The FAP also underlies current popular treatments for circumscribed PTSD. Exposure is the primary behavioral approach to treating clients with problems resulting from trauma (e.g., Foa & Rothbaum, 1997) and is present in all forms of psychological treatment. From a behavioral point of view, all treatments, even ones not classified as "behavioral," generally expose clients to traumatic material as part of the treatment process, and their treatments would be consistent with an exposure model. The learning principle underlying exposure is extinction. Extinction occurs when the evocative stimulus is presented and then is not followed by an aversive stimulus. Thus, in clinical work, exposure involves presenting the evocative stimulus and making sure that the client does not avoid or escape it. This process of exposure to traumatic material, although potentially healing in its effects, is by necessity emotionally challenging for the client. In fact, clients who initially experience high levels of distress upon imagined contact with their traumas, followed by gradual habituation, tend to show more improvement than those who do not report high levels of initial distress or who do not report habituation to high levels of stress (Jaycox, Foa, & Morral, 1998). If the client avoids or escapes, then the behaviors of avoidance or escape are strengthened (reinforced), and there is no therapeutic progress. Even worse, the problem may be exacerbated.
For example, in using exposure to treat a person suffering from the trauma of a rape, the client would reexperience the emotional arousal present during it (see Riggs, Cahill, & Foa, Chapter 4, this volume). This reexperience could be evoked through imagination, discussion, going to the place where the rape occurred, or any other method that would promote rape-related emotional responding. The emotional arousal would need to be high and sustained; the client would need to remain aroused until that arousal began to decrease. If the client terminated the reexperiencing before the decrease in arousal began, symptoms could even worsen.
Three necessary conditions and one highly desirable one must be met before this kind of exposure-based treatment can begin. First, the evocative stimuli must be known and specifiable. That is, the clinician must know what the evocative stimuli are before a method for exposure can be devised. Second, the client must be cooperative. That is, the client must be willing to talk about the trauma and tolerate a certain amount of anxiety by agreeing to place him- or herself in the presence of the evocative stimuli. Third, the therapist must also be willing to hear about the trauma and potentially experience emotional arousal as a part of the treatment. Finally, it is highly desirable that the evocative stimuli be presented in vivo. That is, it is always best when the evocative stimuli be presented in a real form rather than via talk or imagination (Goldfried, 1985).
It is important to note that when exposure treatments are successful, the arousal symptoms that can have diminished the person's ability to participate fully in life are greatly attenuated. This does not mean that the sorrow connected with the losses sustained in a trauma is forgotten. The sadness about being raped, attacked by a dog, or losing one's house or beloved pet would naturally linger and would inform life from that point on. The intrusive, uncomfortable, life-interfering aspects of arousal and avoidance, however, would be greatly reduced.
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