Traumatology

© 2022 American Psychological Association 2023, Vol. 29, No. 2, 102–111

ISSN: 1085-9373 https://doi.org/10.1037/trm0000376

Fantastic Reality: The Role of Imagination, Playfulness, and Creativity in

Healing Trauma

Dori Rubinstein1, 2 and Mooli Lahad1, 3

1
The Community Stress Prevention Center, Kiryat Shmona, Israel
2
School of Public Health, Ben-Gurion University of the Negev
3
Department of Psychology, Tel Hai Academic College
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

The objective of this study is to examine the role of imagination, playfulness, and creativity in healing
This document is copyrighted by the American Psychological Association or one of its allied publishers.

or coping with trauma. A range of evidence-based trauma-focused treatments use imagination effec-
tively, though often without theoretical references. This article provides an up-to-date, nonsystematic lit-
erature review, exploring the presented objective and focusing on the role of imagination in the
treatment of posttraumatic stress disorder (PTSD). A computerized literature search, defined inclusion
criteria, and synthesis aim to promote understanding in the field. We review brain overlaps pertaining to
imagination and PTSD, presenting a hypothesis that the hippocampus and the default mode network
play an important role in both. Creativity is presented as a significant predictor of resilience after trau-
matic exposure. Moreover, we discuss how resilience to, and coping with, a traumatic event is enabled
by using playfulness. Finally, we discuss the gap between the frequent use of imagination in the treat-
ment of PTSD and the lack of intended understanding of its mechanisms that bring about change. The
fantastic reality model is presented as a theoretical and applied concept used in the utilization of imagi-
nation and playfulness to support therapeutic change. SEE FAR CBT protocol is presented as a thera-
peutic integrative approach that combines body and cognition, accommodating imagination and
playfulness as sources of recovery. It interweaves imagination as part of the renarration of trauma,
allowing wishful/fantastic elements to foster healing and promote resolution.

Keywords: imagination, posttraumatic stress disorder, playfulness, creativity, fantastic reality

“Imagination is the only weapon in the war against reality.”
—Lewis Carroll
Take a moment and imagine a safe place, outdoors, in nature, or
indoors, anywhere you feel relaxed, calm, and secure. Focus on that
image, and then describe it quietly to yourself; focus on your body
asking yourself where it is felt. Most will probably experience this
process as a simple and pleasant task. But for some, who suffer
from posttraumatic stress disorder (PTSD), it may be a difficult
task, intrusive at times and requiring extensive practice. In this arti-
cle, we will discuss the role of imagination, playfulness, and crea-
tivity in developing resilience, coping, and the treatment of trauma.
We suggest that PTSD is, in essence, a disorder of the imagination.
Indeed, it is the same imagination taking over the patient in flash-
backs, causing significant suffering and accompanied by a sense of
helplessness and hopelessness: “I am going crazy” or, worse yet, “I
This article was published Online First February 10, 2022.
The authors are grateful to the late Shai Seleck, a playful being, for his
support, and encouragement throughout the study.
Correspondence concerning this article should be addressed to Dori
Rubinstein, School of Public Health, Ben-Gurion University of the Negev,
P.O.B. 653 Beer-Sheva, Israel. Email: doriru@post.bgu.ac.il
am crazy.” Imagination, however, also allows many to soar on its
wings to great heights, for example, to plan an incredible summer
vacation or dream of a good and satisfying future.
The imagination exercise we have started with is called safe
place. It is incorporated in various types of treatments and thera-
pies and is part of evidence-based treatment protocols such as eye
movement desensitization and reprocessing (EMDR; Shapiro &
Forrest, 2016) and prolonged exposure (PE; Back et al., 2014). It
is an effective and common treatment tool for coping with hyper-
arousal and traumatic and invasive memories and for regaining a
sense of security, control, and freedom of choice (Williams & Poi-
jula, 2016). Over years of clinical work with adults and children
who suffer from PTSD, we have seen that they have difficulty
with tasks that require a controlled, detailed, continuous, and flexi-
ble activation of the imagination. We observed that PTSD patients
seem to be threatened by going to the imaginative space, perhaps
because it requires a sense of playfulness (discussed later in this
article). Indeed, imagination can be a source of mental suffering,
but we argue that imagination can also serve as a source for heal-
ing. In practice, effective methods for trauma-focused therapy
such as PE and EMDR use the imaginative mechanism otherwise
known as “imaginal exposure” by actively instructing the client to
imagine the incident as if it is happening now to work with and
change the traumatic memory and narrative (Holmes, 2014; Lahad
et al., 2016).

