University of Mississippi Medical Center/G.V. “Sonny” Montgomery VAMC Psychology Internship Training Program
PROLONGED EXPOSURE THERAPY FOR PTSD
Based on Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences
(Foa, Hembree, & Rothbaum, 2007)
Overview
Treatment Rationale Treatment Components
Psychoeducation Breathing Retraining
In vivo exposure Treatment Components In vivo exposure (cont.) Imaginal Exposure
Common Problems Avoidance Under/Over-engagement
Other Considerations Measuring progress & termination Therapist reactions
PTSD Diagnosis
Necessary Trauma for PTSD – DSM-5
Criterion A: 1) Exposure to a traumatic event;2) Witnessing of an event;3) Indirect learning that the event occurred;4) Indirect exposure of details*
Sexual assault Motor vehicle accident Physical assault Witness death or serious injury Combat Torture
Children may experience different response
Diagnostic Symptoms of PTSD – DSM-5
Criterion B: Intrusion Trauma is persistently reexperienced (memories,
dreams, flashbacks, psychological or physiological reactivity to stimuli)
Criterion C: Avoidance Persistent avoidance of trauma stimuli
Diagnostic Symptoms of PTSD – DSM-5
Criterion D: Negative Thoughts and Mood e.g., Continuous negative emotionality; distorted blame
Criterion E: Hyperarousal Persistent symptoms of increased arousal
(concentration, sleep, anger, startle, hypervigilance, reckless behavior)
Diagnostic Symptoms of PTSD (cont.)
Criterion F: Symptoms must persist for more than 1 monthCriterion G: Symptoms cause significant distress or impairmentCriterion H: Not induced by substances and/or medical conditions
Treatment Rationale and Myths
Rationale for the Treatment Program The program focuses on addressing trauma related fears and
symptoms.
Three main factors prolong post-trauma problems:1. Avoidance of trauma related situations (e.g., sleeping without a light,
going out alone)2. Avoidance of trauma related thoughts and images (e.g., avoiding talking
about memory)3. The presence of automatic cognitions: “The world is extremely
dangerous;” “The victim is extremely incompetent.”
These avoidance strategies prevent the client from processing the trauma, from modifying the automatic cognitions (e.g., trauma reminders are not dangerous).
Rationale for the Treatment Program
The two primary procedures are:
1. Imaginal exposure Repeated reliving of the traumatic event. Confronting painful experiences enhances the processing of these
experiences.
2. In vivo exposure Repeatedly approaching trauma related situations that are avoided
since the trauma. Very effective in reducing excessive fear and unnecessary avoidance. Enables the client to realize that these situations are not dangerous. Bonus: behavioral activation
Both exposures modify automatic cognitions associated with the trauma.
“What the heck was I thinking, I was 8 years old! It was not my fault.”
Myths regarding exposure therapy
Patients prefer other treatments Patients will likely experience increased PTSD
symptoms Efficacy evidence for exposure therapy does not
generalize to the real world because RCT samples do not represent patients seen in real clinical practice
Exposure therapy leads to symptom exacerbation and high dropout rates
Myths regarding exposure therapy
Patients prefer other treatments Patients will likely experience increased PTSD
symptoms Efficacy evidence for exposure therapy does not
generalize to the real world because RCT samples do not represent patients seen in real clinical practice
Exposure therapy leads to symptom exacerbation and high dropout rates
Becker et al. (2007). An analog study of patient preferences for exposure versus alternative treatments for PTSD. Behaviour Research and Therapy. N=160
Top Choice (%) Top 2 (%)
Exposure 51% 71%
Cognitive Behavioral Therapy 22% 58%
Psychodynamic 16% 38%
Sertraline 9% 24%
Thought Field Therapy 3% 7%
My Buddy Therapy 1% 2%
EMDR 0% 0%
Becker et al. (2009). Law enforcement preferences for PTSD treatment and crisis management alternatives. Behaviour Research and Therapy. N=379
Top Choice (%) Top 2 (%)Exposure 26% 59%
Cognitive Behavioral Therapy 37% 57%
Psychodynamic 13% 29%
Sertraline 9% 22%
Brief eclectic psychotherapy 9% 21%
EMDR 2% 6%
Myths regarding exposure therapy
Patients prefer other treatments Patients will likely experience increased PTSD
symptoms Efficacy evidence for exposure therapy does not
generalize to the real world because RCT samples do not represent patients seen in real clinical practice
Exposure therapy leads to symptom exacerbation and high dropout rates
Myths regarding exposure therapyFoa et al. (2002). Does Imaginal Exposure Exacerbate PTSD Symptoms? Journal of Consulting and Clinical Psychology.
