I explained to Ernest that the best way to get over his traumatic injury is to focus on it with full detail until the anxiety loses potency, and he gets used to the things he so far avoided. He first did not understand how this is different from his compulsion to write prose about his distress, but he was willing to try, as the seemingly brave approach seemed appropriate to him.
When first asked to rank his fears, he could not admit any fear. Later he was willing to write a list of "things he'd rather not have to face". On the bottom of the list he wrote things like sleeping with the lights off, in the middle of the list he wrote things like being trapped in a prison cell, and at the top he wrote he feared physical torture and severe injury. These things kept him anxious and awake at nights.
Explaining treatment rational took up most of the next two meetings and Ernest did not perform his homework for them. We discussed this as avoidance on his part, and agreed to move very slowly up his list of things he'd rather not face. We also agreed to start first in the therapy room, and only later at home when he was alone.
Ernest sat in the dark without screaming after two very gradual training sessions. After three sessions I even left the room for a few minutes and found him dozing in the dark, as he was exhausted with lack of sleep. At home, he changed his working schedule from writing before dawn to writing in the late morning, and he began to catch some sleep in the dawn hours.
Therapy continued, and Ernest's most major in vivo was swimming in the deep sea, where he used to fear he would be torn to shreds by sharks. He said that being in the water cooled him even better than a Mojito. He could sleep, he was much less edgy, being more calm allowed him to function sexually and enjoy his wife's support and warmth. After 6 months follow-up he was bellow clinical level for PTSD, however, changing his working schedule to daytime made him more distracted and he did not publish additional prose.
Another disturbing image - Hemingway drinking while ready to shoot sharks: