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The healing potential of imagination in the treatment of psychotrauma: An

alternative explanation for the effectiveness of the treatment of PTSD using
fantastic reality

Article · February 2012

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Mooli Lahad Dmitry Leykin

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THE HEALING POTENTIAL OF IMAGINATION
IN THE TREATMENT OF PSYCHOTRAUMA:
AN ALTERNATIVE EXPLANATION FOR THE
EFFECTIVENESS OF THE TREATMENT OF
PTSD USING FANTASTIC REALITY

Mooli Lahad and Dmitry Leykin

This chapter consists of three parts. First we will discuss the concept of
Fantastic Reality, then we will introduce a new protocol for the treatment of
psychotrauma using combined methods and emphasizing the centrality of
imagination and last, we will discuss its uniqueness and distinction in
comparison to the current cognitive behavior therapy (CBT) treatments of post
traumatic stress disorder (PTSD).

FANTASTIC REALITY (FR)

Fantastic Reality (FR) is the "as if" space, where every "if" is possible. It
allows the psyche to play again as it did in early childhood, in a space where
laws of reality do not govern. In this space it is possible to invent stories as
part of a journey in quest of answers and insights for real life situations for
which logical solutions are no longer satisfactory. In FR, it is possible to
search for logical metaphorical answers and solutions and images, with the
aim of ascertaining how applicable they may be in the future. Often, the
journey to FR and back brings about relief, even when there is no practical
2 Mooli Lahad and Dmitry Leykin

application of the "insights" or "gaining of knowledge" experienced. This

relief may stem from the "distancing for the sake of bringing near" principle.
Being in FR is often experienced as a state that simulates a trance. It is
possible that the resulting relief comprises the sensorial experience of all early
childhood abilities that enable the adult sharing this to experience that
Winnicott calls creating a world (Lahad, 2006).
Findings of various studies show that between a third to a half of our
waking hours as adults are spent daydreaming, holding imaginary
conversations, fantasizing about an upcoming vacation or in imaginative re-
narration of a past rendezvous with a loved one (Klinger, 1990). In his book
Halom Hanefesh (The Dream of the Soul) (Cohen, 1996, pages 21-22), the
author quotes the following excerpt from Coch-Strauss and colleagues:

"The potential images of dreams and the awakening fantasies offer us

the necessary materials to discover and define ourselves. All we must do is to
use them wisely. With these channels we can win a fresh, personal, creative
perspective of ourselves and the world around us. This will help us go beyond
our usual points of reference in our search for solutions to problems we
encounter."

During childhood, there is no differentiation or separation made between

reality and imagination. As all children who believe in fairies will testify,
Tinker Bell, Peter Pan’s fairy, demands that we declare our belief in fairies,
otherwise they are doomed to die. What child would allow such a sweet fairy
to die?
Children can easily move back and forth between reality and imagination.
The younger they are, the more this is considered advantageous. But adults in
our culture try to wean themselves from the ability to imagine, or at least to
conceal and hide this ability, lest they lose points in the race to "appear sane."
This mechanism is at our disposal during times of crisis and grave danger.
It enables us to temporarily detach ourselves from the terrible, life-threatening
event (Horowitz, 1986; Putnam, 1993; 1997; Merckelbach and Candel, 2004).
We know about this detachment from accounts of rape victims, survivors of
traumatic disasters, torture victims, prisoners and hostages.
The victims report this amazing detachment – this dissociation in the
service of survival. "It is possible to see these conscious situations as one of
nature's small graces that shield against unbearable pain… detached conscious
situations are similar to a hypnotic trance. In both cases there is a relinquishing
of voluntary action, suspension of initiative and critical judgment, subjective
 The Healing Potential of Imagination… 3

distancing or peace, increased conceptualizing of images, changes in feelings

including sensory numbness, analgesia, distortion of reality, including
detachment from the self, detachment from reality and changes in the sense of
time." (Hilgred in Herman, 1992, page 62).
FR is the link between the infinite ability of the creative imagination to
create a world picture, desired or required, and the actions taken to solve
problems in reality in the shared space of therapy. In FR the three laws of the
"real" world: Time, place and role, do not rule. In reality things can happen
only at a certain time and in a certain place, and preferably the person
participating will have a specific role. Sometimes people must play several
roles simultaneously. This is usually experienced as a burden or a heavy load
that impairs functioning. We tend to refer to it as "dual or multiple
responsibilities" that prevents us from feeling that we are fully in the moment.
In FR one can shrink time or stretch it, and have things happen 'here and
now' and 'then and there' at the same time. The place can be simultaneously the
real space (therapy room) and another magical venue. This place can be inside
(a palace, for example) or outside (a dense forest). The client can
simultaneously be himself and play another role. The roles can be realistic,
desirable, imaginary, etc.
Landy (1993) explains the paradox at the core of the dramatic experience:
"It is possible that the most significant aspect of the dramatic paradox has to
do with the fact that the actor and the role are at the same time separate and
united and the reality of the existence of the actor lies in his coexistence with
the fictitious reality of the role he is playing” (p. 11).
Winnicott (1971) discusses a similar space called "the potential space."
This is the psychic space where positive, fulfilling experiences occur; where
there is no need for a realistic object and one can move between reality and
imagination. The potential space differs from person to person. Its existence
depends upon life experiences and not on genetic tendencies. According to
Winnicott (1971), play takes place in the in-between space, the space between
the child's inner and outer worlds, between reality and imagination.
Healing or relaxation is experienced by permitting the psyche to play like
a child's. This experience is possible in a noncritical, nonjudgmental, non-self-
righteous space; a space that is creative, encouraging and where play is
encouraged. This is a space where the invention and fabrication of stories is
permitted, a space in which to daydream and to fantasize while fully aware
that the movement from reality to FR is in the service of the coping self, and
its goal is not to detach from real life.
4 Mooli Lahad and Dmitry Leykin

