Traumatic Incident Reduction:
Cognitive-Emotive Resolution of the Post-Traumatic Stress Disorder by Robert H. Moore, Ph. D.

Problem Profile | Primary and Secondary Trauma | PTSD and Cognition |
Traumatic Incident Reduction | Notes | Bibliography | The Author

Traumatic Incident Reduction

The most thorough and reliable approach to the resolution of both long­standing and recent disaster PTSD currently in use is Traumatic Incident Reduction (TIR), a guided cognitive imagery procedure developed by Gerbode (1989). A high­precision refinement of earlier cognitive desensitization procedures, TIR effectively resolves the outstanding trauma of the majority of the PTSD clients with whom it is used when carried out according to its strict guidelines.

TIR appears to be more efficient and more effective than other cognitive­imagery or desensitization procedures, as such procedures frequently focus mainly (and most often incompletely) on secondary episodes. By tracing each traumatic reaction to its original or primary trauma(ta) and by taking each primary trauma to its full resolution or procedural "end point" at one sitting (a crucial requirement), the TIR process leaves clients observably relieved, often smiling, and no longer committed to their previously errant cognitions. At that point, the traumatic incidents, their associated irrational ideation, and consequent PTSD have been fully handled, and clients are able to re­engage life comfortably in ways they might not have been able to do since their original traumata.

Done one­on­one, the core TIR procedure may be completed in as little as twenty minutes or it may require two or three hours (average: 1.5 hrs) of "viewing" per incident. No procedure that is confined to the fifty-minute hour can be considered flexible enough to handle the average primary traumatic incident. The therapist needs to be willing to take the time necessary to guide the client back through the relevant trauma, carefully following TIR procedural guidelines, to permit the client to work through the painful memories of the experience in order to restructure its cognitive content as needed for full resolution.

Ideally, PTSD clients correctly identify their active primary incidents during intake. Clients who have regular flashbacks generally do this with ease. Such clients may be briefed on TIR the same day and, if not on drugs, scheduled for viewing the next day. Their PTSD problems can often be alleviated within the week. It is not unusual for a TIR narrative procedure to resolve an "unoccluded" (obvious) primary traumatic incident in as little as two or three hours. Case resolution then would depend mainly on how many primary and secondary traumata needed to be addressed to restore full functioning.

More commonly, however, PTSD clients do not correctly identify all their active primary incidents at intake. A war veteran, for instance, may at first report with conviction that it all dates back to Vietnam; he's only had the problem since then, and that is the content of his flashbacks. Once he gets into it, however, he is sometimes surprised to discover that his wartime experience was actually secondary to some previously occluded or less memorable earlier trauma.

In chronic cases, including some phobias and panic disorders in which flashbacks are absent, clients often have no clue at intake as to where or when their reaction patterns were actually acquired. Although technically not classified as PTSD, many such clients have had a significant number of stressful experiences over the years. Yet they cannot, at first, identify any one incident as having been much more significant than any other. They are often thoroughly frustrated and discouraged, as well as genuinely baffled, about the persistence of their symptoms. Those among them who lead otherwise comfortable lives and seem not to think much less rationally, day­to­day, than the majority of the population frequently come to the usually erroneous conclusion that their problems must be genetic in origin ("run in the family"). (Needless to say, such cases are not resolved within the week.) They are not generally a problem for TIR, however, as they may be handled to resolution very adequately by the thematic approach, a variation of the narrative procedure. Thematic TIR does not require clients to be aware of or to identify correctly the relevant historic components of their cases right at the start of their intervention. Instead, the thematic procedure simply traces each manifest (present time) emotional and somatic symptom (theme) back through its chain(s) of secondary incidents, one at a time, until the originally occluded primaries come into awareness and can be dealt with routinely.

Toward clients' understanding of the TIR routine, which assuredly will be new to them, it is often useful to draw upon the illustrative value of the Pavlovian example mentioned earlier and with which they may already be familiar. One may point out, in this connection, that when the dog's salivation response to the bell (primary stimulus) is extinguished, the light (secondary stimulus) loses its restimulative potential automatically (Hilgard, 1962). Likewise, once a primary incident is completely resolved, none of the stimuli that had later become associated with it as secondary restimulators is capable of triggering any further reaction (Gerbode, 1989). This means that when the veteran fully resolves his "artillery attack" (and any other related primary incidents), he will no longer be vulnerable to restimulation triggered by the various secondarily toxic stimuli associated with that experience. At that point, fried chicken and mother­in­law are back to representing nothing more than fried chicken and mother­in­law.

This may seem like a rather classical Pavlovian explanation, but one of TIR's main concerns is the ultimate correction of the PTSD client's trauma-related thought processes. Once clients realize that it was the cumulative effect of their traumatic incident networks on their cognitive­emotive response sets over a period of time that is responsible for the persistence of their PTSD symptoms, and once they understand that there is a way to shut down the networks' active components permanently, they'll be happy to use the TIR approach, even if they are already accustomed to another technique. Then, even thoroughly frustrated and discouraged chronic and absent­flashback PTSD clients will begin to feel hopeful.