102
1
 THE ROLE OF IMAGINATION IN HEALING TRAUMA
Imagination has been neglected in psychological research in
general (Tateo, 2015) and clinical-therapeutic research of post-
trauma in particular; it has rarely received a theoretical reference
(Lahad & Leykin, 2012; Pearson, 2019). During the past 30 years,
PTSD research has emphasized the cognitive (mostly memory),
emotional, physical, and social components but not the imagina-
tion (Lahad & Leykin, 2012; Rubinstein et al., 2020). The purpose
of this article, therefore, is to present an up-to-date review describ-
ing the potential role of imagination in supporting resilience and
coping with trauma and exploring its feasibility in the treatment of
PTSD.
Imagination is one of the characteristics that make us human
and special. Without it, our world would be meaningless, and we
would be unable to interpret the sensory experience or find logic
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in our life experiences (Abraham & Bubic, 2015; Johnson, 2013).
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Imagination allows us to better plan our future and flexibly con-
sider past experiences and memories (Zheng et al., 2014), think
outside the box (Gaither et al., 2015), stimulate and suppress emo-
tions (Finnbogadóttir & Berntsen, 2014), and help rehabilitate
learning and memory capabilities (Grilli & McFarland, 2011).
As central and vital in everyday life, imagination uses a variety
of areas in the brain, dominating all cerebral lobes and hemi-
spheres (Fox et al., 2015). Based on our clinical, theoretical
research of trauma and recovery (Lahad, 2017, 2019), we claim
that as much as imagination is a source of pain and suffering dur-
ing loss, trauma, and severe mental conditions (e.g., depression,
schizophrenia), it is also a source of hope, optimism, and comfort
in distressing situations. Hence, we argue it can be used in the
treatment of trauma adopting the known concept of Hippocrates;
“By similar things a disease is produced and through the applica-
tion of the like is cured,” meaning, if imagination is capable of
causing illness, it is also capable of curing it. Interesting overlaps
arise from brain imaging research.
Brain Overlaps Between Imagination and PTSD
The current development in neuroscience through advanced
brain simulation tools allows examining connections between
identified brain structures and functions concerning posttrauma
and the imagination “functions.” Our brain creates models of the
world around us, and we can use these interpretations not only to
grasp and comprehend what we see every given moment but also
to reexperience scenes from the past and imagine the future or
even a completely fantastic scenario. Zeidman and Maguire’s
study (2016) shows that these cognitive functions—imagining,
perceiving, and remembering past events—all incorporate the ac-
tivity of the anterior hippocampus (the part of the limbic system
associated with memory and emotion). Another review indicates
that hippocampal abnormality can lead to significant difficulty in
everyday situations that require the flexible and creative use of
images (Rubin et al., 2014). The hippocampal system and its inter-
actions with neocortical areas of storage provide us with the neces-
sary database for creating, updating, and maintaining mental
images used in the service of declarative memory (Duff et al.,
2013). In their study, Duff et al. (2013) have demonstrated how
people with bilateral hippocampal damage perform significantly
worse than healthy participants through a range of creativity tasks.
Over the years, extensive empirical neurophysiological data
have been accumulated on the topic of PTSD, a large portion of
103
which was done via brain imaging studies. Today it is even possi-
ble to perform a PTSD diagnosis with over 90% accuracy by func-
tional MRI (fMRI; Christova et al., 2015). A large number of
brain imaging studies have revealed diminished medial temporal
lobe activation and reduced hippocampal volume in patients with
PTSD (for reviews and meta-analyses, see Bremner, 2007; Karl et
al., 2006; Pitman et al., 2012; Shin & Liberzon, 2010; Woon et al.,
2010). Furthermore, clinical improvement in individuals with
PTSD has been positively correlated with increased hippocampal
volume (Levy-Gigi et al., 2013). Hence, it can be indicated that
the hippocampus plays a vital role in both PTSD, as well as mem-
ory, creativity, and use of the imagination.
Another brain network that has a central role in creativity is the
default mode network (DMN; Beaty et al., 2019; Jung et al., 2013;
Raichle & Snyder, 2007). This system is composed of several
areas in the brain that work together in coordination when the per-
son is not busy with deliberate tasks and is at rest. The DMN is
associated with remembering the past, envisioning future events,
and mentalization of the thoughts and perspectives of other people
(Jung et al., 2016). These brain regions have been consistently
reported as activated during creativity tasks (Beaty et al., 2014;
Jung et al., 2013). Recent work (Beaty et al., 2016, 2017, 2019)
has shown that the DMN’s interaction with executive control net-
works is associated with novel metaphor production, goal-directed
memory retrieval, prepotent-response inhibition, and internally
focused attention. Other recent findings suggest that the actual ex-
perience of trauma may be related to changes in the DMN
(DiGangi et al., 2016). PTSD has been found to be associated with
decreased connectivity within DMN (linked to mind wandering,
autobiographical memory, and self-referential processes) as well
as alterations in connectivity patterns between DMN and other
brain networks (Lokshina et al., 2021). fMRI studies have revealed
both hippocampal abnormalities and alteration in DMN functions
in PTSD patients (Pitman et al., 2012; Reuveni et al., 2016; Shin
& Liberzon, 2010; Sripada et al., 2012); separately, they have
found correlations between alterations in those regions and deficits
in imagination and creativity (Beaty et al., 2014, 2019; Zeidman &
Maguire, 2016).