FANTASTIC REALITY AND DISSOCIATION

In mainstream psychology and psychotherapy, the transcendence into FR
during or immediately following a traumatic incident (and certainly later on) is
considered to be dissociation.
Dissociation is described by the Webster new world medical dictionary as
detachment of the mind from the emotional state or even from the body.
Dissociation is characterized by a sense of the world as a dreamlike or unreal
place and may be accompanied by poor memory of the specific events, which
in severe form is known as dissociative amnesia (Cardena and Spiegel, 1993).
The term dissociation refers to the act of separating or the state of being
separated, and is one of the strongest predicators of PTSD. In some studies, the
closer in time this occurred, the greater the chances of it being a major risk
factor predicting the possible development of PTSD. In 2003, Ozer and
colleagues found that peritraumatic dissociation – (PTDIS) that occurs in
close- time proximity to the event, predicts a higher risk of developing PTSD
(they claim that 70 percent of those who have experienced PTDIS at the acute
stage (ASR) will develop PTSD) (Ozer, Best, Lipsey and Weiss 2003).
However, in a critical review of dissociation, Bryant (2007) questions
whether it is in fact a critical predictor. An attempt to study PTDIS was
recently made by Kaplansky in her doctoral research (2009). She examined the
link between the ability to transcend to FR and PTSD. Looking for definite
PTDIS, she decided to work with people who had been in life-threatening
traumatic situations and voluntarily described a situation that was closely
associated with FR. Kaplansky examined a group who had had near death
experiences (NDE) Greyson,( 1991; 1993; 2000).
The people in this group were exposed to an extreme life-threatening
event (cardiac arrest, rape, terrorist act, road accident). They gave an account
of the event which included the following elements of FR: Transcendence; a
tunnel with light at the end; an encounter with spirit beings; a feeling of being
out of one's body; and a sense that ,life flashed before my eyes like in a movie.
(Kaplansky, 2009). As this phenomenon occurs at the PTDIS stage, it may
present a risk that the members of the group will develop PTSD (Brooks,
Bryant, Silove, Creamer et al., 2009). Kaplansky's research replicated
Greyson's findings from 2000 and found that the NDE group not only did not
suffer PTSD but its scores on the anxiety and dissociation scales were low in
comparison to both the general population and to clients diagnosed as
suffering from PTSD. When she checked the PTSD group she therefore
 The Healing Potential of Imagination… 5

expected that they would not report NDE experiences; however, this was not
the case.
The study shows that clients suffering from PTSD also had NDE.
Nevertheless, unlike those who transcended into FR (almost 70% of the stories
included floating, light, meeting spirit beings and other NDE features) the
PTSD group’s most common NDE experience was "seeing my life flash
before my eyes" (over ten times more). This means the client was aware of its
life's termination of all that have happened to him, in other words out of all the
NDE experiences this is the closest to reality. It may include elements of guilt,
remorse, deep sorrow at relinquishing life, and no joy that those encountering
the light or the spiritual beings, report on.
Looking for a potential explanation in the childhood experiences of the
NDE group that might have "trained them to transcend into FR," Kaplansky
asked them about childhood imaginative activities. Her study demonstrates a
clear distinction between the NDE group, the control group and the group
suffering from PTSD in the way they used imagination and its outcomes in
their childhood (i.e. playing musical instruments, dancing, painting,
participating in drama or theater and most of all, telling and listening to
stories). Those who reported experiencing NDE surpassed the rest in the
length of time and the intensity of their stay in FR, and yet maintained their
ability to move back and forth between FR and reality. In addition, the study
raises the possibility that children who "practiced" transcending into FR and
whose parents encouraged such activity, may developed some protective
feature for encountering extremely threatening situations, or some resiliency.
Kaplansky maintains that dissociation is an attempt by the human brain to
protect the individual from the horror of exposure to death and to
psychotrauma, however, not everyone manages to exploit this mechanism to
its fullest potential. The study proposes making a distinction between complete
dissociation – NDE – and partial dissociation. The former "saves" the one
exposed from the horror of death, while the latter continues for a time in the
brain's desperate, but unsuccessful attempt to conclude the process of
transcendence into FR. The PTSD sufferer remains trapped in the fragments of
dissociation that embitter his life (Kaplansky, 2009). This study is one of the
foundations upon which we propose to use FR in treatment or in re-narration
of trauma. This will enable the individual to combine fantastic elements with
an otherwise impossible and unbearable event so that he can undergo the
healing experience that dreaming and transcending make possible.
The findings regarding the excessive use of imaginative involvement in
childhood and the subsequent experience of NDE, supports findings of
6 Mooli Lahad and Dmitry Leykin

