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// Case Example: Prolonged Exposure

Through the use of repeated imaginal exposures, Terry slowly began to feel more conformable with discussing the trauma and telling people about his experience.

About this Example

The first case example about Terry documents the treatment of PTSD using Prolonged Exposure . The second is an example of in-session imaginal exposure with a different client. Prolonged Exposure is strongly recommended by the APA Clinical Practice Guideline for the Treatment of PTSD. Download case study (PDF, 107KB).

Terry, a 42-year-old earthquake survivor, had been experiencing PTSD symptoms for more than eight years. Terry consistently avoided thoughts and images related to witnessing the injuries and deaths of others during the earthquake. Throughout the years, he began spending an increasing amount of time at work and filling his days with hobbies and activities.

By the time he sought treatment, Terry had managed to fill his entire week with various obligations in order to keep his mind occupied and to minimize the possibility that he would think about the traumatic event. He also worked hard to convince others that the earthquake had not affected him. He did this by avoiding people that knew he had gone through this experience and by quickly changing the topic when it came up. However, he found that whenever he had free time, he would have unwanted intrusive thoughts and images about the earthquake. In addition, he was having increasingly distressing nightmares that were causing him to lose several hours of sleep each night. His repeated violent awakenings throughout the night had also disturbed his wife’s sleep, resulting in them no longer sharing a bedroom. Terry found that the harder he worked to avoid these thoughts, the more frequent they would become, and that they were getting stronger each day. He feared that if he thought about the memory he would lose control of his emotions and would not be able to cope. He was concerned that the fear and panic that occurred when he was reminded of the trauma would last forever. By avoiding thoughts about the memory, he never allowed himself to test out his predictions. Furthermore, through his repeated avoidance of the trauma memory, his fear continued to grow.

Terry eventually sought treatment because his symptoms were significantly impairing his work and family life. After receiving a thorough assessment of his PTSD and comorbid symptoms, psychoeducation about PTSD symptoms, and a rationale for using imaginal exposures, Terry received a number of sessions of imaginal exposure. With encouragement from his therapist, he engaged with the trauma memory in session by providing a detailed account of what he witnessed during the earthquake. The therapist prompted him to begin the account at the point at which he initially was aware that the earthquake was happening. She prompted him to describe in detail where he was at the time, who he was with, what he saw, how it ended, the sensations he had, and importantly, what he was thinking and feeling at the time. With each recounting, the therapist asked Terry to provide even more sensory and emotional details about the experience to facilitate habituation to the memory and to increase his mastery of his anxiety related to facing it. These retellings were recorded so that Terry could listen to the account outside of session for homework.

By engaging with the memory in a systematic manner and not allowing himself to escape or avoid it, he recognized that his fear and anxiety subsided as the exposures went on. Furthermore, he was able to test some of the predictions he had made about what would happen if he allowed himself to think about the trauma. He recognized that he could fully maintain control of his emotions and that, although he felt fear and anxiety throughout the exposure, these feelings quickly passed. Through the use of repeated imaginal exposures, Terry slowly began to feel more comfortable with discussing the trauma and telling people about his experience. He no longer feared the memory and was able to recognize that the memory itself was not dangerous.

The following case example is an excerpt from an imaginal exposure with a client who was in a motor vehicle accident with his wife and young child, in which his child was killed. Although only part of the exposure is provided, when conducting imaginal exposures in session, the exposure should be conducted until the end of the memory and repeated for at least 45 to 60 minutes. The example below was the first imaginal exposure conducted with this client. With the first exposure it is common for a client’s Subjective Units of Distress Scale (SUDS) rating to be elevated throughout the entire memory. With repetition during the session, as well as across several sessions, the memory will elicit lower distress ratings and it will take a shorter duration to have the distress rating reduce across the exposure.

Therapist: Let’s start by having you close your eyes and sit comfortably in your chair. I’d like you to go back to the memory of what happened during the accident. Try to talk about it as if you were back in the moment or as if it were happening right now. Remember to talk in first person and not as if you were watching the event take place from another person’s perspective. You may experience a number of strong emotions, but I want you to remember that it is just a memory and that a memory itself can’t cause you any harm. You are safe here in the office. The memory alone isn’t dangerous. During the exposure I’m going to ask you how distressed you are using the SUDS ratings. Try to tell me as quickly as you can and go right back into the memory. If you feel overly afraid or anxious, you may open your eyes, but try to stay with the memory. However, do your best to keep them closed throughout the exposure. During the exposure I won’t be speaking much, except to help keep you moving forward. We will talk about it when you are done. Are you ready to start?

