exposure therapy. Add a record of these to your personal notes.

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Post-Traumatic Stress Disorder (PTSD) in the Global Context

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