This article and other similar articles can be found in Beyond Trauma: Conversations on Traumatic Incident Reduction, 2nd Edition available from the bookstore at www.TIRbook.com
The views and opinions expressed in these articles and interviews are those of the individuals speaking, and do not necessarily represent those of Applied Metapsychology International.
Developed by Frank A. Gerbode, MD, TIR is a regressive desensitization procedure for reducing or eliminating the negative residual impact of traumatic experience. As such it finds a major application in cases of post-traumatic stress disorder (PTSD). A one-on-one guided imagery process, TIR is also useful in remediation of specific unwanted stress responses, such as panic attacks, that occur without significant provocation. Thematic TIR traces such conditioned responses back through the history of their occurrence in a client’s life to the stressful incidents primarily responsible for their acquisition. The resolution of the primary incidents then reduces or eliminates the target stress response.
As an intervention technique, TIR is both directive and client-centered. It is directive in that the therapist who is called a “facilitator” guides the client, called a “viewer” repetitively through an imaginal replay of a specific trauma. It is client -or, as Dr. Gerbode prefers, “person-centered”, in that a TIR facilitator doesn’t interpret or critique the viewer’s experience or tell him how he should feel or what to think about it. A patient and systematic anamnesis [recollection, recalling to mind], TIR un-suppresses the trauma being addressed to provide the viewer the opportunity to review and revise his perspective on it. TIR’s uniqueness lies, in part, in the fact that a session continues until the viewer is completely relieved of whatever stress the target trauma originally provoked and any cognitive distortions (e.g., observations, decisions, conclusions) embedded within the incident have been restructured. (Gerbode, 1989)
TIR’s Philosophic Roots
TIR and virtually every other contemporary regressive and imaginal desensitization procedure used in the remediation of trauma – including “sequential analysis” (Blundell and Cade), “direct therapeutic exposure” (Boudewyns), “prolonged imaginal exposure” (Foa and Olasov), “gradual dosing” (Horowitz), “dianetics” (Hubbard), “flooding” (Keane and Kaloupek), “repetitive review” (Raimy), and “implosion” (Stampfl and Lewis) – derive directly from principles clearly articulated in the earliest writings of Freud and Pavlov. Although the latter, Pavlov, is properly credited with the identification of the “conditional reflex” and its chain-linked “secondary signaling system” (the model most commonly referenced in connection with PTSD acquisition), Freud earlier had made the equivalent observation about the development of the traumatic neuroses. He wrote:
What left the symptom behind was not always a single experience. On the contrary, the result was usually brought about by the convergence of several traumas, and often by the repetition of a great number of similar ones. Thus it was necessary to reproduce the whole chain of pathogenic memories in chronological order, or rather in reversed order, the latest ones first and the earliest ones last. (1984, p. 37)
The essential congruity of the Pavlovian and Freudian observations, in this connection, prompted Astrup (1965) to note that:
From a conditional reflex point of view, psychoanalytic therapy represents a continuous association experiment with subtle analysis of second signaling system connections… (p. 126)
As TIR draws heavily on these same well-established principals, Dr. Gerbode, who was originally schooled in psychoanalysis, and Dr. Robert H. Moore – a cognitive – behaviorist colleague, and author of these notes – routinely reference this intersection of the Freudian and Pavlovian constructs in presentations of TIR to the mental health professions.
PTSD And Imaginal Procedures
Whether favoring the remedial logic of “abreaction” or of “extinction,” dedicated trauma workers display a strong and growing philosophic and clinical consensus regarding the importance of addressing traumatic experience with a guided imagery procedure like that employed by TIR.
In their review of theoretical and empirical issues in the treatment of PTSD, Fairbank and Nicholson (1987) conclude that, of all the approaches in use, only those involving some form of direct imaginal exposure to the trauma have been successful.
Roth and Newman (1991) describe the ideal resolution process as one involving “a re-experiencing of the affect associated with the trauma in the context of painful memories” (p.281). Such a process, the authors point out, brings the individual “to both an emotional and cognitive understanding of the meaning of the trauma and the impact it has had…and would lead to a reduction in symptoms and to successful integration of the trauma experience” (p.281).
Grossberg and Wilson (1968) have shown that repeated visualization of a fearful situation produces a significant drop in the physiological response [as measured by galvanic skin response (GSR) as a biofeedback measurement] to the threatening image.
Folkins, Lawson, Opton, and Lazarus (1968) have demonstrated the efficacy of rehearsal in fantasy in reducing the physiological response (GSR) to a frightening movie.
