Traumatic Incident Reduction Association

Case Studies using TIR and Related Technique

The views and opinions expressed in these articles and interviews are those of the individuals speaking, and do not necessarily represent those of Applied Metapsychology International or the TIR Association.

Thematic TIR in Application: Test Anxiety Case Summary

By Robert H. Moore, Ph.D.
[Ed. Note: A sufficient number of clinically insignificant details in this case illustration have been altered to ensure the anonymity of the client.]

The tidiest example of TIR in application to PTSD would be of a straightforward Basic TIR on a one-of-a-kind trauma to which the client had been flashing back regularly and which resolved in due course without the involvement of earlier incidents or complexities of any sort.

A more typical example, on the other hand, should illustrate the interesting and often hidden connection of a client's current complaint with some aspect of his trauma history. Given that "Tom" didn't report actively flash back when he first appeared for therapy, his case provides such an example.

Tom was a first year law student with a whopping case of test anxiety. He'd had the problem for as long as he could remember, at least since junior high school, but it didn't really catch up with him till he got to college. There, he controlled his most disruptive thoughts with alcohol and/or a mild tranquilizer and sometimes actually did well enough in his studies to be exempt from the feared final exams. But he was clean of drugs, and sober, when he sat for the LSAT [Law School Admissions Test] and he choked up and "bombed" [failed] the test. Unable to see how he would get into (much less through) law school if he couldn't take a test without his "chemical courage", he went for help.

It didn't take more than ten or twelve sessions of biofeedback-based (electromyograph, EMG) relaxation training and cognitive reorientation to bring his test-related anxiety, palpitations, throat constriction, and nausea under his control. At that point, he was able to re-confront the LSAT and scored well enough the second time to get into law school. The demands of his first semester, however, put Tom into a panic he couldn't completely shake. His image of himself as a student eroded with each successive challenge. He barely survived his mid-year exams by alternating periods of study with periods of cassette-guided relaxation. By the time he came to see me, with final exams approaching, he was on academic probation and in dread of flunking out.

To give him a bit of breathing space, I first reinforced the relaxation and quieting routines he'd learned in college. Then I set about to discover just what it was (cognitively) that pushed his buttons so badly in connection with being tested. It had always felt, he said, as if his respectability hung on the outcome, as though each test were a rite of passage, and if he didn't do well he would forever be "consigned to hell." No matter that he had usually done well at whatever he tried; he was "haunted" by the cumulative evidence of his inadequacy. He approached each and every test, audition, and interview with fear and dread, throbbing nauseously throughout as though he were on trial for his life. (Not an unfamiliar presentation for a test anxiety case.)

We know that dramatic reactions in non-dangerous circumstances are frequently secondary to earlier trauma (whether the client reports actively flashing back or simply a "haunting inadequacy"), and my attention was hooked to some extent by his description of the way he "had always felt" in testing situations. So I briefed Tom on the essentials of PTSD and TIR and invited him to take a look at the problem in retrospect. He agreed. As he had no special interest in any particular historic episode, I took the thematic approach. His choice of themes: "anxiety." ("Not just any old anxiety", he made it clear but "that throat-clutching, nauseating kind of anxiety" peculiar to the threat of a testing situation.) And he had no trouble recalling the several occasions on which he'd had it most acutely.

The first incident he selected, the bombed [failed] LSAT, "turned on" (reactivated) very shortly after he got into viewing it. His pulsed raced noticeably and he reported that waves of nausea punctuated the memory of this "trial by entrance exam." By his fourth time through reviewing the incident, the persistence of his discomfort made it clear we should look earlier for another incident containing anxiety.

His major comprehensive exam as a senior in college was indeed such an incident. He had passed the test, but he choked up badly doing it. Similar circumstance; similar emotional/visceral reaction. It took only two or three repetitions to give him a headache (on top of everything else) and confirm our need to look for yet an earlier incident.

It took him a while to spot the next one, because he was expecting it to be - and was at first looking for - an earlier testing situation of some sort. But the Thematic question is unequivocal: "Is there an earlier incident containing anxiety?" So it surprised him for a moment (though only for a moment) when he recalled suffering the same excruciating anxiety after school one day in the tenth grade. He had gotten so nervous auditioning for a part in a play that he threw up right there on stage in front of everybody. I thought maybe we had a primary incident there for a moment, but as a viewer's verbal and non-verbal indicators are always - but always - senior to a facilitator's unspoken personal speculation about what's going on in the session, I was soon convinced otherwise. After five repetitions, Tom's embarrassment (added to his earlier discomforts) was still unabated. So there must have been an earlier incident containing that kind of anxiety.

Several minutes passed during which Tom silently reviewed memories of his early years, his tightly squinting eyes reflecting the urgency of his need for relief from the cumulative discomforts of the incidents he'd been viewing for nearly an hour. Then quite abruptly his squint intensified momentarily, his head jerked back, and he dissolved into anguished and uncontrollable sobbing. The impact of whatever he had recalled was such that Tom sobbed and gagged continuously for nearly five minutes before he could so much as speak. (During those minutes, I simply waited quietly.) And when he did speak it was in the desperately rasping, tearful voice of a ten year old little league [very young baseball player] infielder who had just taken the full force of a line drive [a ball hit straight down the line of the baseball field] square in the face, in his first game. He'd had just a fleeting look at the ball as it leapt off the bat in his direction faster than he could bring up his glove to meet it. The next thing he knew, he was on his back and gagging painfully on what was left of his front teeth and gums. Add to that a splitting headache, nausea, embarrassment, the rigors of reconstructive surgery and with it all the certain knowledge that "by displaying such complete incompetence as he had done - jerk that he was! - he had forever lost the respect he had so yearned to win from his peers."

It wasn't an easy incident for Tom to face. His first several times through were nothing more than a blinding, consciousness-obliterating flash. Only gradually over the next ten to fifteen agonizing repetitions did the incident open up and reveal the brutality of its impact to his conscious inspection. And only gradually thereafter did it lighten to the point at which he could recount its traumatic detail without gasping in pain. But it did completely discharge, as primary traumatic incidents inevitably do if one is diligent and patient. "I caught it right in the teeth," Tom said dryly at the end, "and I made a big deal out of how bad it made me look. It hurt like hell, that's for sure! But I blew it out of all proportion. And that's all there is to it!" Two and a half hours into the session, thoroughly exhausted but amazed and exhilarated, he added "I thought since I'd stopped reverberating over that mess while I was still in high school, that it was history. I'd never have believed it could still affect me that way. Boy was I wrong about that! That was unbelievable!"

Tom reported in his next (and last) session that he'd "had a smile that wouldn't quit" for several days following his TIR session and that although he hadn't been put (literally) to the test, he couldn't imagine why he should ever again be shaken by any exam or interview. He was to call me without hesitation if he had the slightest recurrence of his test-related discomfort. When I hadn't heard from him by the end of the year, I put him on the list to receive our follow-up "Counseling Effectiveness Questionnaire." Felt-tipped boldly across his reply, right beneath the heading that identified his presenting problem, Tom's brief response said it all: "TEST ANXIETY? WHAT TEST ANXIETY?"


Correct Thematic TIR technique requires the selection and running of one very specific symptom or theme at a time. In this case, although Tom describes his "anxiety" in terms that make it sound like a symptom cluster, the facilitator was persuaded that "that kind of anxiety," in fact represented one well-defined theme. Had it turned out to be only one of several individually distinguishable and separable themes (e.g. anxiety, constricted throat, nausea, embarrassment, etc.) each potentially with a sequence and primary of its own, the appropriate procedure would have been to address and run as many of them separately as held Tom's interest.

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