Creativity as a Mechanism for Resilience and Coping
With Trauma
The direct relationship between creativity and PTSD was sel-
dom described in the literature, but there is recurring evidence that
creativity can serve as a protective factor, increasing resilience and
improving coping with PTSD (Metzl & Morrell, 2008; Thomson
& Jaque, 2016). Creativity is an expression of the imagination,
requiring fast connection and replacement of mental representa-
tions, to create new ideas and ways of thinking (Rubin et al.,
2014). In the past 4 decades, creative ability is divided into four
dimensions (Torrance, 1974): (a) originality, (b) flexibility, (c) flu-
ency, and (d) elaboration (processing details; Duff et al., 2013; for
a more comprehensive review, see Cramond et al., 2005). An
extensive meta-analytical work that reviewed 25 years of research
on emotion and creativity has found that positive emotions (such
as happiness) have a positive context and activate creativity,
unlike anxiety and fear, which were found to correlate with
decreased creativity on all levels (Baas et al., 2008). Creativity
may be a product of emotions; that is, it can be influenced by
 104 RUBINSTEIN AND LAHAD
emotions, stress, or trauma. This relationship can be mediated or
moderated by traits such as inhibition control and resiliency (Duan
et al., 2019; Liang et al., 2021). However, creativity may also elicit
emotions, serve as a protective factor against trauma, and reinforce
resilience components (for a more extensive review, see Metzl &
Morrell, 2008; Thomson & Jaque, 2016).
Metzl (2009) examined creative thinking and resilience among
80 survivors of Hurricane Katrina and found that originality and
flexibility predicted resilience to the storm events. Another study
that followed Palestinian children during the first Intifada found
that increased creativity, rather than intelligence, predicted better
coping and adjustment (Punamäki et al., 2001). Based on their
study, Punamäki et al. (2001) thought that during the events them-
selves, children are afraid to use their imagination and prefer to
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hold a rational approach, thus narrowing their emotional expres-
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sion and processing, which in the long run can serve as an obstacle
to adaptive coping. They recommended intervention methods that
activate imagination and creativity. Russ and Wallace (2013)
found that when children play, they train their creative abilities
and develop tolerance and endurance for an array of complex and
intense emotions that life may present in the future. Mottweiler
and Taylor (2014) found that children who are encouraged to take
part in role-playing games regularly improve their creativity,
which, along with emotional regulation, and unstructured play was
found to increase well-being and improve the quality of life.
Gregerson (2007) recommended incorporating creativity com-
ponents into mental disorder treatment, including trauma and
PTSD therapy. Yet, it is important to mention that a study that
examined creativity and PTSD among dancers and athletes found
that taking part in an adult and creative play-form will probably
not cure PTSD, but it can contribute to better coping. This study
has found that among individuals who suffer from PTSD, creative
work improves efficiency and self-management, providing mean-
ing and satisfaction (Thomson & Jaque, 2016). In conclusion, cre-
ativity has been found to serve as a protective factor against
general psychological difficulties (not necessarily against specific
symptoms or hardships) and as a significant predictor for resilience
to trauma (Metzl, 2009; Tol et al., 2013). More research is needed,
however, to determine how imagination, creativity, and play foster
resilience under adversity (Capurso & Ragni, 2016).