10.5% reported an increase in PTSD symptoms, 21.1% in anxiety, and 9.2% in depression following first imaginal exposure session
Patients who had an increase in symptoms were no more likely to drop out of treatment than patients who did not have an increase
Treatment outcome was not related to symptom exacerbation For those who experienced symptom exacerbation, the increase
lasted 1-2 weeks
Myths regarding exposure therapy
Patients prefer other treatments Patients will likely experience increased PTSD
symptoms Efficacy evidence for exposure therapy does not
generalize to the real world because RCT samples do not represent patients seen in real clinical practice
Exposure therapy leads to symptom exacerbation and high dropout rates
Myths regarding exposure therapy Coffey et al. 2013
PTSD-alcohol dependent sample (N=120)
Intent to treat sample 65% PTSD sxs reduction 70% depression sxs reduction
Treatment completers sample (≥ 8 sessions) 75% PTSD sxs reduction 78% depression sxs reduction
6-mo alcohol outcomes Over 90% days abstinent from
alcohol and drugs
Participant Demographics (N=120)
Age 33.7 (10.2)
Sex (female) 46.7%
Race White Black/African American
80%18.3%
Employment Full-time Part-time Unemployed
55%9.2%35.8%
Any co-occurring drug dependence 98.3%
Current comorbid psychiatric diagnosis Major depression Other anxiety disorder
80.8%69.7%
Alcohol Dependence Scale total score (substantial) 25.67
Clinician Administered PTSD Scale total severity 79.26
Total Criterion A events 9.6 (2-22)
Myths regarding exposure therapy
Patients prefer other treatments Patients will likely experience increased PTSD
symptoms Efficacy evidence for exposure therapy does not
generalize to the real world Exposure therapy leads to symptom exacerbation
and high dropout rates
Myths regarding exposure therapyHembree et al. (2003). Do Patients Drop Out Prematurely From ExposureTherapy for PTSD? Journal of Traumatic Stress.
Identified 25 controlled studies of cognitive behavioral treatment for PTSD that included data on dropout Exposure alone= 20.5% Stress inoculation training (SIT) or cognitive therapy (CT) alone = 22.1% Exposure + CT or SIT = 26.9% EMDR= 18.9% Controls (overwhelmingly a waitlist)= 11.4%
Compared to other treatments Meta-analysis of 19 medication trials for PTSD = 32% (Van Ettten & Taylor, 1998)
Depressed survivors of CSA receiving specialized therapy in CMHC = 40% (Fisher, Winne, & Ley, 1993)
Depressed patients receiving CT in private practice = 50% (Persons et al., 1998)
Session Descriptions
Session 1 Overview of Treatment
Main tools = imaginal & in vivo exposure 10-12 weekly sessions, 60-90 mins each
The manual uses 90 min. sessions but they can be completed in 60 min.