Client: Yes.

Therapist: What is your SUDS just before we start?

Client: 80.

Therapist: Okay. Take yourself back to the day of the accident. What happened just before?

Client: I am driving home from visiting my brother-in-law and his family. It is getting dark and it is drizzling. It’s hard to see the lines dividing my lane from oncoming traffic. I’m looking in my rearview mirror to check on my son who is falling asleep in his car seat. My wife is sitting beside me and asking me about something that her brother had said to me while she was in the kitchen. I’m looking in the rearview mirror again and I see a car. It’s coming toward us extremely fast. Its high beams are on and it’s flashing them at me. Now I see another car just behind it. They keep on cutting each other off. They are getting very close to my car and are trying to pass me. I try to move over to let them pass, but there is no shoulder on the road for me to slow down or pull onto. My wife is very nervous. She turns to look out the rear windshield. I’m shaking and I don’t know what to do. The cars are very close now. They are just behind me to the right. They are trying to squeeze past me on the right side, between me and the guardrail.

I try to let them pass by moving a bit into the oncoming traffic lane. Their high beams are hitting my mirror and making it hard for me to see.

Therapist: What’s your SUDS rating?

Client: 100. They are finally passing me on my right side. My wife is screaming at me to move over. I hear a loud horn. My car is still partly in the oncoming traffic lane . . . (The client pauses for a number of seconds.)

Therapist: You’re doing great. Keep going.

Client: The second car is now passing and I hear the horn again. It’s loud. Like a big truck. I still can’t see very well and I’m sweating. My wife is saying something to me but I can’t make out what she is saying. The horn is getting louder and it keeps sounding over and over again. Even with the second car passing me, something is still blinding me. I realize that it is a truck coming toward us and that I’m in its way because I moved into its lane. I try to swerve back into my lane, but it is too late. (The client, now visibly distressed, is having trouble continuing. He is crying and shaking his head back and forth, as if saying “no”.)

Therapist: Remember, it’s just a memory. You are safe here in the office; keep going.

Client: The truck hits us on the back left side door, the seat where my son was sitting. (The client is sweating and becoming tearful.)

Therapist: I know this is hard, but stay with the memory. (The therapist notes this section of the memory as a potential hot spot. The client pauses for a few more seconds and then continues.)

Client: I hear a loud crash. The car is spinning violently. My wife keeps screaming and the car keeps spinning. I can’t see anything and all I hear is my wife’s screaming. The car finally stops. I’m bleeding from my left arm and the window is broken. I look at my wife beside me and she is crying. I ask her if she is hurt. She says no. We simultaneously look at the backseat to check on our son. His car seat is turned in the backseat and he is lying sideways in it. His body is twisted in the car seat. He isn’t moving and he isn’t breathing. He isn’t making a sound. I’m screaming for my wife to call 911, but she is just sitting there sobbing. I crawl over the seat and now I’m in the backseat with my son. I want to hold him but I know I shouldn’t move him. I fumble to find my cell phone in my pocket and call 911. The dispatch operator answers almost immediately. She asks if I need firefighters, an ambulance, or the police, but I can’t answer. I am crying and I keep repeating, “It was an accident.” My wife is screaming now. She keeps on saying, “My baby is dead, my baby is dead.” The dispatch operator asks for my location. I tell her I’m just east of Exit 92 heading west on the I90. She tells me that help is on the way. She’s now asking me to check on the baby. I tell her that he’s not breathing and she tells me not to touch him and that the ambulance will be there soon. I can hear sirens. The sound is getting louder and louder. It sounds as if there are 100 police cars heading toward us. The police and paramedics arrive. They take my wife and I to the back of an ambulance and turn us so we can’t see our car. The paramedics ask us if we are okay. I tell them we are fine, but my wife can’t stop crying. She is shaking and screaming. The paramedics see the cut on my arm and start to treat it. They tell me that it isn’t too deep and that I won’t need stiches. I keep asking about my baby, but the paramedics won’t give me a response. Finally, I see a police officer begin to move toward us. (The client pauses. He is tearful.)