The Possible Link Between Playfulness and Coping
With Trauma
Play encourages creativity by using the imagination. It is con-
sidered to be a therapeutic tool and an effective way of coping for
children, especially those who have experienced trauma (Clark,
2016; Pat-Horenczyk et al., 2014; Ryan et al., 2017). Furthermore,
play and playfulness are used in the clinical world, not only with
children who have experienced trauma but also with elderly people
(Monahan, 2015), adults (Bat Or & Megides, 2016), and families
(Cohen et al., 2014; Tucker & Smith-Adcock, 2017). Play simulat-
ing various real-life situations contributes to the ability to create a
narrative, which later serves to construct a coherent traumatic nar-
rative, thus helping to cope with stressful events (Cohen et al.,
2010). As early as 30 years ago, several studies found that children
are excellent fantasy creators. Compared with children who do not
use their imagination to play and communicate with others, those
who initiate imagination into play have better concentration, enjoy
their activities more, are less aggressive, and develop better social
and cognitive skills and emotional capabilities as well as learning
to efficiently organize information and perform a more effective
integration of their external and internal experiences (Lieberman,
2014; Møller, 2015; Tower & Singer, 1980). Imaginary friends
and attachment to a transitional object during childhood were both
found to correspond to decreased future impulsiveness and aggres-
sion, greater self-containment, and an ability to think creatively
(Singer & Singer, 1990; Taylor, 1999). Cohen et al. (2014)
showed that children with resilience to traumatic terrorist events
were characterized by participating in games and exhibiting good
abilities to plan and play a coherent, creative game, with a suffi-
cient narrative, while being aware of the game and their role in it
(in terms of the fantastic reality [FR] model described herein, it is
the ability to freely transition between the realms of imagination
and reality). In addition, they showed an ability to self-soothe and
a tendency to create a relationship with an adult during the play.
These characteristics can go into the “playfulness” category.
Playfulness refers to a variety of spontaneous responses (cogni-
tive, physical, and sociobehavioral) that are expressed through
imagination, creativity, curiosity, pleasure, and humor. From a de-
velopmental perspective, playfulness can be regarded as a stable
character trait that is most notable during play and interpersonal
interactions (Lieberman, 2014). According to Staempfli (2007), a
person characterized by high playfulness will be guided by inner
motivation; they will set goals; they are inclined to attribute self-
meaning to objects, and they have the ability to “pretend,” be
active, and be involved. Bundy (1997) added that a person who is
characterized by increased playfulness will also have inner control,
the freedom to suspend reality, constructing and framing a play
set, and will also share it with another. Without playfulness, a
child may have difficulties experiencing thoughts, emotions,
wishes, and fantasies as valuable, though not exactly the same as
reality. Therefore, playfulness is crucial to the development of our
mentalization capacity (Bateman & Fonagy, 2004). Two main
components that can explain part of the connection between play-
fulness and resilience to traumatic events are positive emotions
and the ability to self-regulate (Bonanno et al., 2011; Cohen et al.,
2014).
Hence, resilience to and coping with a traumatic event may be
enabled thanks to playfulness and play. This play element, along
with imagination, helps to delay the threatening reality and to cre-
ate a coherent and flexible narrative. Moreover, play and imagina-
tion lead to an individual becoming active and involved,
experiencing positive emotions, regulating negative feelings, and
providing control and self-motivation (Lahad, 2019). We claim
that clients (children who became adults) who suffer from PTSD
adopt a vigilant approach to prevent the painful intrusive memo-
ries from surfacing and overwhelming them or to ensure they do
not miss the external ominous signals. Therefore, they tend to
avoid playing, because play and playfulness contradict the ability
to remain vigilant against the danger of the intrusive content. This
position may also be influenced by the fact that some people who
suffer from PTSD also suffer from depression; therefore, to them,
playfulness may be an out-of-reach mental state.
Similar clinical observations led Lahad and Doron (2010) to de-
velop a therapeutic model inviting the client to gradually practice
playful skills in a make-believe space, thus developing playfulness
 THE ROLE OF IMAGINATION IN HEALING TRAUMA
that enables change in “dead-end” situations. These are facilitated
in the clinic through an FR space (Lahad & Leykin, 2012).
Fantastic Reality: Purposeful Use of Imagination in
the Treatment of PTSD
During times of crisis and great danger, people use their imagi-
nation, allowing them to temporarily detach from a terrible, life-
threatening event. Knowledge of such “dissociation” comes from
survivors of traumatic incidents, torture victims, hostages, and
captives, as well as sexual assault and rape victims, who all talk
about this wonderful imagination ability that aids survival.
Lahad coined the term “fantastic reality” (Lahad, 2000, 2005).
The FR is the “as if” space, where every “if” is possible. It allows
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the psyche to play again as it did in early childhood, in a space
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where laws of reality do not govern. In this space, it is possible to
fabricate stories as part of a journey in search of answers and
insights, of real-life situations in which logical solutions are no
longer satisfactory. Actually, in the FR, it is possible to search for
logical, metaphorical answers and solutions and images, to exam-
ine how applicable they will be in the future. Often, the journey to
FR and back brings about relief, even when there is no practical
application of the “insights” or “knowledge gained.” This relief
may stem from the “distancing for the sake of bringing near” prin-
ciple. The FR is the “as if” space. It is the space where anything is
possible and everything is feasible. In this reality, 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 place, and preferably
the person participating will have a specific role. Sometimes peo-
ple have several roles or more, usually experienced in reality as a
burden or feeling unable to be in the moment. In the FR, one can
shrink time—or stretch it—and have things going on here and
now—as well as then and there—all at the same time. The place
can be the same as the real space (therapy room), or a separate,
magical venue. This place can be inside (a palace, for example, or
outside [a thick forest]). The client can simultaneously be himself
or herself and play another role. The various roles can be realistic,
desired, or imaginary characters, and so on.