researchers 25 years earlier. Council and Greyson (1985) found that 63

participants who reported prototypical NDE were found to be significantly
high in personality trait called Fantasy Proneness. Coined by Wilson and
Barber (1983), such personality disposition involves a childhood history of
intense imaginative involvement in reading, play activities, and
mystical/religious experiences. Further evidence that may support the theory
about the efforts of PTDIS to attempt to be a conduit to FR is the finding of
Candel and Merckelbach (2004) who reported a positive correlation between
PTDIS experiences and indices that report a tendency to fantasize. As
mentioned earlier, researchers describe people with a tendency to fantasize (e.i
fantasy proneness) as "fantasizers" in childhood and adulthood, who, among
other things, have difficulty distinguishing between "real" and fantastic events
that occur in subjective reality (Wilson and Barber, 1983). Recently, this
personality trait was found to have a direct and unmistakable connection to the
tendency to cope via the mechanism of imagination in time of stress, as
measured by the BASIC PH integrative multi-dimensional model of coping
mechanisms inventory (Lahad and Leykin, unpublished data). Furthermore, a
positive correlation between a tendency to fantasize and standard dissociation
indices was also found in earlier studies (Dissociative Experiences Scale;
Bernstein and Putnam, 1986). (See Merckelbach, Horselenberg and Murris,
2001.) From the perspective of memory theory, we may understand that
combining fantastic elements in the treatment of trauma victims is founded on
the complexity of the human memory, as seen especially in the memory of
traumatic events. The dual representation theory of Brewin et al. (1996)
proposes that the traumatic information is processed in one of two memory
systems and creates two separate representations. The first system is the
verbally accessible memory (VAM). This system processes autobiographical
memories of the event and is associated with the later verbal description of the
trauma. Information that did not receive enough attention to be saved in the
VAM, is codified in the situationally accessible memory (SAM). This system
saves sensory information, especially visual-spatial data, in the form of
images. Hence, using images in therapy, including creating positive images
and associating them with negatively charged ones, rests on the dominance of
the SAM system and the traumatic memory. Our clinical experience suggests
that this kind of work has proven most effective.
And so, the preceding leads to our proposition for the application of the
FR concept and practice in treatment, or in the reconstruction of a traumatic
story. Using FR in the suggested manner enables the individual to merge
fantastic elements into the story of the event in such a way as to benefit from
 The Healing Potential of Imagination… 7

the potential healing experience enabled by the transitioning and the

fantasizing.
PTSD AND THE TREATMENT OF PSYCHOTRAUMA
For years it was believed that there was no remedy or solution for those
suffering from acute psychotrauma. A breakthrough occurred during the past
decade when efficient treatment methods , CBT in their origin, were
discovered that relieve symptoms and even enable a significant number of
people to recover from most of the syndromes (Bisson et al., 2007).The
cognitive treatment that focuses on symptoms, that has been found to be
unequivocally effective in treating post-traumatic clients (Seidler and Wagner,
2005), explains its effectiveness in cognitive models of memory, but in
practice uses the imagination (although no attempt has been made to
conceptualize this parameter and its contribution to the effectiveness of the
treatment). This can be seen both in Prolonged Exposure in the stage of
Imaginal exposure where the client is instructed to imagine the incident "as if"
he is experiencing it and to retell the story as if it were happening now, as well
as with eye movement desensitization reprocessing (EMDR), when the person
imagines (visualizes) the traumatic event.
Cognitive-behavioral models for the treatment of PTSD indicate the
importance of the following aspects: chronological reconstruction of the
narrative, the exposure to in vivo situations otherwise avoided, and the return
to normal, daily functioning. The processing component of the session –
during which the client explores his new attribution of significance to the
event, as compared to the original meaning it had for him at the time of, or
following, the occurrence of the trauma – was found to be very important
(Foa, Keane and Friedman, 2009).
Prolonged exposure and cognitive reconstruction are clearly valuable
means of relieving the effects of the trauma, mainly in the transition from
emotional memory to verbal memory, or from Implicit Memory to Explicit
Memory (Foa et al., 2009). This process activates the governing of the frontal
parts of the brain (sequence and reasoning) also responsible for regulation of
emotions. It is in fact the translation of the experience into "secondary
language" which is important in regulating the terror beyond words
experience. Still, as it is 'translation', it is not tapping into the experience itself
and may leave traces intact such as body memory and other non verbal aspects
that cannot be expressed verbally, beyond words, (i.e. images and
physical/bodily memories).
8 Mooli Lahad and Dmitry Leykin

SEE FAR CBT PROTOCOL COMPONENTS

The proposed treatment model is based on the concepts outlined in
Johnson, Lahad and Gray’s (2009) chapter in the book Effective Treatments
for PTSD - Practice Guidelines from the International Society for Traumatic
Stress Studies, in which they describe the similarities between the creative
therapy techniques and several widely-used techniques for the treatment of
psychotrauma (such as psycho-education, exposure, cognitive restructuring,
re-narration, somatic reactions). However, they also point out that, to date,
despite their potential, the creative therapies have not been examined in even a
quasi-experimental framework. SEE FAR CBT is an attempt to test the
hypothesis that a creative conceptualization, integrated into a treatment
protocol that emphasizes the creative process, can be effective in the treatment
of PTSD. Thus, SEE FAR CBT has modified and adapted elements from
several approaches to the treatment of psychotrauma that have proven
successful in changing and improving the situation of trauma victims (Leith,
Vanslyke and Allen, 2009; Mendis et al., 2008; Parker, Doctor and Selvam,
2008). The combined effective trauma-treatment methods in the model
involve: (a) aspects of Somatic Experience (SE) (Levin and Fredrick, 1997),
(b) Fantastic Reality (FR) (Lahad, 2000, 2005) and (c) Cognitive Behavioral
Therapy (CBT) (Foa et al., 2009). SE is a method focusing on the "body
memory" (Rotschild, 2000; Van der Kolk, Van der Hart and Marmar, 1996), or
the physiological memory (which is embedded in the limbic system). The
basis of this therapeutic process rests on the client's ability to report on
subjective physical sensations through focusing on positive sensations and
emotional resources (i.e., bodily grounded sensations), as well as on negative
sensations (i.e., the implicit traumatic memory), to achieve physiological
energy discharge and improved self-regulation of the physical experience.
FR is a theoretical construct suggested by Lahad (2000, 2005, 2009) as
was elaborated above, to describe the ability of people facing traumatic
situations to transcend into a fantastic space where they feel safe and secure
and where they can deal with and change the unchangeable. The FR concept is
based on several theoretical ideas: (1) Winnicott's concept of potential space
(Winnicott, 1971), interpreted by Ogden (1985) as the "intermediate area of
experiencing that lies between fantasy and reality" (p.129); (2) Jennings'
approach to dramatic space (Jennings, 1994), described by Chesner (1994) as
the place where "the context of illusion and play give permission for more
freedom of exploration and expression" (p. 116); and (3) Landy's ideas of
 The Healing Potential of Imagination… 9

aesthetic distancing (Landy, 1996), summarized by Jenkyns (2001) as "the

state when the individual, while in the act of dramatic engagement, is in a state
of emotional balance" (p.70). What is common to all these approaches is that
they use play and playfulness as part of the healing process (Jennings, 1994;
Landy, 1996; Winnicott, 1971).