The lexicon of TIR reflects its purpose and procedure. The client is called a "viewer" because his/her primary function is to confront, via the viewing process, past trauma. The person conducting the session is called a "facilitator" because his/her purpose is simply to facilitate the viewer's process of viewing (Gerbode, 1989). Just as "physician" and "patient" become "analyst" and "analysand" or "surgeon" and "organ donor," based on the requirements of their respective roles, the designations "facilitator" and "viewer" are reserved for those whose interaction is governed by the singular requirements of the TIR process.

TIR, like other cognitive­imagery processes, differs somewhat from most contemporary therapies. Although it holds errant cognition to be at the root cause of emotional disturbance, unlike the mainstream cognitive approaches, TIR carries the revision process back to the specific experience(s) that originally produced and enforced such cognition. In this regard, TIR is a bit more "personal" than most contemporary cognitive therapies. Instead of relying mainly upon the therapist's insight into or inferences about a client's probable belief structure, as is common in RET, TIR guides clients in the discovery and revision of their own original disturbance­causing cognitions.

What makes such a procedure both necessary and possible is the fact that, in PTSD, the disturbance­causing cognitions (except for the pre­existing ones) were originally generated in response to, and in order to cope with, a traumatically painful and/or upsetting experience. Moreover, the offending cognitions are still being kept in force by the long­term residual impact of the incident. In other words, if it hadn't been for the specific circumstance of the trauma, as subjectively experienced by the client, e.g., "Oh my God, I've been shot! I'm gonna die!", the client wouldn't have formulated the response, e.g., "I should never let my guard down, even for a minute!" Moreover, if the incident hadn't been so emotionally and/or physically painful, making it extremely difficult for the client to confront, its attendant cognition would be a great deal more accessible to routine reappraisal and restructuring.

So, while it remains very useful to be able to infer with reasonable certainty that an anxious client is generally feeling threatened and ineffectual while an angry client would like to assert control over something (pardon the reductionism), these are just some of the more obvious "common denominator" dynamics associated with their respective current disturbances. What we cannot infer but what TIR reveals to clients who have experienced trauma is exactly what happened (at a subjective/cognitive­emotive level) that so overwhelmed them that they would come away from their experience stuck in an involuntary, out­of­date, and irrational mind­set constructed, among other things, of numerous fairly obvious stress-producing mis-evaluations and distortions.

In a certain respect, TIR adds a new dimension to our understanding of the relationship between cognition and emotion. While theorists have long held that irrational thinking tends to promote upset feelings, TIR suggests that one's (traumatically) upset feelings also tend to promote irrational thinking. Dodging the "Which came first?" (chicken or egg) question, it is probably safe to say that, on the face of it, the causal equation appears to be reversible. That is, not only does cognition significantly influence emotion, but emotion appears to significantly influence cognition.

Even more critically significant, at least in cases of PTSD, the remedial equation seems to be reversible as well. Whereas cognitive therapists observe that the restructuring of one's irrational and distorted thinking produces a corresponding reduction of emotional disturbance, TIR confirms Ellis' (1990) observation that a reduction of primary traumatic emotional disturbance produces a corresponding restructuring of one's irrational and distorted thinking! In short, the client whose trauma has been fully reduced and resolved and who has become able to talk (and think) freely and painlessly about it (a TIR goal) almost immediately and self­directedly begins to display a substantively rational (moderate, tolerant, objective) viewpoint regarding that previously painful experience. As always, the client who succeeds in embracing a more rational viewpoint about an experience, regardless of how unfortunate or traumatic that experience once seemed, is no longer disturbed over it or unwittingly under its control. As a consequence, secondary restimulation and flashbacks cease, life's energy and interest revive, and self­esteem rebounds.

What is particularly remarkable about the cognitive restructuring that takes place in TIR is that it takes place so obviously and spontaneously during the course of a given session. Equally remarkable is the fact that it takes place­­ and truly must take place ­­ without didactic or corrective facilitator input. The facilitator's role in TIR is mainly to so conduct the session and guide the viewer in "repeated review" of the selected trauma (in strict accord with the established protocol) that the viewer will be able rationally to restructure his own "misconceptions" about it (Raimy, 1975). Bear in mind that at this level of intervention the viewer is truly the only one who can decipher (by patient and careful re­examination of the cognitive images stored in memory) what actually happened or appeared to happen in the incident, what its significance was, what he or she was thinking at the time, why it was so extraordinarily painful, how he or she coped with that pain, and what trauma­related conclusions and/or decisions were made at the time. So, as the viewer reviews this highly sensitive and very painful material repeatedly in imagery in order to discharge the emotional impact holding the cognitive distortions in place, the facilitator says not a word.

Although in TIR's handling of PTSD the operant trauma­related distortions virtually self­correct once the inordinate emotional distress of the traumatic experience is relieved, viewers frequently want to follow a completed TIR session with some discussion or review of some of the ways in which certain of their newly­surrendered trauma­related beliefs and attitudes had affected them since the occurrence of their original trauma! Most practitioners find this discussion one of those truly rewarding moments in clinical practice. It is not only confirmation of a successfully completed specific intervention. It is re­confirmation of what contemporary theorists have asserted all along about the relationship between cognition and emotion ­­ with the additional suggestion that that relationship may be even more interesting than we had originally supposed.

A fully resolved traumatic experience is neither completely nor mostly forgotten. It is, by definition, simply benign and incapable of intrusive restimulation.