Exposure Therapies for Flashbacks, Nightmares, and Intrusive Memories


Exposure Therapies for Flashbacks, Nightmares, and Intrusive Memories

October 5, 2014
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So far I’ve written about treatments for Arousal symptoms such as irritability, anxiety, and insomnia, and introduced Intrusive Symptoms like flashbacks, intrusive memories, and nightmares. Please remember that it’s important to address the hyperarousal of the sympathetic nervous system before trying any of the exposure therapies discussed below. If you can’t calm down and sleep, it’s not wise to add fuel to the fire.

Exposure therapy comes in many forms, but all have the goal of gradually detoxifying the traumatic memory and integrating it into your normal memory. They all contain the same steps, but some are more formalized than others. The steps are:

1) LET GO of negative emotions and pain

2) Explore the memory in detail

3) Reexamine your feelings, emotional and physical, about the memory

4) Reexamine your beliefs about the memory

5) REPEAT the PROCESS until the memory loses its power

This is a highly repetitive process, like peeling skin off an onion one layer at a time. The first time you approach the memory, you probably won’t do much letting go of feelings or exploring the memory in detail. But as you repeat the process, it should get easier each time. If not, you may be repeating a flashback and need to choose a different therapy approach. But whatever your approach, you’ll undoubtedly repeat these five steps many times before you find yourself at peace.

The first step, letting go of emotions and pain, is the hardest for most folks. We all avoid terror, fear, grief, disgust, anger, shame, guilt, and other negative emotions. If the memory involves a physical injury, the pain can be remembered by the body, and bodywork in the form of exercise or massage can release it. Different approaches work at different times and for different personalities and traumas. Pick what works for you, but don’t be afraid to experiment.

Ways to Let Go:

1)Cry, scream, curse

2)Share with others and accept support.

3)Use art, music, poetry, theater, or dance to express yourself

4)Visualize draining the feelings and pain into an object, another person, or pet.


6)Mindfulness (keeping focused in the present) and Meditation (emptying your mind of emotions and thought, while focusing on a higher concept)

7)Eye movements (like in REM sleep or EMDR)


9)Spirituality (giving your problems over to a higher power) and Forgiveness (of both yourself and others)

To make exposure therapy a little easier, therapists use a variety of approaches. We’ll look at them one at a time.

Telling your story is the oldest approach and still widely used. Back in ancient times warriors told stories around the campfire about their most dangerous adventures. This approach was formalized in Latin America for victims of governmental torture. It involves simply telling your story in detail to a receptive and supportive audience. You can tell it, write it, draw it, or even act it out, but you need at least one person to provide an audience. The more detail you include, and the more you repeat your story, the better. Both detail and repetition are essential. The first time you tell a memory, the affect may get overwhelming. Don’t let that scare you off. The affect should decrease with each telling. Encouragement and supportive feedback help. Listeners need to listen and support, not judge, but their realistic feedback can positively change how you perceive the memory. Remember to include all the details. Even a song playing in the background may become a trigger if you don’t mention it in your reprocessing.

When talking fails. If talking triggers you into a flashback, then the previous therapy won’t work. I found that EMDR was helpful for those memories. Medications or massage may also help.

What is EMDR? It’s an abbreviation for “Eye movement desensitization and restructuring” and accomplishes the same goal of detoxifying memories and integrating them into your normal memory flow. But EMDR uses a natural mechanism that we use every night when we sleep—eye-movements. You’ve heard of REM sleep? That stands for rapid eye movements. It’s a very important stage of sleep, and if you’re deprived of REM sleep, after a few days you will hallucinate. We’re taught that REM sleep helps us process the previous day’s memories. Aha! That’s what we want to do with traumatic memories—right? EMDR is as simple as moving the eyes back and forth while remembering the trauma in detail. Initially it requires a trained therapist, but it doesn’t require you to talk, and once you learn it, you can use it anywhere, anytime. This treatment is specific for PTSD, is proven to work, and there are many licensed therapists who use it both in the VA and in private practice.

The VA offers virtual reality exposure programs for veterans with PTSD. These are another form of exposure therapy designed to reproduce the combat situation in which the trauma originally occurred. Medications may be given and the exposure is done in time-limited bursts. Then a therapist helps the veteran to talk about and reprocess the associated traumatic memories. I’ve heard that this works but have no experience with it, and it’s only available in certain VA treatment centers.

Somatic Re-experiencing is a formal approach to massage and bodywork that helps your body remember and work through both the physical and emotional aspects of the trauma. Like EMDR, it does not require you to talk about the memory, but it can provide significant relief. I would recommend using a trained therapist as bodywork may trigger flashbacks.

A creative approach is Rewriting your Trauma. This was formalized for treating traumatic nightmares, but may work equally well for some flashbacks. You have to start at the beginning of the trauma at the same place the nightmare always starts. But then you change the story so it has a happy ending. The story you create doesn’t have to be real. You’re working with a dream, after all. But it must satisfy your needs emotionally. Then you practice visualizing it, over and over. I explain to folks that the old dream wore a rut into their brain, and they have to practice their revised dream until it makes an even deeper rut. What usually happens is they never dream either dream again. I see it as another approach to detoxify the traumatic memory.

CBT stands for Cognitive Behavioral Therapy and is widely taught to social workers and psychologists. It’s a modern therapy that grew out of Behavioral approaches, like reinforcement of positive behaviors, and Cognitive approaches, like following your thinking back to your assumptions and questioning those. It works well for treating Obsessive Compulsive Disorder and Anxiety Disorders, and is effective with medication for Depression. . In CBT the therapist helps the client examine the problem and the thoughts and behaviors related to that problem. Some therapists are trained to use behavioral desensitization, like progressive exposure to a feared object, to reduce fear, avoidance, and obsessive thinking. In my personal experience, this doesn’t work as quickly as EMDR, especially if your dealing with bad flashbacks.

Bottom line: Once the sympathetic nervous system is under control, you still need to work on your traumatic memories using some type of exposure therapy. If you can talk about the memory, that approach is the least expensive and can work. If you can’t talk without triggering a flashback, try EMDR.


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