Table 1. SEE FAR CBT components and Terminology

Component Source Therapeutic Purpose

Approach
Psychoedu CBT, SE Normalizing client's behavioral reactions, enhancing sense
cation of control, strengthening therapist-client relationship and
trust.
In Vivo CBT Live exposure to situations, places, and avoided behavior
Exposure results in learning control over anxiety.
Desensitiza CBT Gradual habituation to the aversive stimuli (memory or
tion behavior), which results in emotional extenuation and
adaptation.
Relaxation CBT, SE, Prevents hyper-ventilation states and increases control in
Techniques SIT the level of the anxiety.
Resourcing SE Bringing to consciousness positive and pleasant as well as
negative experiences, and being alert to the physiological
sensations – as therapeutic tool for emotional and bodily
discharge.
Safe Place SE, FR, Creates a sense of security and control, along with the
NLP experience of confidence and dominance.
Metaphoric FR Symbolic and associative cards which enable access to
Theraputic deep feelings and assist in narrating the experience by
Cards distancing from it.
Exposure FR, CBT Recollection and reprocessing of the traumatic memory
in FR via re-narrating the subjective story with therapeutic cards
aiming to reconstruct and conceptualize the fragmented
memory in a coherent narrative.
"As if FR Theoretical space elicited by the cards, which enables
space" imaginative play and cognitive flexibility, thus providing
an opportunity to modify the traumatic memory without
changing the outcome.
Pendulatio SE, Discharging mechanism of the stressful/traumatic
n EMDR memory, by movement between resourced areas in the
body, or between different therapeutic cards.
Note: CBT=Cognitive Behavioral Therapy, SE=Somatic Experiencing, FR=Fanastic
Reality, SIT=Stress Inoculation Techniques (Meichenbaum & Deffenbacher,
10 Mooli Lahad and Dmitry Leykin

1988), NLP= Neuro-linguistic programming (Andreas & Andreas, 1992),

EMDR=Eye Movement and Desensitization Reprocessing

Figure 1. SEE FAR CBT Model components.

In practice, FR is introduced by the use of metaphoric therapeutic cards

(TC) (see Ayalon, 2007) to represent both "a pleasant/safe place" (i.e., a
subjective feeling of comfort and security) and the re-narrating process of the
traumatic story. The use of cards as an "externalization" of the otherwise
internally haunting images or as "distancing" (Landy, 1996; White and Epston,
1990), facilitates a sense of control and manageability over the incident.
Moreover, FR allows the client to make use of the "as if space," a space where
all the "ifs" are possible and where the impossible becomes possible. This
practice reintroduces the client to his ability to play and to experience
empowerment. The "as if" space is explained in detail in the coming pages.
The cognitive-behavioral components of SEE FAR CBT, influenced by
PE and other cognitive behavioral therapies (Ellis and MacLaren, 1998; Foa,
Doron and Yadin, 2006; Foa et al., 2009) adopt the following: Repetition of
the story because of the impact this has on the desensitization or habituation
processes; verbalization of the story, because this has the power to make it an
accessible coherent story that can be referred to as past; in vivo gradual
 The Healing Potential of Imagination… 11

exposure because this is a necessary part of the treatment that diminishes non-
threatening, non-dangerous avoidance behavior, thus granting the client a
sense of control and a sense of coherence; a reflective learning experience
discussion at the close of each session; and on-going psycho-education where
the client is made aware of each step in the process thereby becoming a partner
in the quest that moves from hurt to healing. It should be noted that in its
clinical practice, SEE FAR CBT protocol does not apply each one of the
treatment protocols separately, but integrates the elements that have been
found to be clinically effective into a new treatment protocol.

SEE FAR CBT PROTOCOL (LAHAD AND DORON, 2007,

2009)
Therapy consists of several stages (described in Table 2) and clients
receive a weekly, 90-minute session. This is the "gold standard" in the
treatment of psychotrauma and enables efficient and gradual work during the
different stages, especially during the Fantastic Reality (FR) desensitization
process and the FR re-narration sessions.
Thus, there is more time available to establish engagement on the one
hand, and to offer a sufficient "recovery" phase for the client on the other.
Transition from stage to stage is not constrained by the number of sessions and
is a function of the gradual personal process (practicing re-narration in
Fantastic Reality without sufficient desensitization practice or in the absence
of sufficient knowledge of the possible physiological reactions, would not be
effective).
After the initial stages of intake and PTSD diagnosis, followed by psycho-
education and the setting of therapy objectives, which are similar to most
therapies (Foa et al., 2009), the client studies how to reduce arousal and how
to control fearful reactions so that a sense of safety is achieved. Next, the
client practices Somatic Experiencing modalities (i.e., focusing, resourcing)
and is given an explanation about the importance of the discharge of the
blocked physical energy caused by the trauma.
The client is introduced to the power of FR and externalization through a
process of creating an external safe space using therapeutic cards (see Figure
2). The establishment of association between the image and the experience of
relaxation and pleasant sensations assists the client during the therapy
whenever anxiety prevails and the need for stress reduction arises. Then he can
12 Mooli Lahad and Dmitry Leykin

focus on the card, (the external sign for reducing tension and arousal) and than
resume the therapeutic process.

