Transcript Slide 1

PROLONGED EXPOSURE
An Evidence-Based Psychotherapy
for PTSD
Scott Michael, Ph.D., Dana Holohan, Ph.D., Gia Maramba, Ph.D., & Thad Strom, Ph.D.
VA Psychology Training Council
Evidence-Based Psychotherapies Subcommittee
Acknowledgments



Special thank you to Drs. Edna Foa and Elizabeth
Hembree for their invaluable contribution in
disseminating PE training across the VA. This
presentation is based in their research and clinical work
with PE.
We would also like to acknowledge the VA PE Training
initiative, headed by Drs. Josef Ruzek and Afsoon
Eftehari at the National Center for PTSD in Menlo Park,
CA for their work in training VA clinicians nationwide.
For any questions, please contact Scott Michael Ph.D. at
[email protected]
VA Training in
Evidence-Based Psychotherapies
Background



In recent years, health care policy has incorporated evidencebased practice as a central tenet of health care delivery
(Institute of Medicine, 2001)
The VA developed a Mental Health Strategic Plan in response
to the President’s New Freedom Commission on Mental Health
report (2004)
The Mental Health Strategic Plan calls for the implementation
of EBPs at every VAMC in the country
Goals of VA Training in EBPs


To train VA staff from multiple disciplines in
evidence-based psychotherapies
To augment psychotherapies already being offered
in VA medical centers
VA Dissemination and Training in EBPs
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Cognitive Behavioral Therapy (CBT) for Depression
Acceptance and Commitment Therapy (ACT) for Depression
Cognitive Processing Therapy (CPT) for PTSD
Prolonged Exposure (PE) for PTSD
Social Skills Training (SST) for severe mental illness (SMI)
Integrative Behavioral Couple Therapy (IBCT)
Family Psychoeducation (FPE)


Behavioral Family Therapy (BFT)
Multi-Family Group Therapy (MFGT)
EBP Presentations for Interns and
Postdoctoral Fellows


VA EBP roll-out training has been focused on
staff
VA Psychology Training Council (VAPTC)
developed a workgroup in 2009 to focus on
developing EBP didactics for interns and
postdoctoral fellows
Goals of this EBP Presentation


To provide a basic working knowledge of each of
the roll-out EBPs
To provide the foundation for trainees to seek out
further training and supervision in the EBPs they
intend to implement
Limitations


This presentation will not provide equivalent training
to the EBP roll-outs
This presentation will not provide the skills to
implement the treatment without further training and
supervision
Prolonged Exposure
Empirical Research
2008 Institute of Medicine Report:
PTSD Treatments

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Committee set high bar: evidence-based practice
Only cited trauma exposure therapies as meeting this
criteria
No medications met criteria
Reference: Institute of Medicine (IOM) (2008). Treatment of
posttraumatic stress disorder: An assessment of the evidence.
Washington, DC: The National Academies Press.
Published Randomized Studies on Exposure Therapy
(EX) Only and EX Plus SIT or CR
Chronic PTSD:
 EX therapy only
 EX therapy + SIT and/or CR
22 studies
25 studies
Acute PTSD or ASD
 EX therapy only
 EX therapy + SIT and/or CR
1 study
5 studies
Study I With Female Assault Survivors
Treatments:
 Prolonged
 Stress
 SIT
Exposure (PE)
Inoculation Training (SIT)
+ PE
 Waitlist
Controls
Treatments included 9 sessions conducted over 5
weeks
Foa et al.,1999
Comparison of PE, SIT, PE/SIT, and Waitlist
With Female Assault Survivors
PSS-I Total
40
Pre
Post
FU
30
20
10
0
Foa et al., 1999
PE
SIT
PE+SIT
WL
Post-Rx Effect Sizes* of PE vs. SIT vs.
PE/SIT: PTSD
*Effect size compared to waitlist group at post-treatment
Foa et al., 1999
Study II With Female Assault Survivors
Treatments:
 Cognitive
Restructuring (PE/CR)
 Wait Exposure (PE) alone
 PE List (WL)
Treatment includes 9 weekly sessions,
extended to 12 for partial responders
(< 70% improvement)
Foa et al., 2005
Comparison of PE, PE/CR, and Waitlist With
Female Assault Survivors
PSS-I Total
40
Pre
Post
FU
30
20
10
0
PE
Foa et al., 2005
PE/CR
WL
Percent
Percent of Patients With PTSD Diagnosis
Post-Tx
Foa et al., 2005
Last FU
Within-Group Effect Sizes
PSS-I
Foa et al., 2005
BDI
Comparison of PE and PE/CR for Female Survivors of
Rape, Physical Assault, and Childhood Sexual Abuse
Foa et al., 2005
Rape = PA = CSA
Comparison of 9 PE Sessions, 12 CPT Sessions, and
Waitlist With Female Assault Survivors
CAPS Total
90
Pre
Post
FU
60
30
0
PE
Resick et al., 2002
CPT
WL
PE = CPT
PE with Veterans
The Efficacy of PE With 16 U.S. Veterans
(PG, VN, OIF, WWII) Plus One EMT
PSS-SR Total
40
30
Pre
Post
20
10
0
VN = Vietnam, n = 10; PG = Persian Gulf, n = 4;
OIF = Operation Iraqi Freedom, n = 1; WWII = World
War 2, n = 1; EMT = Emergency Medical Technician,
n = 1.
Albrecht, unpublished
The Efficacy of PE With 10 Veterans
VV (n =5)
40
OEF/OIF (n = 5)
30
20
10
0
PrePDS
Rauch et al., in press
PostPDS
CSP #494: Study Design
284 Female Veterans and Active-Duty Personnel with
PTSD in 12 sites and 52 therapists
Random Assignment
141 Total
Prolonged Exposure (PE)
Therapy
Schnurr et al., 2007
143 Total
Comparison Therapy
Present Centered
Therapy (PCT)
CAPS PTSD Scores Lower in PE
Overall d =.27*
*p <.05
Overall d =.46*
Schnurr et al., 2007
CSP #494: Conclusions
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VA patients can benefit from PE
–
PE more effective than PCT for treating PTSD in female
veterans and active duty personnel
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VA patients are highly satisfied with PE