Therapist: You’re doing great; what happened next?

Client: The police officer looks stoic. His face looks flat. He looks at my wife and I and says that he is very sorry. Our son did not survive the crash. My wife begins to scream again, “My baby is dead, my baby is dead.” Her crying seems out of control and the paramedics try to comfort her. I look at the officer with a blank stare and ask him what I’m supposed to do. I can’t feel anything. I feel empty. I know I’m supposed to cry, supposed to feel sad, supposed to feel something, but all I can do is ask the police officer what I’m supposed to do. The officer gives me the address of the hospital where my son is being taken and gives me instructions on how to claim his body from the morgue. I thank the police officer. He then asks me what happened. I tell him about the cars that were racing and the oncoming truck. The police officer takes my statement. He tells me that the truck driver was injured and taken to the hospital. I finish giving him my statement. Another police officer comes and asks my wife for her statement. She has calmed down by now. She returns to where I am sitting, on the back of the ambulance but doesn’t say anything. A police officer tells us that he will take care of getting us home. We get into his car, I give him our address and none of us speak for the entire ride.

Therapist: What’s your SUDS rating?

Client: 70.

Therapist: I know how hard that was for you. You did a great job, and I appreciate you sharing that memory with me. I know at times it feels tough, but it will get easier each time.

Client: I didn’t think I was going to be able to continue.

Therapist: Sometimes it can feel that way, but it’s important to keep going. Remember, it is just a memory, and a memory on its own can’t hurt you. As we keep practicing these exposures you will feel less fear and anxiety. Eventually the memory will no longer cause you any fear. You should be really proud of what you just did. It took a lot of courage to talk about the accident so openly. How do you feel?

Client: I feel okay. A little anxious still.

Therapist: Do you think you could try that again?

Client: I think so.

Therapist: Okay, when you are ready, I want you to start again.

Treating PTSD with cognitive-behavioral therapies: Interventions that work

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19 Aug

Building a tiny house on a trailer is one way to avoid certain limitations that are often unavoidable when building on permanent foundations. For example, while building codes can be a great guide for building a safe home, I’ve never heard of a planning department expressing any desire to examine a tiny house on a trailer.

It makes sense actually – tiny houses on trailers can move to and from different communities; who would inspect them?The truth is tiny houses exist in a grey area between traditional houses and travel trailers.

But this scale of home is not entirely without limits. If you want to be able to pull your house down a highway without a special permit, it must conform to certain size limits. In most U.S. states this maximum size is 13.5-feet tall, 8.5-feet wide, and 40-feet long – 65-feet maximum including the tow vehicle. Extra care must be taken to squeeze the house into this semi-trailer sized imaginary space.

Below is a simple drawing that shows how quickly everything adds up. You can instantly see why so many tiny houses have roof pitches that are no steeper and 12/12 (45-degrees) and walls that are a bit shorter than 8-feet. At first the design challenge seems daunting, but as you browse through all the different homes people have built, you can see that there is still quite a bit you can do within the box.

Commercial travel trailers are designed to be lightweight and aerodynamic. Tiny houses are typically built from heavy building materials,like normal houses. This can make it much more comfortable to live in year-round but every foot in length adds-up and increases the requirements for the trailer and tow vehicle.

For example, a Tumbleweed Fencl is about 19-feet long and weighs just shy of 6,000 pounds empty. Add your belongings and you might start pushing 8,000 pounds. Now theoretically double the length to the 40-foot road limit – you could be talking about a house that weighs 16,000+ pounds, which would require a really big pickup to tow. This is not unthinkable of course, they build pickup trucks that can pull trailers that size; but it is an important consideration to make before committing to that scale.

Building tiny houses on trailers can provide a lot of flexibility and freedom; but like every design challenge, it doesn’t come without trade-offs. While you may not have to talk with building inspectors, you are pretty much on your own to build a safe and strong home on your own.

It’s best to use building codes as guides and add extra reinforcement like earthquake and hurricane straps – after all the house will encounter 60 MPH winds and road vibrations. For some this may sound adverselychallenging – to others it sounds like music to their ears. In either case try starting your design process from these practical size and weight limits.

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