Figure 2. Stage 5: Creating safe place through therapeutic cards with extension in
drawing (21.0 × 29.7 cm).

A CBT component includes making an avoidance list, an in-vivo exposure

task list and a plan for therapy. In-vivo exposure is regularly practiced and
monitored until the end of the treatment. During the next stage, the client is
encouraged to confront an unpleasant/difficult discomfort-inducing memory in
order to practice desensitization and control physiological arousal.
Using the safe place card opposite a symbolic representation of a
distressing (non-traumatic) memory on another card, the client goes through a
process of "pendulation" between the cards until anxiety habituation is
established. In addition, the client is invited to introduce Fantastic Reality (or
playfulness and empowerment), by adding a third card that may "protect" the
quality of the safe space as a calm and reassuring one.
 The Healing Potential of Imagination… 13

Figure 3. Stage 7: Re-narration in the fantastic reality using therapeutic cards.

This new card, placed between the safe space card and the unpleasant
card, is referred to as a "protective card." It is fascinating to observe how this
card moderates arousal. During the last part of the therapeutic process, the
client practices re-narration of the traumatic experience in Fantastic Reality,
using therapeutic cards (see Figure 3).
During the re-narration phase, the client chooses several cards
representing the traumatic event and is encouraged to observe the cards and
then to narrate the story. In the sequel, the client is asked to choose and
remove the cards he "wishes to" exclude, or to reorder the sequence of cards,
and retell the story. This helps him to experiment with possibilities, to "play"
with alternatives and to gain control over his story. Last, the client is instructed
to add new "as if" cards to the array. These cards should represent things or
people which, if the client had had them during the incident, could have
assisted him, without them (the as if cards) changing or erasing the outcome of
the incident..
Observing the client's re-narration through the cards, help the therapist to
identify where the client is "stuck" or "freezes" (i.e. dissociates) and which
parts of the story are too painful. This is unique to this method as the therapist
can practically see where in the sequence it happens. Thus the therapist can
assist the client, after reducing the anxiety level to resume retelling by pointing
to him where the story was previously overwhelming or causing the client to
stop. At the conclusion of treatment the therapist and the client summarize,
evaluate and discuss the therapeutic process.
14 Mooli Lahad and Dmitry Leykin

To summarize this section we argue that SEE FAR CBT has a different
focus in its effectiveness, proposing a new therapeutic model in which three
main elements are stressed: (1) The visual stimulus that is thought to be the
most likely to lead to activation of the visual cortex; (2) The observation point
known as "aesthetic distance;" and (3) The ability to present the positive
elements of empowerment and wishful thinking in Fantastic Reality.
The model was tested with clients suffering from post-traumatic disorder
following rape, violence in the family, robbery, terrorism, war and military
activity. In quasi experimental study comparing EMDR and SEE FAR CBT
conducted among adults suffering from PTSD after the Second Lebanon War
(2006), the treatment method was found to be as effective as EMDR, with SEE
FAR CBT found to be slightly more effective in the continuing improvement a
year later, during follow-up (Lahad, Farhi, Leykin and Kaplansky, 2010).
Findings indicate that the protocol is also beneficial in reducing post-traumatic
symptoms to a below-clinical level among children (Lahad, Farhi and Leykin,
unpublished).
THE UNIQUENESS AND DISTINCTION OF SEE FAR CBT IN
TREATING PTSD - A CRITICAL DISCUSSION
Evidence from neuroscience studies suggests that during repeated trauma-
related imagery tasks, PTSD participants exhibit many more non-verbal
patterns of memory retrieval, characterized by a right-lateralized pattern of
activation, including paralimbic and visual areas (Lanius, Williamson,
Densmore, Boksman, Neufeld, Gati et al., 2004).We suggest that by asking the
client to consciously choose images on cards that represent the traumatic
incident (a subjective choice of images, colors, and shapes) and arranging
these cards in a sequence, we offer better access to the situationally accessible
memory (SAM) memory system, hypothesized by Brewin, Dalgleish and
Joseph (1996) in their dual representation theory.
To initiate the intrusive images and physiological responses among PTSD
clients, the image-based SAM system contains lower level perceptual
processing of the traumatic scene, such as smells and sights which were not
stored in the verbally accessible memory (VAM). Memories in the SAM are
not represented within a complete personal context comprising past, present,
and future, and must be processed in order to be recorded in the VAM system.
Thus, the repeated recollection of the event coupled with the images on the
cards activates the visual cortex and establishes a connection with the
prefrontal cortical areas activated by the narration which follows it. We assert
 The Healing Potential of Imagination… 15