General rationale for PE Trauma interview Introduction of breathing retraining Assign homework:
Practice breathing retraining (10 mins, 3xs/day) Listen to session 1 audiotape Review “Rationale for Treatment” handout
Homework review Discuss Common Reactions to Trauma Assign homework:
Read Common Reaction to Trauma Handout several times
Continue breathing retraining practice
Session 2 – Part 1
Session 2 – Part 2
Homework review Discuss rationale for in vivo exposure Introduce SUDS and anchor points Construct in vivo hierarchy Assign homework:
Practice situations selected for in vivo exposure Review in vivo list of avoided situations & add to it Continue breathing retraining practice
Session 3
Homework review Discuss rationale for imaginal exposure First imaginal exposure to the trauma memory~30-45 minutes
Assign homework: Listen to imaginal exposure audiotape 1x/day Practice in vivo exposures daily Continue breathing retraining practice
Sessions 4-9
Homework review Imaginal exposure (30-45 mins)
*Hot spots Process imaginal exposure Plan in vivo exposure Assign homework:
Listen to imaginal exposure audiotape 1x/day Practice in vivo exposures daily Continue breathing retraining practice
Final Session (Session 10 or 12)
Homework review Brief imaginal exposure (20-30 mins) Process imaginal exposure
Change over course of therapy Review skills & treatment progress Discuss plans for continuing to use exposure
skills *Booster session
https://www.youtube.com/watch?v=2CTWhYRwy2Q
Through minute 13
Clip from Session 1
Facilitating the Therapeutic AllianceThe therapeutic alliance is key in PE—must communicate our care and commitment Praise client for coming to treatment and acknowledge courage Communicate understanding of the client’s symptoms Incorporate examples in treatment descriptions (e.g., common reactions)
Validate client’s experience and be non-judgmental Work collaboratively
Incorporate the client’s judgment regarding pace and targets of therapy
It may be the first time relating the trauma narrative… your reaction is important
Maintaining focus on PTSD & PE The overall aim is to provide emotional support through the
crisis, yet keep PTSD as the major focus Remind client that adhering to treatment, and thereby
decreasing PTSD and associated symptoms, is the best help you can give
Applaud healthy coping and adherence If appropriate, attribute response to crises as related to
PTSD – predict that these situations will improve as PTSD does The “crisis” may not be viewed as a “crisis” or would be better
tolerated if PTSD symptoms are reduced
Bottom Line: Keep these conversations brief… they could be forms of avoidance. Do not let a crisis prevent in-session exposures.
Treatment Components
Format of Treatment Program Behavioral program 9-12 sessions 60 or 90 minute sessions Weekly homework assignments Importance of weekly attendance
Primary Treatment Components
1. PsychoeducationWhat is PTSDRationale
2. Breathing Retraining3. Common Reactions4. SUDS Development5. In-Vivo Exposure
Hierarchy developmentHomework assignment
6. Imaginal Exposure
Psychoeducation & Breathing
Common Reactions to Trauma Fear and anxiety
re-experiencing the trauma flashbacks, nightmares Hypervigilance
over-alertness, startle Irritability, anger, trouble concentrating
Avoidance of trauma reminders Emotional numbing Loss of interests, depression
Feeling of “going crazy” Shame and guilt Poor self image
Common Reactions to trauma
Reviewing the Common Reactions Handout can normalize PTSD symptoms “These reactions are so common following traumas we
had to make up a handout”
Interactive ConversationFocus on not readingGains valuable info for hierarchyBe sure to follow-up to gather further information if the person says “yes, I’ve experienced this thing”
Breathing Retraining The way we breathe affects the way we feel Exhalation, not inhalation, is associated with
relaxation Slow down your breathing to avoid hyperventilation Regular inhale Concentrate on slow exhalation while saying CALM (or
RELAX) to yourself Exhale on two-count
The therapist models breathing retraining for client Client then attempts breathing retraining
In Vivo Exposure
Rationale for In Vivo Exposure Trauma related fears are sometimes unrealistic or
excessive (e.g., going to a shopping mall, fear of all men).
Repeated in vivo exposure: Is counter to negative reinforcement and avoidance Results in extinction, so that the target situation
becomes increasingly less distressing Fosters the realization that the avoided situation is
quite safe Disconfirms the belief that anxiety in the feared
situation continues “forever” Enhanced sense of self control and personal
competence
How to Implement In Vivo Exposure SUDs Introduction Work on SUDS rating scale
100=Trauma Other items on rating scales should not be trauma-
related Check the rating scale:
What is SUDS right now? What would SUDS be in different non-trauma related
situations? Fender bender Call from school—kid is sick Get a tax audit Identity stolen
Present the treatment rationale Give daily life examples of in vivo exposure and extinction
(e.g., a child fearing a big but safe dog like a Golden Retriever) Develop a list of situations the client has been avoiding since
the trauma Ask client to rate the intensity of anxiety (SUDS level) s/he
experiences when imaging confronting each situation Arrange the situations in a hierarchy according to their SUDS Notes:
If the client cannot identify circumstances, suggest typically avoided situations.