Blundell and Cade (1980) independently confirm that repeated visualization of an anxiety-provoking situation produces a significant reduction in the physiological (GSR) response to the threatening image. Frederick (1986) used a very TIR-like desensitization procedure with trauma victims:
He contended that such incident-specific treatment is essential to overcoming PTSD. Using mental images, the client reviews, frame by frame, the entire sequence of the traumatic experience. During the process, the client is able to recall and disclose significant thoughts and feeling related to the trauma and, consequently, anxiety associated with the trauma dissipates. (Hayman, Sommers-Flanagan, and Parsons, 1987)
R. D. Laing concurs:
You can look at it with such narcissistic bonding as to bring tears to your eyes, or grimaces of distaste at what you see. After each paroxysm of self-pity or self-disgust or self-adulation, look at it again and again, and again until those tears are dry, the laughter has subsided, the sobs have ceased. Then look at it, quite dispassionately …until you’ve got nothing to do with it at all.” (Russell and Laing, 1992)
Some trauma therapists employ hypnosis as an accessing tool. Although this is not the case in TIR, it is interesting to note the similarity of the hypnotic and non-hypnotic approaches to resolution, once the client has contacted and begun to un-suppress a traumatic incident.
The Ericksonian procedure for addressing the content of a traumatic incident employs a trance state. Following hypnotic induction, his retrospective “jigsaw” technique guides the client in recovery of the cognitive and emotive components of a painful memory in whatever order the client can most easily confront:
Various bits of the incident recovered in this jigsaw fashion allow you to eventually recover an entire, forgotten traumatic experience of childhood that had been governing this person’s behavior…and handicapping his life very seriously. (Erickson, 1955/80)
MacHovec (1985) confirms that hypnotic regression can be used to help clients recall and revivify a traumatic incident, vent emotions, and gradually reintegrate the experience with improved coping skills.
PTSD And Cognitive Restructuring
Like other effective trauma resolution processes, TIR is not primarily a cathartic technique. Gerbode (1986) affirms the professional consensus that cognitive restructuring is prerequisite for thorough trauma resolution. Raimy (1975) concurs:
Many current therapies attempt primarily to relieve the client or patient of pent-up emotion, either in cathartic episodes or over longer periods of time in which emotional release takes place less dramatically. If we examine catharsis more closely, however, we can readily discover several cognitive events which have significant influence on the experience. If these cognitive events do not occur, no amount of “emotional expression” is likely to be helpful (p. 81).
Speaking specifically to the use of imaginal exposure in the rational-emotive treatment (RET) of PTSD, Warren and Zgourides (1991) report that:
Keane et al’s (1989) implosive therapy, Horowitz’s (1986) gradual dosing, and Foa and Olasov’s (1987) prolonged imaginal exposure are methods that help clients work through their traumatic event, discover and revise meanings, and develop more adaptive responses to the traumatic event. In RET, we incorporate imaginal exposure to the traumatic event.. (and).. While conducting the imaginal exposure and in reviewing imagined and behavioral exposure homework assignments, we are on the lookout for clients’ cognitive and emotional reprocessing of the trauma that may relate to the issues of meaning of the event, shattered assumptions, irrational beliefs, and so on. (p.161)
Beck (1970) lends additional support to the importance of cognitive restructuring during what he calls “rehearsals in fantasy” in his observation that:
When a patient has an unpleasant affect associated with a particular situation, the unpleasant affect may sometimes be eliminated or reduced with repeated imagining of the situation even though the content of the fantasy does not change. The unpleasant affect may be shame, sadness, anxiety, or disgust.
The data collected from patients and these experimental studies suggest that the rehearsals in fantasy produce a cognitive restructuring. With each voluntary repetition of the fantasy, the patient is enabled to discriminate more sharply between real dangers and purely imaginary or remote dangers. As he is able to appraise the fantasy more realistically, the threat and the accompanying anxiety are reduced.
Through fantasy induction (the patient) is able to recognize the specific details of his conception of the situation, to reality-test this conception, and to correct the distortions. The standard techniques of free association or direct discussion of the problem may fail to illuminate the conceptualization, whereas the fantasy expression brings it into sharp focus. Once the distorted picture has been corrected, the patient feels better and can handle the situation more efficiently.
Successful clinical application of TIR requires an absolute minimum of three days of intensive training – which includes skill development exercises, live and videotaped demonstration sessions and both giving and receiving TIR sessions under the supervision of a trainer certified by Applied Metapsychology International – followed by an optional practicum [internship] with consultation/supervision. As of this writing, TIR training for mental health professionals and para-professionals is available in at least ten countries around the world. See the Global training calendar or correspond with the trainer nearest you.