that the use of therapeutic cards (that are associative and idiosyncratic)
facilitates accessibility to this memory and works both within it and on it. It is
only in the second phase that the cognitive narrative organization (VAM) takes
place that enables a more cognitive organization of the experience that is
influenced by processes involving the inhibition of impulse (the role of the
frontal lobes).
Tulving and Craik (2000) point out that the lapse in concentration that
appears with trauma influences the way that memory is encoded, which creates
gaps in the sequence of memory. Since the exact semantic memory is
disrupted following the trauma, the emotional memory completes the picture.
The emotional memory comprises images, sensations and information that is
not accessible to semantic processing. In other words, we are of the opinion
that the traumatic memory is not the memory of a story as recorded by a
journalist or news photographer, but rather is composed of associative, visual,
emotional and non-verbal elements. Similarly, Van der Kolk and Fisler (Van
der Kolk and Fisler, 1995) point out that the memories of the traumatic
experience held by subjects with PTSD are initially characterized by fragments
of dissociative patterns of visual, emotional, audio, sensory and kinesthetic
experiences. Over time, subjects report the appearance of a personal narrative
that can be linked to Explicated Memory. Therefore, reconstruction by means
of therapeutic cards enables a reconstruction of the subjective memory
composed of visual, emotional, associative experience without pretending to
be a virtual reconstruction of the "true" event. as opposed to innovative
technological attempts, such as Virtual Reality,
We argue that in our method re-arranging the narrative by means of the
therapeutic cards is likely to stimulate simultaneously visual cortex (the
images), emotional memory (the association that goes along with the
personally choice of specific cards whilst making contact with the prefrontal
cortex (through the verbalization of the perceived images) .
In a previous study, Spiegel, Hunt and Dondershine (1988) found that
PTSD sufferers exhibited very high levels of the ability to be hypnotized as
compared to subjects with different psychological disorders and normal
subjects. Other studies also link the ability to be hypnotized to the tendency to
fantasize (Wilson and Barber, 1983; Lynn and Rhue, 1988) and so it may be
inferred that PTSD clients may be "expert" in fantasy and imagination, and
that despite the fact that the use of imagination is expressed in a negative way
(i.e. in flashbacks), it is still possible to use the fantasy to create alternatives to
their traumatic story.
16 Mooli Lahad and Dmitry Leykin

Another unique component of the SEE FAR CBT protocol is the sense of
empowerment achieved via the suggestion to remove cards and check the
outcome on the narrative and taking this even further, the instruction to
experiment with potent play by adding the "as if" or "if only" cards. These
cards enable the client to recount the story with helpful elements in so far as
the outcome does not change.
We suggest that the observation of the visual sequence creates a
competing positive visual stimulus that directly affects the visual cortex and is
encoded as an alternative "memory" to the traumatic one, or at least a more
flexible succession of segments of the event. Based on our argument that in
fact, PTSD clients are "experts" in fantasizing or in imagining, we suggest that
it is possible may be able to capitalize on this 'expertise' and train them to use
alternative fantastic solutions.
The observer position is unique to this treatment. In none of the other
effective psychotrauma protocols does the client observe his/her traumatic
story as a distant, observable story. It is the distancing within the artform
which both contains the experience and allows it to be seen from many
perspectives. In aesthetic distancing "the ‘in-between’ or ‘liminal’ state allows
the individual to look at the situation through identification and distancing at
the same time" (Tselikas-Portman, 1999, p.9).
Aesthetic distance, according to Landy (1996) is the midpoint that is a
balance of affect and cognition; "an ideal state in which one is able to think
feelingly and feel without the fear of being overwhelmed with passion" (p. 48).
The positive impact of being an "audience in your own drama /trauma" has
been described by Grinberger (2005) in her research on Holocaust survivors.
The effect of aesthetic distance (Landy, 1996), redefined by us as observing
one's own traumatic story as it unfolds through projective/associative cards
make it possible for the client to master control, and reduce arousal as the
story is "out there " and is less oppressive. This contributes to the sensation of
empowering and thus influences the process that helps the change of helpless
position of the PTSD client. From a victim to a victor.
We suggest that the protocol assists the client to slowly learn to play by
using the cards and Fantastic Reality, thus diminishes the debilitating
influence of the rigid, haunting and especially ,reducing the need to be on an
"on guard position". The adoption of safe and secure place allows the
traumatized clients to re-experience and master their pain through metaphoric
milieus.
 The Healing Potential of Imagination… 17

DISSOCIATION, MEMORY AND THE TENDENCY TO

FANTASIZE
Based on Kaplansky's study (2009) we assume that the natural path of the
brain to handle an impossible reality where no escape or fighting is possible, is
to transcend into FR. Nevertheless, in some cases (leading to the development
of PTSD) this natural path is blocked or interrupted due to the victim's
awareness or consciousness of his finality, mortality or fragility and the
remorse and pain of leaving his loved ones, and this evokes extreme fear and
terror. We suggest that the flashbacks are the continuous attempts of the brain
to complete a healing transcendence that is the natural path to healing. But the
PTSD client stops this attempt at its slightest hint, as the association with these
fragmented memories immediately evokes anxiety and fear and does not allow
the process to be completed.
We therefore suggest an alternative explanation to the effectiveness of the
Exposure treatment, arguing that it forces the clients to undergo full
dissociation (to imagine the event as if it is happening now). As such, the
curative effect of the re-narration is not only in the verbalization and activation
of the governing of emotional regulation parts of the brain (the claim of CBT)
, but also in the fact that it enables full dissociation and thus the activation of
the imaginal aspect that can "see" or suggest other meanings and other
possibilities to what seems to be a frozen memory.
Furthermore, we propose that in the SEE FAR CBT protocol we can trace
where in the sequence the client dissociates. As the story is external and the
client follows the cards, we have an indication as to the point in the sequence
of traumatic events where the disruption in the processing of the information
occurred. Reducing anxiety via the "safe place" external card and then
returning to the exact card in the sequence where the story "stopped" is a much
more accessible, play-like component that helps in the treatment of
dissociative clients.
We suggest that the ability to play that the client gradually acquires during
the course of treatment, by means of using the cards and experiencing
Fantastic Reality, reduces the frequency of the invasive memories. The idea of
Fantastic Reality as a realm of the "as if," an imaginary space where anything
is possible, together with aesthetic distancing, creates a safe and protected
place where the sufferer can on the one hand re-experience his pain but also
control it by means of a metaphoric environment.
18 Mooli Lahad and Dmitry Leykin

Finally, we propose that the SEE FAR CBT protocol is not another
cognitive or body-mind approach to the treatment of psychotrauma, but an
integrated approach that dedicates a place to the imagination as a source for
healing in impossible situations, as has been demonstrated by the brain
research and the (admittedly relatively meager) research on the imagination
and non-pathological dissociation. We are currently engaged in several studies
to examine the phenomena of imagination in short- and long-term exposure to
distressing conditions or states as well as in developing tools to measure the
effects of transcendence into FR in such conditions.

