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Section 13
Guided Imagery for PTSD Clients

Question 13 | Test | Table of Contents

In the last section, we discussed the Emotional Freedom Technique (EFT).

In this section, we will discuss how your client with PTSD can use guided relaxation to find a safe place. I realize relaxation is a basic therapy technique, however, this provides the basic framework for the sections to come dealing with EMDR. The structure of this guided imagery is specifically created to interface with and be the first step for leading into EMDR.

I began using this guided imagery technique with Zach, age 32, who was struggling with being home after five years from leaving the military. Zach stated regarding his first PTSD panic attack, "I don't know what the trigger was, but it hit me hard. I went home one evening and all of sudden, I felt a tightness in my chest, it was hard to breathe, I felt closed in and panicky. I bolted out of bed thinking I was dying. I paced the room in the dark for hours before I exhausted myself. I almost went to the ER that night, but the Soldier in me said to stick it out.

I don't know what the trigger was. Maybe it was the young Soldier, a mother of two who was just redeployed, who I watched cut down after she hanged herself weeks after returning from battle earlier. Maybe it was because it was the same time of year when my uniform was covered with the blood and brains of a 6-year-old Iraqi child who was caught in an IED during Ramadan."

Zach needed a mentally safe place to go to when these attacks occurred while we continued to work on specific traumatic images that Zack still held.

Guided Imagery to Find a Safe Place:

To begin the exercise, I asked Zach to sit in a relaxed manner with uncrossed legs. I asked Zack to close his eyes while taking a deep breath. I explained that during the exercise when his image and feeling are strong I will go through some bilateral stimulation (BLS) to make the image and the feeling stronger.

I asked Zach to imagine going down a flight of 10 steps toward a totally safe and protected place at the bottom of the stairs. With each step he took down, the feeling of relaxation will set in and the tension will diminish. I counted one step at a time for Zach and with each step I offered comforting suggestions for how Zach could become more and more relaxed at each step.

Once Zach reached the last step, I guided him to find his safe place. To help Zach increase the intensity of his experience, I asked him about what he sees, hears, tastes, smells, and feels. I checked in with Zach to confirm that he was totally relaxed, comfortable, and safe in the place he has imagined. For Zach, it was helpful for him to feel more secure by imagining a shield around his safe place that keeps out anything that could cause harm.

Once your client is relaxed, the following is a script that you can use to guide your client in developing a safe place for himself. I used the following script with Zach to continue our guided imagery to form his safe place:

"Close your eyes and imagine a peaceful, gorgeous place. Maybe it is somewhere new, something from your imagination or somewhere you have been before. Let this be a special inner place, it does not matter what the place is as long as it is peaceful, serene, quiet, and beautiful that brings you to ease. This place can be somewhere you have been before where you have felt reflective that was healing or maybe it is somewhere you have seen in a movie, read about, or dreamed of. Notice what you are sensing. What do you see? What do you hear? What are the smells and aromas you are experiencing? What does it feel like? Allow yourself to be immersed in the beauty of the space and the peacefulness.

Creating a power spot:
Find a space within your place that feels particularly good, where you feel particularly calm and comfortable. Let this be your safe place and your power spot where you can draw from the peace and safety you are feelings. Now, keeping your eyes closed, how would you describe this place?"

Bilateral Stimulation to help further strengthen imagery:
During this process I began using bilateral stimulation and asked a few follow up questions to Zach to help further strengthen his imagery. If you recall, we have discussed bilateral stimulation in a previous section. One way to use bilateral stimulation is to tap both knees of your client back and forth. Some examples of follow-up questions I used are: What time of day is it? What season are you in? How are you dressed? What sounds do you hear? What do you see?

What if Your Client Cannot Develop a Safe Place?

Zach initially found it very difficult to find a safe place and he told me, "I am a guy, a military guy, and we don’t do this feeling stuff." I have found the following suggestions to be helpful when working with clients like Zach who find imagining a safe place difficult:

1. Try substituting the word safe for words like comfortable, peaceful, or relaxing because the word safe may be triggering for clients who have been severely traumatized, eliciting memories of not being safe.