This space has been called by Winnicott (1971) the “potential
space.” During therapy, healing and relaxation appear when the
psyche regains its childhood playful mode. This experience is
enabled in an accepting, supporting, and nonjudgmental environ-
ment, encouraging creativity and play. In the FR space, people
with traumatic experiences can transcend to another space, where
they feel safe and can change the unchangeable. This is a mental
state and a function of the imagination as a truly infinite possibility
in which people experience awareness of other imaginal represen-
tations coexisting with the reality around them. People who suffer
from PTSD can use this space to cope with an intrusive traumatic
memory to control, stimulate, change, delay, and even suppress it
(for a comprehensive review, see Lahad & Leykin, 2012).
Fantastic reality ability (FRA) is the tendency and capacity to
use FR in everyday life and in response to stressors and trauma.
Recent work defined FRA as a multifactor construct and described
the evolution of its theory and measurement (FRAME; Rubinstein
et al., 2020). This study presented a new self-report measure,
FRAME, a brief, multifactor measure of imagination used in
response to stress and trauma. This measure assesses FRA in terms
of its four features: coping, transcendence, playfulness, and
105
control. Overall, FRAME demonstrated high internal consistency,
good test–retest reliability, and psychometric qualities. Overall,
responses to this scale demonstrated concurrent validity with ego
resiliency, playfulness, and fantasy proneness. These findings sup-
port the theoretical definition of FRA as a stable, playful, and
adaptive concept (Lahad, 2000, 2005; Rubinstein et al., 2020).
The use of the FRAME in clinical research and practice will
expand our knowledge of the role FRA plays in treatment and
recovery.
The Undefined Use of Imagination, Lacking
Theoretical Reference by Trauma-Focused Treatment
Methods
Using the imagination is not new in psychotherapy. Freud
talked about the interpretation of dreams, Jung about archetypes,
and Winnicott about the potential space that enables change, and
so did others who followed in their footsteps. Today, there are
more efficient and diverse methods of trauma-focused therapy for
people who suffer from PTSD. The majority use imagination as a
therapeutic tool, whether intentionally or unintentionally referring
to it (Holmes, 2014; Lahad et al., 2016; Rubinstein et al., 2020).
Most of the therapeutic approaches in trauma referred to invasive
memories and thoughts, and almost all use words to process the
traumatic experience, giving it a variety of names: cognitive
reconstruction, abreaction, desensitization, flooding. Yet, we real-
ize that traumatic experiences are fused with verbal cognitive
aspects, as well as nonverbal, physical, sensorial, emotional phe-
nomena. Still, imagination has rarely been the center of attention
within therapeutic study in general, or trauma-focused therapy, in
particular.
Retrieval of episodic and autobiographic memories serve as a
common addition in many techniques for the treatment of trauma
and anxiety (Cooper & Clum, 1989). Indeed some of the current
treatment methods use imagination to alter, weaken, and cope with
traumatic memories. These include PE, EMDR, cognitive behavior
therapy (CBT), imaginal flooding, virtual reality exposure therapy,
systematic desensitization, imagery rescripting procedure, acceler-
ated resolution therapy, the narrative system, various creative
methods, and the SEE FAR CBT (see far cognitive behavior ther-
apy) method, which combines several methods, emphasizing
imagination as a tool for change. One of the main components of
CBT is exposure as a process that helps clients cope with threaten-
ing memories and situations (Choi et al., 2009). Imaginal exposure,
a part of the exposure process, necessitates the client revisiting the
traumatic event (imaginal exposure), while in reality they are in the
clinic, feeling safe, so that they can manage the traumatic memory
and emotionally process it, leading to a less painful and threatening
reaction (desensitization; Foa & Kozak, 1986).
Other forms of exposure include repeated presentation of the
traumatic event in the imagination (imaginal flooding; Cooper &
Clum, 1989; Speckens et al., 2006). In this kind of imaginal
method, the clients repeatedly visit the memory, imagining situa-
tions, places, or objects that function as reminders of the trauma or
anxiety triggers until they no longer provoke these strong emo-
tions. Some narrative therapists ask their clients to write a story
about the trauma and then reread it over and over again, as a form
of exposure (Resick & Schnicke, 1993). In virtual reality exposure
therapy, the clients receive a computerized representation of the
 106 RUBINSTEIN AND LAHAD
virtual world, which naturally changes with the movement of the
head. During these sessions, the clients wear a virtual reality hel-
met with stereo earphones that provide visual and auditory cues,
experiencing a virtual reality that serves to reactivate and desensi-
tize their traumatic cues (Carl et al., 2019; Meyerbröker & Emmel-
kamp, 2010).