Also, get creative and think of unusual responses as well E.g., being afraid to get hands dirty or touch meat
Inquire about the objective safety of the situations.
How to Implement In Vivo Exposure
Example of an In Vivo Hierarchy
50 = Staying at home alone during the middle of the day 60 = Driving to a friend’s home in a safe neighborhood in the
day time 70 = Driving to a friend’s home in a safe neighborhood after
dark 75 = Walking down a street in her parent’s neighborhood 80 = Staying alone in her room on the campus with door locked 85 = Walking with a friend on campus 90 = Walking on campus during daytime 100 = Walking on campus at night
Items MUST be objectively & generally SAFE
Session 2B Videohttps://www.youtube.com/watch?v=rZgsYs1xO5I
-from minute 24-31 is explanation about avoidance-from min 34.30-53:30min
Hierarchy Construction
How to Implement In Vivo Exposure (cont.)
Homework Assignment Begin with assigning exposure to situations that
evoke moderate levels of anxiety (e.g., SUDs = 40-60)
Instruct the client to remain in each situation for 30 to 45 minutes, or until his/her anxiety decreases considerably (i.e., 50%)
Easier to simply assign 30-45 min Great Resources:
Phone Apps: http://www.myvaapps.com/
Considerations for In Vivo Exposures
1. Gather as much information as possible from earlier sessions so you already have some ideas for the in-vivo hierarchy.
They might not even know what they’re avoiding, so we need to be on the lookout!
2. Ask them to generate list of things they’ve avoided for homework.
3. Find out their access to internet and other resources Lots of good videos/pictures online they can do, especially for
things that can’t be achieved easily (e.g., watching a fight or war movie)
Can do on phone or computer Sound Bible website great resource But make sure you watch it first and give them the SPECIFIC
information… don’t send them to watch on their own!
1. Remind—don’t engage in avoidance behaviors (no matter how subtle) during imaginals.
Ask about safety behaviors!
2. The SUDS ratings are a guess, so hierarchy items rated as a 50 might be an actual 80, or an actual 20.
3. We want to get an easy win up front, so don’t let that first in-vivo be something that would be too overwhelming.
4. Need to be careful of having hierarchy items that are too broad and therefore cover numerous avoided items.
Considerations for In Vivo Exposures
Role of Safety Behaviors
Validating the initial development of safety behaviorsSafety behaviors may prevent SUDS from reducing and inhibit new learning from occurring
Try getting them to keep track of safety behaviors Next time, do same exercise with less safety behaviors Safety behaviors are often hidden
Cell phoneYou (therapist = safe person)Water bottle
Imaginal Exposure
Rationale for Imaginal Exposure
Repeated recounting of the trauma Reduces distress associated with trauma
Lower distress fewer intrusive memories and nightmares Results in extinction, so trauma can be remembered without
intense, disruptive anxiety Reduced distress/avoidance allows pt. to process trauma
i.e., organize, make sense of it, “file it in the right drawer” Helps distinguishing between “thinking” about the trauma and
actually “re-encountering” it Fosters realization that engaging in the trauma memory does
not result in loss of control or “going crazy” Enhances sense of self control and personal competence
If multiple traumas Collaboratively choose the most intrusive and distressing
memory currently “Which would you remove/get rid of, if possible?”
Implementing Imaginal Exposure
Instructions to client Recall the memory as vividly as possible
Include details of the event (e.g., thoughts, feelings) Not a newspaper account
Describe what you experienced regarding the senses Imagine the trauma is happening now Stay in touch with the feelings the memory elicits Describe the trauma in present tense Close eyes
Implementing Imaginal Exposure
Implementing Imaginal Exposure
Instructions to client (cont.) Will gather SUDS ratings about every 5 minutes Clinician may ask questions to elicit more detail We also asked about the vividness of the image
approximately every other time we ask about SUDS ratings (0-100)
Begin imaginal ASAP following instructions!
Homework Listen to tapes of imaginal exposure once a day and
record SUDS
Following Imaginal Exposure
Reinforce client for having the courage/willingness to do the imaginal!