REFERENCES
Andreas, C. and Andreas, S. (1989). Heart of the mind. Colorado: Real People
Press.
Ayalon, O. (2007). Healing trauma with metaphoric cards. Therapy Today, 18,
22-24.
Bernstein, E.M. and Putnam, F. W. (1986). Development, reliability and
validity of a dissociation scale. Journal of Nervous Mental Disorders. 174,
727–735.
Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., Turner, S.
(2007). Psychological treatments for chronic post-traumatic stress
disorder. British Journal of Psychiatry. 190, 97-104.
Brewin, C. R., Dalgleish, T., and Joseph, S. (1996). A dual representation
theory of posttraumatic stress disorder. Psychological Review, 103, 670-
686.
Brooks, R., Bryant, R.A., Silove, D., Creamer, M., OwDonnell, M.,
McFarlance, A.C., Marmar, C.R. (2009). The latent structure of the
Peritraumatic Dissociative Experiences Questionnaire. Journal of
Traumatic Stress, 22, 153-157.
Bryant, R. A. (2007). Does dissociation further our understanding on PTSD?
Journal of Anxiety disorders, 21, 183-191.
Bryant, R. A., Guthrie, R. M. and Moulds, M. L. (2001). Hypnotizability in
Acute Stress Disorder. American Journal of Psychiatry, 158, 600-604.
Candel, I. and Merckelbach, H. (2004). Peritraumatic dissociation as a
predictor of post-traumatic stress disorder: a critical review.
Comprehensive Psychiatry, 45, 44-45.
 The Healing Potential of Imagination… 19

Cardena, E. and Spiegel, D. (1993). Dissociative Reactions to the San

Francisco Bay Area Earthquake of 1989, American Journal of Psychiatry,
150, 474–478.
Chesner, A. (1994). Dramatherapy and Psychodrama. In S. Jeninges (Ed.).
Handbook of Dramatherapy. London: Routledge.
Cohen, A. (1996). The Dream of the Soul: Imagination, Fantasy and
Daydreaming. Haifa: Amatzia. (Hebrew)
Council, J.R. and Greyson, B. (1985). Near-Death Experiences and the
"Fantasy-Prone" Personality: Preliminary Findings. Paper presented at
the Annual covention of the American Psychological Association. 93rd,
Los Angeles, CA, August 23-27.
Ellis, A. and MacLaren, C. (1998). Rational-emotive behavior therapy: A
therapist's guide. California: Impact Publishers.
Foa, E. B., Doron, M. and Yadin, E. (2006). Prolonged Exposure (2nd
ed).Kiryat Shmona, CSPC. (Hebrew)
Foa, E. B., Keane, T. M., Friedman, M. J., and Cohen, J. A. (2009). Effective
treatments for PTSD. Practice guidelines from the International Society
for Traumatic Stress Studies. New York: The Guilford Press
Greyson, B. (1991) 'Near-death Experiences Precipitated by Suicide Attempt:
Lack of influence of psychopathology, religion, and expectations', Journal
of Near-Death Studies, 9, 183-188
Greyson, B. (1993) 'Varieties of Near Death Experience', Psychiatry, 56, 390-
9.
Greyson, B. (2000). Dissociation in people who have near-death experiences:
Out of their bodies or out of their minds? Lancet, 355, 460-463.
Greyson, B. (2001) 'Posttraumatic Stress Symptoms following Near-death
Experiences', American Journal of Orthopsychiatry, 71, 368-373.
Grinberger , I. (2005) The Therapeutic Qualities of The Process of Re-
Narrating Life Stories with Holocaust Survivors. Doctoral Dissertation,
University of Surrey.
Herman, J. (1992). Trauma and recovery. New York: Basic Books.
Horowitz, M. J. (1986). Stress response syndromes (2nd ed.). New York:
Jason Aronson.
Jenkyns, M. (2001). Dramatherapy and psychoanalysis: some links explored.
In Y. Searle and I. Streng. Where analysis meets the arts. London, Karnac
Books.
Jennings, S. (1994). The handbook of dramatherapy. London and New York:
Routledge.
20 Mooli Lahad and Dmitry Leykin

Johnson, D. R., Lahad, M. and Gray, A. (2009). Creative Therapies for Adults.
In E.B Foa, T.M. Keane, M.J. Friedman and J.A. Cohen (eds.) Effective
treatments for PTSD. Practice guidelines from the International Society
for Traumatic Stress Studies (pp. 491-508). The Guilford Press.
Kaplansky, N. (2009). Dissociating From Death: An Invastigation into the
Resilience Potential of Transcendence into Fantastic Reality during Near-
Death Experiences. Unpublished dissertation, Anglia Ruskin University,
Chelmsford, UK.
Klinger, E. (1990). Daydreaming. Los Angeles, CA: Tarcher (Putnam).
Lahad, M. (2000). Creative Supervision. London: Jessica Kingsley
Publication.
Lahad, M. (2005). Transcending into Fantastic Reality: Story Making with
Adolescents in Crisis. in C. Schaefer, J. Mccormick, and A. Ohnogi (eds.)
International Handbook of Play Therapy: Advances in assessment, theory,
research and practice. Lanham: Jason Aronson Publication.
Lahad, M and Doron M. (2009). SEE FAR CBT. Kiryat Shmona: CSPC.
(Hebrew)
Lahad, M. and Doron, M. (2007). Beyond CBT, See Far CBT Post Traumatic
Stress Disorder Treatment Protocol. Kiryat Shmona: CSPC.
Lahad, M. and Leykin, D. (2009). Fantastic Reality Questionnaire: A measure
for exploring involvement in imaginative activities. Unpublished raw
material.
Lahad, M. (2006) Fantastic Reality, Haifa: Nord Publication. (Hebrew).
Lahad, M. Farhi, M. Leykin, D. Kaplansky, N.(2010) Preliminary study of
a new integrative approach in treating Post Traumatic Stress Disorder: SEE
FAR CBT. The Arts in Psychotherapy, 37 (2010) (p. 391-399).
Lahad, M., Farhi, M., Leykin, D. and Kaplansky, N. (2009). Treatment of
Children with PTSD using SEE FAR CBT. Unpublished raw data.
Landy, R. (1996). Drama therapy and distancing: Reflections on theory and
clinical application. The Arts in Psychotherapy, 23, 367-373.
Landy, R. J. (1993) Persona and Performance, London: Jessica Kingsley
Publishers
Lanius, R. A., Williamson, P. C., Densmore, M., Boksman, K., Neufeld, R.
W., Gati, J. S., Menon, R. S. (2004). The Nature of Traumatic Memories:
A 4-T fMRI Functional Connectivity Analysis. American Journal
Psychiatry, 161, 36-44.
Leith, M. L., Vanslyke, J. and Allen, M. (2009). Somatic Experiencing
Treatment with Social Service Workers Following Hurricanes Katrina and
Rita. Social Work, 15, 9-18.
 The Healing Potential of Imagination… 21