VA therapists can deliver PE
Schnurr et al., 2007
Summary
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Several CBT programs are quite effective for PTSD, with
exposure therapy receiving the most empirical evidence
with a wide range of traumas
PE is more effective than treatment as usual
CBT can be successfully disseminated to community clinics
with non-CBT experts as therapists
PE can be disseminated effectively over long distances
and across cultures
However, relatively few clinicians are using evidence
based treatments for PTSD and other mental disorders in
their practice
Prolonged Exposure
Theoretical Underpinnings
Emotional Processing Theory
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
From Peter Lang (1977)
Fear Structure - a program for escaping danger
 It
includes information about:
 The
feared stimuli
 The fear responses
 The meaning of stimuli and responses

Tiger Example
 Tiger
in zoo elicits different responses than tiger
walking into this room
Trauma Structure
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Specific form of fear structure; forms shortly after a
trauma
Feared stimuli – the sights, sounds, smells present at
time of trauma
Fear/arousal Responses – the emotional/
physiological/behavioral responses at time
Meanings associated with stimuli & responses
Schematic Model of a Memory
Shortly After Combat Trauma
Afraid
Uncontrollable
I - Me
Combat
IED
Crowd
Driving
Trash
Helpless
Dark
Fire
Noise
Yell
Scan
Confused
PTSD
Symptoms
Incompetent
Courtesy of Melissa Polusny, Ph.D.
Dangerous
Trauma Structures
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
Very heavily sensory based
Fragmented and poorly organized
Often contain unrealistic information
 Stimuli
dangerous: “Always swerve from a bag on side
of road”
 Responses are incompetent: “I am weak because I can’t
handle this”

Trauma structures “brought home” with a service
member – served a survival purpose but now
interfere with meaningful life activities
Schematic Model of a Trauma Memory After
Recovery
Afraid
Uncontrollable
I - Me
Combat
IED
Crowd
Driving
Trash
Helpless
Dark
Fire
Noise
Yell
Scan
Confused
Incompetent
Dangerous
Rationale for PE
•
•
•
•
Promotes emotional processing: Learn new, corrective
information – trauma memories and related situations
are not dangerous
Discriminate trauma memories from trauma
Reduce excessive fear and gain perspective on trauma
PTSD commonly impacts core beliefs about self and
world; PE focuses on modifying negative beliefs that
maintain PTSD
▫
▫
▫
“No one can be trusted”
“I am incompetent/weak”
“The world is unsafe”
Role of Avoidance
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Avoidance reduces trauma reexperiencing and
hyperarousal in short term but prolongs in long term
Avoid trauma memories  never challenge traumarelated beliefs
Avoid public  never challenge safety concerns
Maintains trauma structures
Avoidance and negative reinforcement: Leaving or
initially avoiding feared situation leads to relief,
thus strengthening avoidance behavior
Rationale (continued)
•
Two types of exposure
1.
▫
▫
2.
▫
▫
Imaginal exposure
Emotional processing of trauma memory
Learning – Memory is painful but not dangerous
In vivo exposure
Do real-life activities that are avoided
Learning – Many situations are safer than I thought
PE Protocol
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9-15 sessions; averages 10 sessions
90-min sessions
1: Assessment, treatment overview, PTSD psychoeducation,
breathing retraining
2: In vivo Exposure (continue throughout)
3-5: Imaginal exposure
6-9: “Hot Spot” exposure
10: Final imaginal exposure, wrap-up
Example of typical PE session
(session 4 on)

Review homework (10 min)

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In vivo exercises & trauma tape listening
Conduct imaginal exposure (30-45 min)
Process imaginal exposure (15-20 min)
Discuss/implement in vivo exposure (10-20 min)
Assign homework (5-10 min)

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Continue breathing practice
Listen to trauma tape daily
Complete in vivo exercises
In Vivo Exposure
Rationale for In Vivo Exposure
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Introduces corrective information to trauma structures –
disconfirms belief that feared situation is actually
harmful
Prevents avoidance & thus negative reinforcement
Disconfirms belief that anxiety will “last forever”
Habituation – less & less distress with repeated
exposures
Increases sense of competency
Use a good metaphor:

Little boy knocked over by wave, scared of water, parent
gradually brings him closer & closer to water
Habituation

Anxiety

Anxiety increases 
Avoidance
This situation is
dangerous; I got out
just in time;
Something awful
could have happened
Time
Courtesy of Sally Moore, Ph.D.
Habituation


Anxiety

Stop avoidance
Anxiety decreases
on its own
This situation was not
as dangerous as it
felt; I can tolerate
anxiety; I don’t have
to avoid to feel
better
Time
Courtesy of Sally Moore, Ph.D.
Initiating In Vivo Exposure

Anchor the SUDS (subjective units of distress scale)
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Develop a list of feared/avoided activities and
rate the SUDS
Arrange into hierarchy
Counteract stimulus overgeneralization
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0-100 scale; 0 = most relaxed, 100 = most distressed
E.g., Are all Arabs really dangerous?
Repeated practice necessary for habituation
In Vivo Exposure Hierarchy Construction
Tips

Types of activities
Traumatic event dependent: Ask about sights, sounds, smells –
e.g., avoiding Asians/Arabs, BBQs (smell of cooked meat),
certain music/movies
 General hypervigilance: e.g., grocery store, Costco, sitting
back to door at restaurant
 Valued life activities/behavioral activation – the more
valued the avoided activity, the stronger the motivation to do


Do insure safety
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E.g., Don’t encourage walking alone, at night, in dangerous
neighborhood
Safety behaviors: anything that reduces anxiety – e.g.,
facing door, closing shades, carrying weapons – need to
be systematically removed
Hierarchy
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Grocery store with partner, not busy
Restaurant with partner, back to wall
Grocery store alone, not busy
Grocery store with partner, moderately busy
In line, facing sideways, wall to back
Restaurant, whole family, back to wall
Restaurant with partner, back to tables
Elevator,1 or 2 people
Movie with friends
In line, facing forward or no wall at back
Grocery store with partner, crowded
Grocery store alone, moderately busy
Feeling hot/sweaty
Elevator, many people
Mall alone, moderately busy
Gym
Restaurant, whole family, back to tables
Go to friend’s house
Mall alone, crowded
Grocery store alone, crowded
30
35
45
50
50
50
60
60
60
65
65
65
70
75
75
80
80
80
95
100
Courtesy of Sally Moore, Ph.D.
Hierarchy
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Grocery store with partner, not busy
Restaurant with partner, back to wall
Grocery store alone, not busy
Grocery store with partner, moderately busy
Restaurant, whole family, back to wall
Grocery store with partner, crowded
Restaurant with partner, back to tables
Grocery store alone, moderately busy
Mall alone, moderately busy
Restaurant, whole family, back to tables
Mall alone, crowded
Grocery store alone, crowded
In line, facing sideways, wall to back
Elevator,1 or 2 people
In line, facing forward or no wall at back
Elevator, many people
Feeling hot/sweaty
Gym
Movie with friends
Go to friend’s house
30
35
45
50
50
65
60
65
75
80
95
100
50
60
65
75
70
80
60
80
Themes:
Crowds
Enclosed
areas
Heat
Socializing
Courtesy of Sally Moore, Ph.D.
Selection of Initial In Vivo Exposures
Initial exposures:
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
Goal: Success
experience
Relatively low SUDS
(30-40)
Collaboratively selected
If possible, things patient
already doing with some
success
Don’t pick big unknown
(e.g., going to
potentially dangerous
neighborhood)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Grocery store with partner, not busy
Grocery store with partner, moderately busy
Grocery store with partner, crowded
In line, facing sideways, wall to back
In line, facing forward or no wall at back
Elevator,1 or 2 people
Elevator, many people
Grocery store alone, not busy
Grocery store alone, moderately busy
Grocery store alone, crowded
Feeling hot/sweaty
Gym
Restaurant with partner, back to wall
Restaurant with partner, back to tables
Restaurant, whole family, back to wall
Restaurant, whole family, back to tables
Mall alone, moderately busy
Mall alone, crowded
Movie with friends
Go to friend’s house
30
50
65
50
65
40
75
45
65
100
70
80
35
60
50
80
75
95
60
80
How to do In Vivo Exposure


Select activity w/ moderate SUDS (e.g., 30-40)
Ideally: stay in exposure activity until SUDS decreases 50%



Stay for at least 30 minutes & until SUDS decrease from peak
levels
Systematically remove safety behaviors

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This may not occur initially, but should stay until SUDS drops some
Example: 1. Sit at back of empty movie theater; 2. Sit at back
of crowded theater; 3. Sit in middle but on aisle; 4. Sit in middle
of crowded theater
Work your way up the hierarchy – goal is to complete
hardest items at top by end of PE
Ideally they’ll do daily in vivo exposure!
Imaginal Exposure
Rationale for Imaginal Exposure

Repeated trauma reexperiencing indicates
“unfinished business”
 Use
a good metaphor
 File

cabinet
Undigested Food Boil
Unread Book
Avoidance works in short term to alleviate distress
but functions to maintain distress over long term
 Serves
good survival function but
 Prevents emotional processing
Goals of Imaginal Exposure
Emotionally process & organize trauma
memory
 Differentiate between “revisiting” & “reliving”
 While memory is painful, isn’t dangerous –
won’t lose control or sanity
 Habituate to anxiety in trauma memory
 Promote competence and mastery

Selecting the Index Trauma


Many patients will have multiple traumas
Select the “worst” trauma first
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Most prominent in reexperiencing
Most distressing or troubling
“If you could magically erase any one event, which one would
you choose?”
Most patients will only need to work on 1 trauma,
particularly if worst is selected
If PTSD scores do not fall by completion of trauma
processing, indicates possible “hidden” trauma they did not
initially report
May opt to work on 2nd trauma after 1st done; do so if
patient wants to and/or PTSD symptoms not decreasing
Conducting Imaginal Exposure

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Use present tense
Close eyes
Monitor SUDS every 5 minutes
Ask for sensory info, be very detail-oriented
Be aware of cognitive avoidance
Be very supportive; gently encourage patient to complete
story
Completes as many accounts as possible in time allotted



45-60 min 1st time; 30-45 min subsequently
Tape record – assign daily listening as homework
Avoid “failure” experiences – try to not let them stop midway
Therapeutic Stance in Imaginal
Exposure
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Initially stay out of their way – let patient tell story
without much prompting 1st time
Will have numerous opportunities: Patient likely to
complete ~ 20 times with you
Orient toward details of memory in order to increase
engagement
Sensory info is powerful engager
Be aware of “editing”: overly analytic, abstract, staying
disengaged
Do not attempt to foster insight during imaginal
Processing – Do attempt to foster insight
Processing
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Always start with validation
Provide containment and support
Follow patient’s lead – ask for reactions, insights, “How
was that for you?”
Normalize reactions during and following trauma
In early sessions, do not begin to challenge beliefs
As imaginal exposure progresses, may lightly challenge
faulty beliefs but use open-ended questions
If need be, increase challenges but remain in Socratic
questioning mode – allow patient to come to own
insights
Hot Spots Procedure


Sessions 6 – 9
Chose the “Hot Spot” – the worst part of the event
 Discuss
with patient, offer your thoughts, but let him/her
choose


Trauma may have several hot spots – work on worst
one for several sessions until habituates, then move
to next
Repeat as many times as possible in 30-45 min
Special Issues
Treating PTSD
Avoidance
Under-Engagement
Over-Engagement
PE is a treatment for PTSD

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
While PE focuses on trauma, it is specifically designed
to treat PTSD
Not everyone who experienced trauma has PTSD
PE will not be (as) effective for those who do not meet
diagnostic criteria for PTSD
Potential Problems
Lack of/low reexperiencing – poor target for imaginal
 Low avoidance – few avoided situations for in vivo
 Not sufficiently distressed to adhere – distress motivates
exposure therapy; if patient not very distressed, why would
s/he bother?