Brie processing What was the client’s reaction to the imaginal exposure? If SUDS decreased during, point that out to client. If not,
congratulate them for staying with the difficult memory Clients often discuss increased awareness of what
happened during the trauma Discuss differences that occur over time in their
experience of recounting the trauma memory
Timing Your Session
60-minute session Set agenda as the person walks in the door5 minutes for brief homework checking (no problem-solving) Break “how are you doing?” habit
8:00—Set agenda; review homework and measures BRIEFLY; remind instruction and rationale for imaginal as needed
8:10—Start imaginal (35 minutes, ending with a few minutes of diaphragmatic breathing)
8:45—End imaginal 8:45—Problem-solve previous homework; assign new homework
(5 minutes)
Imaginal Exposure to Hotspots
Hotspots: Portions of the memory that remain distressing even though most everything else in the narrative is not (i.e., SUDS < 20)
Typically not addressed until at least halfway through treatment
Identify the most distressing moments during the recounting by Self-report of client SUDS levels Facial expressions and body language during imaginal
Once/if identified: Specify the beginning and end of the hotspot (about 5
minutes) Ask client to repeat the recounting without pause
between repetitions Ask client to recount as many details as possible Help the client focus on feelings and thoughts by
probing
Imaginal Exposure to Hotspots
DON’T MAKE A ROOKIE MISTAKE!
THE MOST COMMON MISTAKE NEW PE THERAPISTS MAKE IS
FOCUSING ON HOT SPOTS TOO SOON!
DON’T MAKE A ROOKIE MISTAKE!
THE MOST COMMON MISTAKE NEW PE THERAPISTS MAKE IS
FOCUSING ON HOT SPOTS TOO SOON!
Therapist-Client Alliance During Imaginal
Express support and empathy with client’s distressPeriodically reassure client that he/she is safe (e.g., “I know this is tough; you are doing a good job staying with it”)Monitor client’s emotional response Probe for thoughts and feelings encouraging emotional engagement If client becomes overwhelmed with distress (e.g., threatening to
stop imaginal exposure), conduct imaginal with client’s eyes open (perhaps looking at the floor)
Allow sufficient time to discuss and process experience and calm client as needed Use breathing retraining after
https://www.youtube.com/watch?v=YZbJZMmoLwU
Session 3 Video - Imaginal
https://www.youtube.com/watch?v=9aTDIiTr99Y
Video Clip - Foa
Factors that Impair Engagement
Factors that Impair Effective Emotional Engagement in Imaginal Exposure Avoidance
Under-engagement
Over-engagement
Avoidance
Addressing Avoidance
Validate client’s fear and urges to avoid Review the rationale for treatment
Avoidance reduces anxiety in the short term but prevents new learning in the long term
The incident was dangerous, but the memories are not Use analogies/metaphors to support the rationale
e.g., “Holding your nose”never get used to bad smell e.g., emotional hot stove
Addressing Avoidance
“Roll with resistance” Review reasons why client sought PTSD treatment
How do symptoms interfere with life satisfaction?
Review the progress that client has already made Provide a lot of support and encouragement
If needed, schedule inter-session phone contact to provide support and discuss homework progress
Problem-solve solutions to concrete obstacles together
Addressing Avoidance
What about when resistance comes up during imaginal exposure? Encourage to continue on— “It is in your best interest to
continue.” Be observant of when client might be wanting to stop (e.g., pay
attention to body language), and be prepared for the resistance. Right before starting another retelling:
Over-reinforce: “You are doing a GREAT job; you are not letting the fear/avoidance win; start over and do just as you were doing!”
If they REFUSE, last resort: Listen to last imaginal tape Do in-session in vivo exposure
*Do not reinforce avoidance*!!
