“This is a stick-up!”
I never thought I’d hear that expression in real life, but oddly enough those were the words a man chose to tell my wife and me that he was mugging us. The “stick-up” happened many years ago on a warm night in July as we walked home from dinner when we were living in Washington, DC.
It was a terrifying experience, as the assailant grabbed me to separate me from my wife, and then wrestled my wife’s purse away from her, threatening to shoot us if we fought back. Thankfully we escaped with only minor bruises and scrapes.
After this kind of traumatic event, it’s common to avoid certain situations, either because they remind us of the upsetting incident or because we’re afraid that something similar will happen again. What we avoid depends on our specific trauma; common examples include:
- Being in any type of crowd
- Going to the grocery store
- Walking outside at night
- Attending sporting events
- Eating out at restaurants
A Smaller World
Many of the men and women I’ve treated for posttraumatic stress disorder (PTSD) were frustrated by the limitations their avoidance was causing, and were looking for relief.
“If you’ve developed the habit of avoiding situations because they trigger intense negative emotions, that can really make your life smaller and smaller,” said Dr. Carmen McLean, a research scientist at the National Center for PTSD who specializes in evidence-based PTSD treatment.
A shrunken world often leads to depression since we’re missing out on the things in life that are fun and meaningful. We can also start to believe that we can’t manage our life, and to see ourselves as inadequate. Many people I’ve treated have described feeling defective for not being able to get over their trauma, and get back to the things they like and need to do.
In Vivo Exposure Therapy
One of the most effective ways to reclaim life is through in vivo exposure therapy, which is a powerful part of cognitive behavioral approaches to PTSD treatment. Exposure is based on the principle that when we face things we’re afraid of that aren’t actually dangerous, fear diminishes.
By confronting their fears, trauma survivors “learn that these situations are safe,” said Dr. McLean. “It helps people open up their world again so they can do the things that are important in their lives.” In vivo exposure also boosts our self-efficacy, as we see ourselves doing challenging things that make our life better.
The process for doing in vivo exposure is straightforward:
1. Make a List
The first step is to “make a list of all the things you would like to be able to do comfortably that you haven’t been able to do comfortably, because of the impact of the trauma,” explains Dr. McLean. You can work with a friend or family member if you need help coming up with ideas for exposure. Aim to include activities that would be relatively easy to start with, as well as more challenging ones that you’ll need to work up to.
Once you’ve listed all the activities you can think of, use a 0 to 10 scale to rate each one for how difficult you think it would be. Going to the grocery store in the daytime might be a four, for example, while a crowded baseball game could be an eight.
Finally, arrange the activities from easiest to hardest based on the ratings you gave them. The result will be your exposure hierarchy, which is simply a ranked listing of the activities you’ll complete one by one. I like to create the hierarchy in a spreadsheet so it’s easy to sort the items and insert new ones, but paper and pen work fine, too.
2. Start with Activities That Are Manageable
The second step is to choose a first exposure activity to complete. Set yourself up for success by picking an activity that’s manageable, and put it in your calendar for a specific time. Plan to stay in the situation through the anxiety you’ll probably feel, which is how our nervous system learns that the situation is relatively safe.
When we stay through our discomfort, we also “learn from experience that we can tolerate temporary discomfort,” said Dr. McLean, “and that it decreases over time.” If we flee out of fear, we can reinforce the belief that the situation is dangerous and intolerable. You’ll probably need to repeat the exposure activity, which further increases a sense of mastery over it.
3. Move Up to More Difficult Activities
Finally, progress up your hierarchy to more difficult activities. “Gradually and systematically approach those things,” advises McLean. “Exposure builds on itself as you move up to more challenging situations.”
It’s just like climbing a ladder: As you ascend the lower “rungs” of your hierarchy, the higher items that felt too hard to do will come within reach. Many of the people I’ve led through this process were surprised at being able to do activities that not long before had felt impossibly difficult.
If you’re recovering from a traumatic event, in vivo exposure can be a crucial part of your healing. In the process you’ll become more aware of the unshakable strength and courage that live inside you.
The full conversation with Dr. Carmen McLean is available here: “Ep. 147: How Does Effective Trauma Treatment Heal the Body and Brain?“