In the imagery rescripting procedure, the clients focus on the
contents of their invasive image or the memory and imagine,
sharply and clearly, positive alternative outcomes. The client then
assimilates into their story assisted by their therapist (repeatedly
telling the story of the positive outcomes, directed by questions
and play, assimilating the desired alternative results; Brewin et al.,
2009; Hackmann, 1998). In systematic desensitization, the client
gradually brings up reminders of the trauma in their imagination,
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combined with relaxation training. According to Shapiro, in
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EMDR the client is asked to imagine a scene or an image from the
trauma, focusing on the accompanying cognition and arousal,
while the therapist moves two fingers in front of the client’s face,
within his or her field of vision, instructing him or her to follow
the movement (Jeffries & Davis, 2013).
Accelerated resolution therapy is a new treatment method that
uses components of EMDR, with an emphasis on using the imagi-
nation and stimulating it with metaphors. The client is asked to
imagine an invented alternative story for the traumatic event,
assisted by the therapist–client he or she assimilates it in his or her
memory as a replacement for the threatening memory (Waits et
al., 2017). A large element of the abovementioned methods
involves the use of relaxation exercises while using imagination or
guided fantasy to reduce anxiety levels. One of the common meth-
ods is called “safe place,” mentioned at the beginning of this arti-
cle, in which the client is requested to imagine a place where he or
she feels safe, providing as much detail as possible, which the
therapist repeats out loud. After the exercise becomes accessible
for the client and he or she learns to use it effectively, he or she
can use it both within and outside of therapy whenever the anxiety
level rises. This, and other similar exercises that use imagination
in various ways, give the patient a sense of control as well as a
sense of choice and change; he or she experiences anxiety as a
wave that may rises, and lessen the arousal–relaxation curve.
The cognitive-focused therapy that is effective with PTSD
(Seidler & Wagner, 2006) explains the efficacy of the cognitive
memory model, but it uses imagination without explaining its
mechanism. The imaginary reconstruction in PE is a good exam-
ple, as it asks the client to bring up the traumatic memory and
imagine it. In fact, it uses imagination to lower the distress and
anxiety by “calling” the inner representation of the incident, aim-
ing at desensitization and a narrative shift.
We argue that the treatments that focus on reconstructing the
event force the clients to experience “induced dissociation”
because the event that the client is asked to recall does not exist in
the “here and now,” nor are the details mentioned in it are neces-
sarily “real.” We, therefore, claim that imaginal exposure or recon-
struction are instructing tools to help the client transcend into FR
—or to the “as if” space—where the story is retold repeatedly,
allowing addition of mitigating details or even editing of the story.
This has a potential soothing effect on the dissociative process that
occurred in the traumatic event itself and was violated due to a
sense of terror and helplessness. We claim that alongside the cog-
nitive formation of the story are the imaginative creative parts that
give the “healing” effect in reconstruction. SEE FAR CBT is a rel-
atively new protocol for the treatment of PTSD that interweaves
imagination as part of the renarration of trauma allowing wishful/
fantastic elements to an otherwise unbearable frozen memory of
an event (or events) to foster healing and promote resolution
(Lahad & Leykin, 2012).
SEE FAR CBT
SEE FAR CBT is a protocol-based therapeutic method (Lahad
& Doron, 2010) for PTSD and anxiety-related disorders. This is a
creative protocol based on empowerment that is enabled by using
imagination and the FR space. The model emphasizes the role of
the FR and imagination in creating an alternative narrative for the
traumatic event by using therapeutic cards that enable distancing
and externalization of the story. As clients observe the reconstruc-
tion in cards they have chosen to tell the traumatic story, they
become spectators in their life’s drama. They also play the role of
editor as they can “remove” disturbing images, change their posi-
tion, add alleviating images, and so forth. Thus, they can edit an
otherwise “frozen story” and “play” with its components (Figure
2). This model is anchored in Winnicott’s, Jennings’ and Landy’s
theories on play and also on the externalization principles of narra-
tive approach (Jennings, 1994; Landy, 1996; White & Epston,
1990; Winnicott, 1971). This process also incorporates CBT meth-
ods and concepts for the therapeutic end of the protocol, especially
components of PE (Ellis & MacLaren, 1998; Foa et al., 2009),
psycho-education, real-life exposure, and on body memory (Clem-
ents, 2003; Levine, 1997; Van der Kolk et al., 1996). SEE FAR
CBT has been found to be effective in significantly reducing post-
traumatic symptoms over time (Lahad et al., 2010, 2016).
