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??