Should I do imaginal reliving or narrative writing when working on my client’s trauma memories?

Our thinking on this topic, and that of the OxCADAT team run by Anke Ehlers and David Clark, has evolved over the years. Imaginal reliving was probably our usual preferred option as it had an excellent evidence base through Edna Foa’s development of Prolonged Exposure Therapy (Foa et al., 1991) and was a great way of quickly accessing and beginning to process the important meanings and emotions bound up in trauma memories for most people. However, in later trials, we began to use narrative writing much more, as a consequence of testing out different formats of treatment delivery, such as internet-delivered treatments, and found it also to work very well. Nowadays, we see both options as equally effective clinically, but there may be a few reasons to choose one or the other. These haven’t been evaluated in research, so are only really based on clinical experience so are not ‘hard and fast’ rules!

Just to note that the content of a reliving or a written narrative is essentially exactly the same. We are asking clients to describe the trauma in detail, including thoughts, emotions, physiological sensations and other sensory details, in the first person, from a point just before the trauma to a point where they felt safe (if this wasn’t for a long time, we can ‘fast forward’ to a later point). Hotspot updates are included either verbally in imaginal reliving, or by writing them into the narrative (usually in a different colour to help them stand out) as they are developed. For more on the nuts and bolts of how to do reliving or narrative writing, see the videos on OxCADAT resources.

Imaginal reliving is usually the fastest method to use, so is great if you are trying to get going with treatment and cur through any avoidance. It is also usually a more direct route to meaning and emotion, which will quickly help you flag up hotspots and start updating trauma memories, often within one session. For most people (although not all), imagining the traumatic event(s) and talking them through in detail, is a powerful experience. It can be distressing, but clients tend to report it as “worth the pain” (Shearing et al., 2011), and distress is usually temporary and quickly replaced with relief.

Imaginal reliving can also be better for clients who struggle with literacy. Even if the therapist does the writing of the written narrative (under the client’s direction), it might still feel off-puttingly wordy for someone who struggles with reading and/or has negative associations with paperwork or prefers not to see their words written down.

The emotional intensity of imaginal reliving might mean that a written narrative is preferable for some clients, but be a little bit careful that this isn’t just because they (or you!) want to avoid the memory and associated emotions entirely! For clients who are very dissociative or tend to become overwhelmingly distressed when they activate the trauma memories to the extent that they disengage (a bit of distress is normal), then narrative writing is sometimes a better option as it provides a little bit more distance from the memory. It also makes it easier for you and your client to pace the session, pausing as needed to use ‘then vs now’ or grounding strategies if they are starting to dissociate.

Some people struggle to access the trauma memory in imagination, for example if they have aphantasia, so might work better with written narratives, site visits or even ‘bird’s eye reliving’ where we draw the area where the trauma happened as a spatial map, and use objects to ‘play’ the story out as if we are watching it from above. This is another good strategy for dissociation as it promotes a less immersive observer perspective. It can also help give a more objective stance when we are working on guilt appraisals (e.g. ‘when you look down on the scene as an objective observer, who do you think is responsible for what is happening?’).

A written narrative can also be useful if the trauma happened over a long period of time or if the memory is very fragmented or gappy. If you write on either a whiteboard or an electronic document, it is easy to rearrange parts of the memory as it becomes clearer or add more details as they emerge. You can also ‘map the gap’ where there is a memory gap, for example due to loss of consciousness, and can add in (again, usually in a different colour) information about what likely happened in the gap, even if it is not remembered. A more complete and coherent narrative aids memory processing, so this is often an important intervention for some trauma memories.

Written narratives and imaginal reliving are not mutually exclusive so you can switch between the two. For example, if you start reliving and are struggling to get through it without dissociation interrupting the session, you can try a written narrative and potentially return to reliving as the memory becomes less triggering. Or, if you have done a written narrative, you can then focus in on certain hotspots using imaginal reliving, or just relive certain sections and bring in updates to help them really connect at an emotional level.

Either can be used if your client does not have English as a first language and you can discuss with your client which they prefer. Even if you are having the sessions in English, your client may prefer to speak or write the narrative in their first language as it lessens the cognitive load of them needing to translate for you, which can improve engagement with the memory. However, you will need them to provide you with a translation so you know what is going on! If you are working with an interpreter, you can do reliving by asking your client to speak in chunks, giving time for your interpreter to translate and for you to intervene with questions as needed. Simultaneous translation is also possible, with the interpreter translating quietly to you as your client speaks (it is best if the interpreter sits next to you during this), but it can be tricky to keep up and for you to ask questions with this approach. For a written narrative, you’d need to ask your interpreter if they are happy to write a version of the narrative in your client’s first language, while you write a version in English (ideally underneath on the same document to help you keep track).

In short, both imaginal reliving and narrative writing work well and may confer certain advantages. You can discuss with your client what they would prefer and also use supervision to talk through the pros and cons. But don’t spend too much time deciding – as with lots of elements of treatment, the best thing to do is something!

Key points

· Both imaginal reliving and written narratives can be used to process trauma memories

· Both consist of a detailed account of the trauma, including thoughts, feelings and sensory details

· Imaginal reliving is a fast route to the emotions and meanings associated with the trauma memory and can be better for those with poor literacy or a dislike of paperwork

· Narrative writing can be preferable for people who dissociate or become highly distressed

as it provides distance and is easier to pace

· Written narratives can be easier for long trauma narratives and can be used to organise fragmented or gappy memories

· It is possible to switch between imaginal reliving and narrative writing during therapy

· Both can be used when English is not your client’s first language.

References

Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59(5), 715.

Shearing, V., Lee, D., & Clohessy, S. (2011). How do clients experience reliving as part of trauma‐focused cognitive behavioural therapy for posttraumatic stress disorder?. Psychology and Psychotherapy: Theory, Research and Practice, 84(4), 458-475.