Facilitating Homework Compliance
Reiterate the rationale Client must understand why she is being asked to do
homework
Find out what is getting in the way: Organization (e.g., lost sheet, forgot) Practical issues (e.g., no time, no privacy) Avoidance
Intervention guided by nature of compliance problem(s) If extinction not evident in homework completed over
multiple sessions, ask about safety behaviors
Under-engagement
Identifying Under-engagement Difficulty accessing memory (low SUDS and/or vividness)
Emotionally disconnected/detached from memory Difficulty visualizing event Rushes through retelling
Discrepancy in reporting of SUDS & vividness May describe trauma in detail, but report low SUDS and vividness
during retelling May report high SUDS during imaginal retelling, but appearance
is discrepant with the high rating
Narrative may sound like a “police report”
Addressing Under-engagement
Reiterate the rationale for imaginal exposure It is essential that client understand why she or he is being asked to
confront this painful memory
Explore feared consequences of engagement with the memory
Validate client’s feelings while, at the same time, helping her realize that being in distress is not dangerous
Avoid conversations during retelling Reduces emotional engagement with memory
Procedures to Increase Engagement in Imaginal Exposure Encourage client to keep eyes closed and use present tense (if
not already doing so)
Probe for details, sensory information, feelings, and thoughts
with brief questions. Ask in present tense (e.g., “How does it smell?,” “What are you
feeling in your body?”)
Keep probe questions very brief, infrequent, and directed only
at what the client is describing at that moment
If needed, role-play the proper procedure for client to
demonstrate the way trauma recounting should be done
Over-Engagement
Identifying Over-Engagement If client is too distressed/dissociating/”checked-out”,
he is not processing This is a form of avoidance! Not terribly common.
Reports very high SUDS/vividness ratings that remain high Within and between sessions
Identifying Over-Engagement (cont.)
Appears visibly very distressed This alone should not be considered evidence of over-
engagement (i.e., the memories are distressing to all clients)
Difficulty maintaining sense of safety and “groundedness” May have flashbacks: Retelling becomes re-experiencing Physical movements mirror actual actions
This is also quite common and may only indicate full engagement in the task; explore with client before intervening
Addressing Over-Engagement
Reiterate the rationale Client must understand why she is being asked to confront this painful
memory
Goal is to help the client successfully disclose some part of the memory while managing distress
Discuss, in advance, ways to facilitate grounding and support Do not attempt a comforting touch unless you’ve discussed in advance
Reduce the vividness of the memory Modify procedures
Procedures for Reducing Engagement in Imaginal Exposure
Have client use past tense and/or keep eyes open Increase use of empathic, “grounding” statements
“You’re doing a great job staying with it” “I know that this is distressing, but you are safe here in my office” “Remember, memories can’t hurt you”
If client seems “stuck,” ask “And now what’s happening?” to move the memory forward Can foster realization that, although horrible, this moment ended
If patient appears to dissociate, ask her/him to name and describe 5 objects in the room
Strongly praise client’s efforts Help client appreciate that she is able to emotionally engage
in the memory and describe trauma while managing distress Remind client that each exposure gets her closer to the life
she wants If needed, do a few minutes of slow, paced breathing If necessary, can write trauma narrative rather than vocalize it
Try reading out loud repeatedly Alternately, can write repeatedly
Procedures for Reducing Engagement in Imaginal Exposure
Session Descriptions Review
Session 1 Overview of Treatment
Main tools = imaginal & in vivo exposure 10-12 weekly sessions, 60-90 mins each
General rationale for PE Trauma interview Introduction of breathing retraining Assign homework:
Practice breathing retraining (10 mins, 3xs/day) Review “Rationale for Treatment” handout
Homework review Discuss Common Reactions to Trauma Assign homework:
Read Common Reaction to Trauma Handout several times
Continue breathing retraining practice
Session 2 – Part 1
Session 2 – Part 2
Homework review Discuss rationale for in vivo exposure Introduce SUDS and anchor points Construct in vivo hierarchy Assign homework:
Practice situations selected for in vivo exposure Review in vivo list of avoided situations & add to it Continue breathing retraining practice
Session 3
Homework review Discuss rationale for imaginal exposure First imaginal exposure to the trauma memory~30-45 minutes
Assign homework: Listen to imaginal exposure audiotape 1x/day Practice in vivo exposures daily Continue breathing retraining practice
Sessions 4-9
Homework review Imaginal exposure (30-45 mins)
*Hot spots Process imaginal exposure Plan in vivo exposure Assign homework:
Listen to imaginal exposure audiotape 1x/day Practice in vivo exposures daily Continue breathing retraining practice
Final Session (Session 10 or 12)
Homework review Brief imaginal exposure (20-30 mins) Process imaginal exposure
Change over course of therapy Review skills & treatment progress Discuss plans for continuing to use exposure
skills *Booster session
Questions??
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