544 TREATMENT OF SPECIFIC ANXIETY DISORDERS
In cognitive therapy clients are asked to complete a Trauma Narrative as a home-
work assignment for the first phase of imaginal exposure. Individuals write an account
of the worst traumatic incident in as much detail as can be remembered (see Foa &
Rothbaum, 1998; Resick, Monson, & Rizvi, 2008; Shipherd et al., 2006; Taylor, 2006).
The following instructions can be given for writing the Trauma Narrative:
“In order to begin our work on your distressing memories of the trauma, I would
like to assign homework that asks you to write an account of the worst trauma you
have experienced. The account should be written in the present tense, as if you were
experiencing the trauma at that moment. Please try to include as much detail of the
experience as you can remember. In particular include all the thoughts, feelings,
sensations, and responses that you experienced during the trauma. Allow your-
self to fully experience the emotions of the trauma. If you come to a difficult spot
in the narrative where you can’t remember very clearly or have doubts about the
experience, place a question mark (?). It is expected that you will find this exercise
distressing because you are reliving the events in your mind’s eye. You should work
on the account over several days and probably limit yourself to 30–45 minutes on
each occasion. If you have any concerns about the homework assignment or experi-
ence a sustained worsening of your symptoms over several hours, please contact my
office immediately and wait for further directions before resuming your work on
the narrative. Do not be concerned about the grammar, completeness, or accuracy
of your narrative. We will be working on it together in the next session. At this
point I would like you to do as much as you can on your own so that we can get a
start on your Trauma Narrative.”At the following session the client is asked to read aloud the Trauma Narrative.
Individuals are asked to rate their anxiety/distress level on a 0–100 scale before and
after reading the narrative. The therapist asks about any automatic thoughts experi-
enced while reading the narrative. Particular attention is paid to the most distressing
points in the trauma (i.e., hot spots) and the automatic thoughts or appraisals associ-
ated with them (Ehlers, Clark, Hackmann, McManus, & Fennell, 2005). After a com-
plete first reading of the narrative without interruption, the client is asked to read the
account several more times. The cognitive therapist may interrupt successive readings
with Socratic questioning designed to clarify and elaborate on details about the account
and help the client fully explore associated thoughts and feelings. If anxiety/distress rat-
ings decline over repeated readings of the narrative, this should be noted as empirical
evidence for the positive benefits of repeated exposure. Also any unhelpful automatic
thoughts or beliefs associated with the narrative, especially appraisals that occur during
the “hot spots” in the trauma, are dealt with by cognitive restructuring.
The Trauma Narrative can be used as the basis for developing an imaginal trauma
script that can be used for within- session and between- session imaginal exposure. An
audiotape of the script can be made and the client can be asked to engage in 45–60 min-
utes of imaginal exposure to the script each day until distress is reduced (Taylor, 2006).
The imaginal script should be rewritten periodically to reflect new details and insights.
The Exposure Practice Record (see Appendix 7.2) can be used to record between- session
imaginal exposures. For further discussion on how to implement imaginal exposure and