Coping with Real, Remembered and Imagined Stress II: Exposure Methods

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By Monica Neel, PSYD and Jim Fauerbach, PHD


Editor’s Note: This article is the second in a series of articles based on research funded by the National Institute on Disability and Rehabilitation Research (NIDRR).


Recovery from a burn injury includes not only healing wounds and regaining physical function, but also reestablishing psychological wellbeing. After their injuries, burn survivors are often confronted with a host of new stressors:

  • Fearful memories of how the injury occurred,
  • Changes in physical appearance, and
  • Returning to various injury-related or social settings and activities. 

One common, but not necessarily beneficial, way to cope with such stress is avoidance. Examples of avoidance include saying to yourself, “I’m not going to think about what happened…it upsets me too much,” or “I’ll just send someone else to the grocery store because I can’t stand it when people stare.”

While it is a normal human response to want to avoid upsetting memories and situations, such avoidance may actually hinder your psychological recovery. Although in the short run you may feel better by avoiding painful thoughts or experiences and the uncertainty of the challenges you face, that strategy may, in the long run, prolong your distress and prevent you from re-entering social situations.

In the first article in this series,* we described how to use focusing methods to cope with stress. This article explores another valuable tool—exposure methods.


The goal is to “stay in” long enough to get used to your “cold water.”GETTING USED TO THE “COLD WATER”

Do you remember a time when you’ve gone to the ocean in early summer? While we all have different strategies for getting used to cold water, some people never let themselves get used to it. You’ve probably seen them at the water’s edge, letting their feet get wet and then jumping away because it’s too cold, only to return 5 minutes later and try again—then discovering it’s still just as cold as the last time! These individuals never stay in the water long enough to get used to the temperature and, because of their avoidance, may miss lots of fun opportunities. 

There are many ways to get used to the cold water. Some people at the ocean may jump in all at once and still others wade in gradually concentrating on the lessening of the cold ocean temperature. These individuals would likely tell you that if you stay in long enough, you’ll “get used to the water.” The technical term for this process is “habituation”—a major goal of the coping strategy we are going to emphasize in this article. The idea is to help you get used to your own personal “cold water.”

As a burn survivor, your “cold water” may be fearful memories about your injury, returning to the scene of injury, or entering social situations that are now uncomfortable. If you only “dip your toe” into your own “cold water” and pull it back out, you may never “adjust to the temperature” or regain comfort with situations or memories you’ve been avoiding since your burn injury. 



Exposure methods are designed to help you directly conquer the fears that you may be experiencing since your burn injury by encouraging you to stay in the water long enough to get used to the temperature. When you avoid memories or situations, you will likely continue to believe that they are dangerous and, as such, will continue to feel distressed. This distress is a signal that you have “unfinished business,” and, as you’ve probably discovered, no matter how hard you try to push thoughts away or avoid situations, the distress still lingers.

However, when you confront memories or situations that you have been avoiding, you will find that your anxiety will gradually decrease as you “stay in” or habituate to the memory or situation. Peers can provide you with support and reassurance.Coping through exposure training can help you fully achieve psychological healing following your burn injury by helping you confront the memories or situations that now make you feel afraid. While walking through this process, it is important to be aware of the primary goals of this method of coping with stress:

  • Learn how avoiding memories and situations leads to continued distress.
  • Begin the process of habituation by staying with a certain memory or situation in an organized and controlled way. 
  • Begin the process of accepting the past and committing to the future. You can do this by creating a personal “take-home message” that is designed to help you feel safe from potential harm, or confident when entering new social situations.

Two main types of exposure training are designed to achieve the above goals:

  •  In Vivo (Real Life) Exposure—Involves physically going into the difficult situations. In vivo exposure is best used to re-enter social settings or the setting where your burn injury occurred. In the following description, we will describe a specific strategy called self-paced in vivo exposure—a strategy that will permit you to gain increased comfort and decreased distress, fear, or anxiety when entering a specific setting, such as the scene of your burn injury. You may also find it helpful to adapt these ideas to help you re-enter social situations that have been challenging to you since your burn injury
  • Imaginal Exposure—Enables you to systematically review in your mind’s eye something that has already occurred. Imaginal exposure could be used to fully process the circumstances surrounding your burn injury if this is a memory that you avoid or “block out.” This is often most helpful as an intermediate step in severe cases and is often best conducted with the guidance of a mental health professional. 