2. Help your client identify a specific quality that he or she would need to make the space safe. I asked Zach, "What quality would you need for this place to be safe for you?" Zach responded, "I would need to feel strong and powerful" to which I replied, "Can you identify a time when you have felt strong and powerful?" After thinking about it for a few seconds, Zach said, "When I was running regularly I sure felt strong and powerful." I then asked Zach to bring up a memory of him running when he felt strong and powerful and he was able to. Once Zach had that memory in his head I asked him to try and bring that feeling into his safe place.

3. A client may have a safe object or person he or she could bring to the session. Zach brought in his dog to a session because his dog helped him feel much safer. He was able to pet and hug his dog whenever he wanted to take a break from the process.

4. You may want to help your client think of an image or a metaphor of resilience, stability, and triumph. For example Zach came up with the image of a large mountain. I asked Zach what he was feeling in his body when he thought of this image and he felt strong and powerful. To help reinforce and anchor the image I added bilateral stimulation by asking Zach to press his palm with his fingers. At a later time, Zach could return to the image by pressing his palms with his fingers.

5. Finally, your client may find it useful to conjure positive memories or conflict- free images. The idea with this suggestion is to find images of things that will help your client relax his or her nervous system. Many clients who experienced a traumatic event develop nervous systems that are attuned to only dangerous stimulus and do not register memories of nontraumatic, ordinary life experiences that would act to counter their perception of the world as dangerous. As you may know, positive conflict-free images come from your client’s everyday experiences when he or she felt present and whole. You can strengthen his or her image by asking a series of sensory details. For Zach, walking his dog in the park was a positive, conflict-free image that allowed him to feel that his life was not all terrible.

In this section we discussed using guided imagery to help your clients create a safe place for themselves. When using the guided imagery, we discussed using follow-up questions (such as What time of day is it? What season are you in? How are you dressed? What sounds do you hear? What do you see?) to help further strengthen your client’s image. We also discussed five suggestions to help clients who cannot develop a safe place: substituting the word safe for words like comfortable, peaceful, or relaxing; identify a specific quality that he or she would need to make the space safe; bring a safe object or person; help your client think of an image or a metaphor of resilience, stability, and triumph; and conjure positive memories or conflict- free images.

In the next section we will discuss how your client can identify nurturing figures to use as an inner resource before beginning the EMDR process.

Parnell 85-91 case study:
Reviewed 2023

Imagery Rescripting as a stand-alone treatment for posttraumatic stress disorder related to childhood abuse: A randomized controlled trial

Raabe, S., Ehring, T., Marquenie, L., Arntz, A., & Kindt, M. (2022). Imagery Rescripting as a stand-alone treatment for posttraumatic stress disorder related to childhood abuse: A randomized controlled trial. Journal of behavior therapy and experimental psychiatry, 77, 101769.

Peer-Reviewed Journal Article References:
Hoffart, A., Øktedalen, T., Langkaas, T. F., & Wampold, B. E. (2013). Alliance and outcome in varying imagery procedures for PTSD: A study of within-person processes. Journal of Counseling Psychology, 60(4), 471–482. 

Sell, C., Möller, H., & Taubner, S. (2018). Effectiveness of integrative imagery- and trance-based psychodynamic therapies: Guided imagery psychotherapy and hypnopsychotherapy. Journal of Psychotherapy Integration, 28(1), 90–113.

Stanley, I. H., Rogers, M. L., Hanson, J. E., Gutierrez, P. M., & Joiner, T. E. (2019). PTSD symptom clusters and suicide attempts among high-risk military service members: A three-month prospective investigation. Journal of Consulting and Clinical Psychology, 87(1), 67–78. 

Staples, J. K., Gordon, J. S., Hamilton, M., & Uddo, M. (2020). Mind-body skills groups for treatment of war-traumatized veterans: A randomized controlled study. Psychological Trauma: Theory, Research, Practice, and Policy.

What are five suggestions you can use to help your client who cannot develop a safe place? To select and enter your answer go to Test.

Section 14
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