In a naturalistic study performed after the second Lebanon War
(Lahad et al., 2010), a sample of 42 patients who suffered from
PTSD were treated with SEE FAR CBT and compared with those
who were treated with EMDR. The conclusions of the study show
that both methods are effective in treating PTSD and that SEE
FAR CBT is the method whose ability to alleviate the mental dis-
tress of its sufferers is equal to an existing and research-based ther-
apeutic approach (for more information, see Lahad et al., 2010).
Another study (Lahad et al., 2016) was conducted on 25 Israeli
children who lived in the conflict area of Sderot and its surround-
ings; they attended 13 therapeutic sessions, during which the
child-adapted SEE FAR CBT protocol was used. These children
were compared with a matched control group from Sderot that
took part in CBT intervention in school. The findings of the study
showed that after therapy or group intervention, children who
were treated with SEE FAR CBT exhibited lower levels (40%) of
PTSD than children who took part in the group interventions
(68%; Figure 1). Furthermore, the most significant difference that
was found between the groups was the reduction of the symptoms
from the intrusive cluster. Along with the improvement in PTSD
symptoms, both groups also exhibited a significant reduction in
physical symptoms, reporting fewer headaches, stomach aches,
cases of nausea, sleep disorders, and other health issues.
We suggest that this method offers a unique aspect to PTSD
patients, introducing the regaining of control through the use of
imagination via therapeutic cards. Control and playfulness are
experienced in various ways: by the patient choosing the cards,
positioning them, and changing their place or even removing them
 THE ROLE OF IMAGINATION IN HEALING TRAUMA 107

Figure 1
Differences in Posttraumatic Stress Disorder Symptoms Between Children Who
Were Treated With SEE FAR CBT and Control Groups That Were Treated With
PI (Cognitive Behavior Therapy), by Measurement Times
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Note. Error bars denote standard error. CPSS = Child Post-traumatic Symptoms Scale; PI þ
OK = psychological inoculation and “OK” circles intervention (for more information, see
Lahad et al., 2016).

altogether and by choosing potential support using “If only” cards
to add to the story. The empowering element of this method lies in
the potential inclusion of the “as if” positive images that clients
choose to add to their story representing wishful elements, or peo-
ple who, had they been present at the time of the traumatic event,
could have helped the clients—without the “as if” cards changing
or erasing the outcome of the incident (Figure 2). The new visual
sequence creates a positive or more tolerable stimulation, compet-
ing in terms of the flexible brain (Doidge, 2016) with the traumatic
memory pathway in the brain. For example, according to the prin-
ciple rule of brain plasticity, redundant nerve cells connect to each
other (Doidge, 2016). Therefore, beyond the sense of control, this
alternative calming visual pathway directly affects the visual,
sensory, or experiential memory pathways of the event, as well as
directly acting to change the perception of nonverbal and verbal
levels. As a result, the new narrative created using cards emerges
as an alternative to the traumatic memory, or at least a more flexi-
ble order of events (for more theoretical details, see Lahad & Ley-
kin, 2012). From this perspective of the brain flexibility and its
ability to change and develop, we suggest that methods that com-
bine imagination play allow “a window of flexibility” for
improved health and resilience development (Lahad, 2019; McE-
wen, 2016). Hence, SEE FAR CBT is not just another cognitive or
body–mind method for treating psycho-trauma, but an integrative
approach that gives room for visual imagination as a source of
healing in “impossible” situations.

Figure 2
SEE FAR CBT: Renarration in Fantastic Reality Using Therapeutic Cards
 108 RUBINSTEIN AND LAHAD
Method/Literature Search for the Present Article
This research adopted a nonsystematic review approach aimed
at identifying and summarizing what has previously been pub-
lished, avoiding duplications and exploring the roles of imagina-
tion, playfulness, and creativity in coping with trauma and in the
treatment of PTSD. The literature search for the present article
explored these roles and aimed to fill in the gap between the fre-
quent clinical use of imagination in the treatment of PTSD and the
lack of theoretical intended understanding of the mechanisms that
bring about change. This was done by using the PubMed,
EMBASE, and Google Scholar electronic databases. The main
searching keywords were paired together to explore relationships
and common ground (i.e., “trauma imagination,” “PTSD imagina-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
tion,” “trauma creativity,” “PTSD creativity,” “trauma playful-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ness,” “PTSD playfulness,” “imagination trauma focused
therapy,” “Imagination resiliency,” “creativity resiliency”). More-
over, following the current developments in neuroscience, the
searching strategy was completed by supplementary terms (i.e.,
imagination brain, creativity brain, trauma brain, PTSD brain).