Astrup, C. (1965). Pavlovian psychiatry: a new synthesis Springfield, IL: Charles C. Thomas.
Beck, A. T. (1970). “Role of fantasies in psychotherapy and psychopathology”. The Journal of Nervous and Mental Disease, 150, 3-17.
Blundell, G. G., and Cade, C. M. (1980). Self-awareness and E.S.R. London: Audio Ltd.
Boudewyns, P. A., Hyer, L., Woods, M. G., Harrison, W. R., and McCranie, E. (1990). “PTSD among Vietnam veterans: An early look at treatment outcome using direct therapeutic exposure.”Journal of Traumatic Stress, 3, 359-368.
Erickson, M. (1955/80). Self-exploration in the hypnotic state. In E. Rossi (Ed.), The collected papers of Milton H. Erickson on Hypnosis. Vol IV. Innovative Hypnotherapy (427-436). New York: Irvington.
Fairbank, J. A., and Nicholson, R. A. (1987). Theoretical and empirical issues in the treatment of post-traumatic stress disorder in Vietnam veterans. Journal of Clinical Psychology, 43, 44-55.
Foa, E. B., and Olasov, B. (1989). “Treatment of post-traumatic stress disorder.” Workshop conducted at Advances in Theory and Treatment of Anxiety Disorders, Philadelphia, PA.
Folkins, C. H., Lawson, K. D., Opton, E. M. and Lazarus, R.S. (1968). “Desensitization and the experimental reduction of threat.” Journal of Abnormal Psychology, 73, 100-113.
Frederick, C. J. (1986, August) Psychic trauma and terrorism. Paper presented at the annual meeting of the American Psychological Association, Washington, D.C.
Freud, S. (1984). Two short accounts of psychoanalysis. In J. Strachey (Tr.), Five lectures on psychoanalysis (p. 37). Singapore: Penguin Books.
Gerbode, F.A. (1986). Indicators and end points. The Journal of Metapsychology, 1, 51-56.
Gerbode, F.A. (2009). Beyond Psychology: an Introduction to Metapsychology, 4th Ed. Menlo Park, CA: IRM.
Grossberg, J. M., and Wilson, H. K. (1968). Physiological changes accompanying the visualization of fearful and neutral situations. Journal of Personality and Social Psychology, 10, 124-133.
Hayman, P. M., Sommers-Flanagan, R., and Parsons, J. P. (1987). Aftermath of violence: posttraumatic stress disorder among Vietnam veterans. Journal of Counseling and Development, 65, 365.
Horowitz, M. (1986). Stress Response Syndromes (2nd ed.) Northvale, NJ: Jason Aronson.
Keane, T. M., Fairbank, J. A., Caddell, J. M., and Zimering, R. T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260.
Keane, T. M., and Kaloupek, D. G. (1982). Imaginal flooding in the treatment of a posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 50, 138-140.
Lyons, J. A., and Keane, T. M. (1989). Implosive therapy for the treatment of combat-related PTSD. Journal of Traumatic Stress, 2, 137-152.
MacHovec, F. J. (1985). Treatment variables and the use of hypnosis in the brief therapy of post traumatic stress disorders. International Journal of Clinical & Experimental Hypnosis, 33, 6-14.
Manton, M., and Talbot, A. (1990). Crisis intervention after an armed hold-up: Guidelines for counsellors. Journal of Traumatic Stress, 3, 507-22.
Moore, R.H. (1993). Traumatic incident reduction: a cognitive-emotive treatment of post-traumatic stress disorder.
In W. Dryden and L. Hill (Eds.) Innovations in rational-emotive therapy. Newbury Park, CA: Sage.
Pavlov, I. P. (1927). Conditioned reflexes. New York: Oxford Univ. Press.
Raimy, V. (1975). Misunderstandings of the self. San Francisco: Jossey-Bass Publishers.
Roth, S., and Newman, E. (1991). The process of coping with sexual trauma. Journal of Traumatic Stress, 4, 279-297.
Russell, R., and Laing R. D. (1992). R.D. Laing & me: lessons in love. Lake Placid, NY: Hillgarth Press.
Stampfl, T. G., and Lewis, D. J. (1967). Essentials of implosive therapy: A learning-theory-based psychodynamic behavioral therapy. Journal of Abnormal Psychology, 72, 496-503.
Turner, S. M. (1979). Systematic desensitization of fears and anxiety in rape victims. Paper presented at the annual meeting of the Assoc. for the Advancement of Behavior Therapy, San Francisco, CA.
Warren, R., and Zgourides, G. D. (1991). Anxiety disorder: A rational-emotive perspective.. Elmsford, NY: Pergamon.