An important component to any exposure technique is monitoring your level of distress when in a specific situation or when recalling a particular memory. This can be done using the Subjective Units of Discomfort, or SUD, scale. The SUD scale runs from 0 to 100, where “0” means you are completely calm, and “100” means you are extremely upset—the most you have ever been in your life. Usually when people say they have an SUD rating of 100, they may be experiencing very unpleasant and strong physical reactions, such as sweaty palms, heart palpitations, difficulty breathing, dizziness, and anxiety.

What was your SUD rating the last time you were in a restaurant? What do you think your SUD level was when your burn injury occurred?

Checking your SUD rating is a key component to exposure training that will act like a “thermometer” to take your “anxiety temperature.” You should rate your discomfort using the SUD scale before beginning the exposure session and every 10 minutes during the exposure. Remember, the key to exposure training is staying in the water long enough to get used to the cold temperature. Therefore, it is very important that you continue your exposure session until your SUD rating has decreased by at least half when compared with your rating at the beginning of the session. For example, if you plan to use self-paced in vivo exposure to attempt to re-enter the setting in which your burn injury occurred, your beginning SUD rating might be 80. In this case, it would be important to stay in this setting until your SUD rating decreases to 40. (We recommend at least 1 hour.) Remember, if you “jump out of the ocean” right away, the water will still feel just as cold when you try to go back in. Similarly, if you leave the setting of your burn injury while you’re feeling very nervous and afraid, you will continue to feel just as afraid each time you return.

To help you stay in the situation you have chosen, focus your attention and awareness on the following:

  • Physical Environment—Describe and take in the setting around you. Where are you? What can you see? What time of day is it? What is the lighting like and where does the light come from (lights, sun, etc.). Describe any furniture or equipment around the area. Using present sensory focusing as described in the first article of this series can be helpful here.
  • Social Setting—Describe any people in the area. How are they dressed? What are they doing? Do you know them? What are they thinking and feeling?
  • You—Now describe yourself. What are you wearing? Where are you standing/sitting? What are you thinking and feeling?
  • What’s Happening—In step-by-step fashion, use your senses to take in what is happening around you. What do you see? hear? smell? What does your sense of touch tell you? By staying in the situation, you have the opportunity to become accustomed to this place again without your fear getting in the way. Using dia-phragmatic breathing techniques can be very helpful at these times. 



  • Repeating the Exposure—Allow yourself several chances to go back to this place multiple times (staying at least 1 hour each time). The first time you go, your SUD rating may be 80 at the beginning and 40 by the end. The next time you go, your SUD rating may be 64 at the beginning and 32 by the end. Each time you return (and stay long enough to allow your SUD to drop by half), you are becoming an active participant in managing your fears and anxiety.
  • Peer Support—Because you may be quite anxious when conducting an exposure session, it may be useful to find several informed peers (preferably trained in the Phoenix Society’s SOAR program!) who can provide you with support and reassurance. You may want to be accompanied by a support person who knows both you and the setting.
  • Safety—Be sure that you have permission to reenter the setting and that it is objectively safe.
  • Your “Take-Home Message”—After each 1-hour exposure coping effort, take some time to reflect on the experience. Consider the factors that contributed to your injury and how you can prevent similar occurrences to yourself or others by focusing on ways to make the environment safer. By taking this control, you will feel safer in your ability to predict and plan for potential threats. Focus on what you have learned and summarize this into your personal “take-home message.” 



There are times when self-paced exposure coping is not sufficient. When distress is severe or social problems are prolonged, the hurdle may be too great to overcome solely with your own resources. The guidance of a mental health professional can allow for a more gradual and systematic habituation. Alternatively, a professional can also assist in selecting among various other treatment option for those that might work best for you.

With therapist-led exposure, the goal of treatment is to habituate to the upsetting memories and events by “reliving,” either in your mind or in real life, the memory of how you were injured or a social situation that is distressing to you. When done effectively by a trained mental health professional, exposure therapy is a safe and scientifically proven method for reducing fear and anxiety, increasing adaptive thinking, and improving quality of life.


This story is an excerpt from The Phoenix Society’s® Burn Support News, Fall Edition 2003, Issue 3. Burn Support News is a tri-annual publication that contains articles on the emotional, psychological, and social aspects of burn recovery.  All Rights Reserved.
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