Due to the relative paucity of studies, and their wide heterogene-
ity, we decided to proceed with a nonsystematic narrative review.
The inclusion criteria included all types of articles that led to
identifying common ground between keywords. Accordingly,
abstracts were searched for relevancy and redundancy. The exclu-
sion criteria were articles for which full text was not available,
were not in English or Hebrew, were redundant or beyond research
scope, or were grey literature. From the articles retrieved in the
first round of search, additional references were identified by a
manual search among the cited references. Relevant studies were
added to expand background points (e.g., on the diverse use of
imagination). This cycle was repeated until a “saturation point”
was reached.
At the next stage, similar themes were synthesized from the
existing material (e.g., brain and PTSD alongside brain and crea-
tivity) or shared topics approached by differing research para-
digms or differing clinical/theory “language” (e.g., clinical use of
imagination among names and theories). Synthesis was aimed to
reduce the gap between clinical and theoretical fields presented in
the research, thus promoting future research that may expand our
understanding about the roles of imagination, playfulness, and cre-
ativity in relation to trauma, and trauma-focused therapy. Subse-
quently, the concepts of FR and SEE FAR CBT were introduced
as a “bridge” over the presented gap, and a separate search was
performed for these keywords to use the existing literature to pro-
mote these concepts and methods, offering a new, overarching,
theoretical, and clinical model in the field.
Limitation
This article should be interpreted in terms of its limitations.
First, this was a nonsystematic review article, meaning that the
exact same results may be hard to reproduce. That being said, we
have tried to be transparent about our assumptions and planning,
as well as selection and evaluation biases described in the Method
section. Unlike systematic reviews, the Method section is not man-
datory, but its inclusion adds clarity to the key messages of the lit-
erature search (Ferrari, 2015). Second, specific wording in the
field may create bias, for example, a search for “imagination”
instead of “imagery” may miss research on visual and mental
imagery.
Summary and Conclusion
In this review, we have tried to establish the principal roles
that imagination, playfulness, and creativity have in develop-
ing resilience, coping, and treating trauma. First, we indicated
brain abnormalities that imagination and PTSD share, and
argued that the hippocampus and the DMN play an important
role in PTSD, imagination, and creativity. Future neuroscience
research should carefully consider addressing these brain
regions, testing PTSD sufferers with imaginative-creative or
therapeutic tasks, thus promoting a better understanding of ill-
ness and cure.
Second, we have discussed creativity as an expression of
imagination, which has been found to serve as a protective fac-
tor against general psychological difficulties, and as a signifi-
cant predictor for resilience when facing trauma. Third, we
have demonstrated how play and playfulness enable resiliency
using the imagination, and how they are considered as an effi-
cient therapeutic tool, especially for those who have been
through a traumatic event. We argued that PTSD clients adopt a
vigilant approach and avoid playing, perhaps because play and
playfulness contradict the ability to remain vigilant against the
danger of the intrusive memory. On the other hand, playfulness
may help people to cope with threatening reality, create a
coherent and flexible narrative and memory, stay active and
socially involved, regulate negative feelings, and provide con-
trol and self-motivation. These are all made possible in therapy
through the FR space. People who suffer from PTSD can use
this space to cope with a traumatic and intrusive memory, by
controlling it, stimulating change, delaying it, and even sup-
pressing it. We also presented the new FRAME measurement: a
brief, multifactor measure of imagination use in response to
stress and trauma. The use of the FRAME in clinical research
and practice will expand our knowledge of the role that FR
plays in treatment and recovery. Finally, we have indicated the
gap between the frequent use of imagination as a clinical and
therapeutic tool in practice, and the understanding and realiza-
tion of the mechanism that leads to change in the field. We have
described several methods that use the imagination in an undif-
ferentiated way.
The SEE FAR CBT method has been presented as an approach
that combines body and cognition, making room for imagination
and playfulness as sources of healing. We claim that one of the
missing theoretical references in the field concerns the healing
power of imagination to play, create, and reconstruct. In trauma-
focused therapy, this power can promote a more adaptive and
competing memory to the traumatic memory, or at the very least
can make the memory more flexible and accessible. We argue that
according to the first rule of brain plasticity, given that nerve cells
firing connect (Doidge, 2016), a competing soothing evidentiary
pathway is created, which promotes the “healing” effect in the
reconstruction in SEE FAR CBT, according to our conclusion.
More research is needed to determine how imagination, creativity,
and playfulness foster trauma resilience and promote change in
therapy.
 THE ROLE OF IMAGINATION IN HEALING TRAUMA
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Received July 4, 2021
Revision received November 19, 2021
Accepted November 23, 2021 n