Recognizing Avoidance


No show! Or cancelling often
Not completing homework


Listens to tape while…..

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Doing housework, driving, keeping busy, etc.
Drinks during exposure exercises

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Foa: ideally daily but at least 4-5 times per week
Several drinks at dinner; drinking during tape listening
In vivo: does not stay long enough; uses safeties
Under-engaged in imaginal work
Edits during imaginal
Addressing Avoidance

Always validate patient’s concerns/fears


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Review rationale
Remind why patient came to treatment

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
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Avoidance reduces anxiety in short-term but impedes meaningful activities in
long-term
Know your patient’s values and goals – what do they want more of?
Schedule phone calls during week
Problem-solve impediments to therapy


What is the ultimate fear: Go crazy, lose control, feel sad forever, never be
able to turn it off
Ex: Can’t afford to eat out often – go to mall food court and have coffee, sit in
middle with back to crowd
Stay focused on PE


Life happens, but PE is short-term
Do your best to not deviate or suspend protocol if possible
Under-Engagement


Less feared by clinicians than over-engagement but
far more common
Engagement is a continuum
 Many
are low engagers; under-engagers are
qualitatively different

Many patients begin on less engaged side, then
become more engaged as PE progresses
 Don’t
jump to conclusion patient is an under-engager
too soon
Identifying Under-Engagement

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
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Provides a “military report” version (strictly factual)
Reports low SUDS
Behaviorally seems un-engaged in emotions/story
Moves quickly through story
Jumps over (probably most traumatic) details of
story
 “Then


he raped me, then I got up to go to bathroom”
Difficulty accessing memory or details of memory
Reports high SUDS but seems un-engaged
Addressing Under-Engagement
During Imaginal
 Always validate how hard this is and their efforts,
but avoid conversations – keep comments brief
 “You’re



doing great”; “I know how hard this is for you”
Focus on sensory details – sensory details are strong
engagers – smells, touch, sounds
Focus on bodily sensations that occurred during
trauma
Can use external stimuli to prime: e.g., chopper
sounds
Addressing Under-Engagement, cont’d
During Processing or prior to Imaginal
 Validate efforts
 Reiterate rationale
 Remind them of personal reasons to engage in PE
 Explore feared consequences of engagement: Go
crazy, lose control, sadness will never stop
 Role-play proper procedures - show how effective
imaginal work looks like
Over-Engagement


More feared by clinicians but quite uncommon
Engagement is a continuum
 Many
are high engagers; over-engagers are
qualitatively different


Do not jump to conclusion that patient is overengaged if they are highly engaged and emotive
Reporting “100” SUDS does not immediately
indicate over-engagement
Identifying Over-Engagement

Hysterically sobs and cannot keep speaking
 This

persists for more than one session
Dissociates strongly during session and not
responsive to your voice
 Shows
signs of reliving trauma in the therapy room;
behaviors mimic what actually happened
Addressing Over-Engagement



Validate and reiterate rationale – emphasize goal is to
revisit, not relive, memory
Remind that memories are upsetting but not dangerous
If necessary, modify imaginal instructions





Eyes open and/or use past tense
If dissociative, can use grounding, but preferably not during
account (try in between accounts)
If stuck – help move along to next step
Can use hierarchy of memories and start with less distressful
memory
Can have patient write trauma narrative; try in beginning
and attempt to move toward verbal recounting if possible
Knowing when to end PE

Let the numbers tell the tale

Have PCL scores dropped sufficiently?



50 is cut-off for PTSD DX; however aim for lower scores
Have SUDS levels routinely decreased ~ 50% for both in vivo
and imaginal exposures?
Look for other signs of improvement; PCL isn’t everything

See signs of habituation during imaginal?



Tells story with less intense affect, shows behavioral signs of being
more relaxed
Reports that it seems more like a memory, less like reliving
Is patient more engaged with life?

Doing more; being more spontaneous; greater emotional range and
engagement?