Levine, P. and Frederick, A. (1997). Waking the tiger: Healing trauma

through the innate capacity to transform overwhelming experiences.
Berkeley, CA: North Atlantic Books.
Lynn, S. J., Pintar, J., and Rhue, J. W. (1997). Fantasy-proneness, dissociation,
and narrative construction. In S. Powers and S. Krippner (Eds.), Broken
Selves: Dissociative narratives and phenomena. New York:
Bruner/Mazel.
Lynn, S. J. and Ruhe, J. W. (1988). Fantasy Proneness; Hypnosis, Develop-
mental Antecedents and Psychopathology. American Psychology, 143 ,
35-44.
Meichenbaum, D. H. and Deffenbacher, J. L. (1988). Stress Inoculation
Training. The Counseling Psychologist, 16, 69-90.
Mendis, D. D, Mello, M. F., Ventura, P., Passarela, Cde P., Mari, Jde J.
(2008). A systematic review on the effectiveness of cognitive behavioral
therapy for posttraumatic stress disorder. The International Journal of
Psychiatry in Medicine, 38, 241-259.
Merckelbach, H., Horselenberg, R., Murris, P. (2001). The Creative
Experiences Questionnaire (CEQ): a brief self-report measure of fantasy
proneness. Personality and Individual Differences, 31, 987-995.
Ogden, T. H. (1985). On Potential Space. International Journal of
Psychoanalysis, 66, 129-141.
Ozer, E. J., Best, S. R., Lipsey, T. L. and Weiss, D. S. (2003). Predictors of
posttraumatic stress disorder and symptoms in adults: a meta-
analysis.Psychological Bulliten, 129, 52-73.
Parker, C., Doctor, R. M., and Selvam, R. (2008). Somatic Therapy Treatment
Effects With Tsunami Survivors. Traumatology, 14, 103-109.
Putnam, F. W. (1993). Dissociative Disorders in Children: Profile and
problems. Child Abuse and Neglect, 17, 39-45.
Putnam, F. W. (1997) Dissociation in Children and Adolescents: A
Developmental Perspective, New York: The Guilford Press.
Rothschild, B. (2000). The Body Remembers. The Psychophysiology of
Trauma and Trauma Treatment. New York: W.W.Norton and Company.
Schiller, D., Monfils, M.H., Raio, C.M., Johnson, D.C., LeDoux, J.E. and
Phelps, E.A. (2008) Preventing the return of fear in humans using
reconsolidation update mechanisms. Nature, 463, 49-53.
Seidler, G. H., Wagner, F. E. (2006). Comparing the efficacy of EMDR and
trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a
meta-analytic study. Psychological Medicine, 36, 1515-1522
 22 Mooli Lahad and Dmitry Leykin

Spiegel, D., Hunt, T. and Dondershine, H.E. (1988). Dissociation and

hypnotizability in posttraumatic stress disorder. American Journal of
Psychiatry, 145, 301-305.
Steinberg, M. (2001). Updating Diagnostic Criteria for Dissociative Disorders.
Journal of Trauma and Dissociation, 2, 59-63.
Tselikas-Portman, E. (1999). Supervision and Dramatherapy, JKP, London.
Tulving, E. and Craik, F.I.M. (Eds.) (2000). The Oxford Handbook of Memory.
New York: Oxford University Press.
Van der Kolk, B. A., and Fisler, R. (1995). The psychological processing of
traumatic memories: Review and experimental confirmation. Journal of
Traumatic Stress, 8, 505-525.
Van der Kolk, B. A., Van der Hart, O. and Marmar, C. R. (1996). Dissociation
and information processing in posttraumatic stress disorder. In Van der
Kolk, B., McFarlane, A. C. and Weisaeth, L. (Eds.), Traumatic stress: The
effects of overwhelming experience on mind, body and society (pp. 303-
327). New York: Guilford Press.
Van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S. and Spinazzola, J.
(2005). Disorders of Extreme Stress: The Empirical Foundation of a
Complex Adaptation to Trauma. Journal of Traumatic Stress, 18, 389-
399.
Wilson, S. C. and Barber, T. X. (1983). The fantasy-prone personality:
Implications for understanding imagery, hypnosis, and parapsychological
phenomena. In A. A. Sheikh (Ed.), Imagery: Current theory, research, and
application (pp. 340-390). New York: John Wiley.
Winnicott, D. W. (1971). Playing and reality. London: Tavistock.

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