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 evidence based 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

       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  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 Exposure (PE)  Stress Inoculation Training (SIT)  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

40 30 20 10 0

Foa et al., 1999

PE SIT PE+SIT WL Pre Post FU

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

40 30 20 10 0

Foa et al., 2005

PE PE/CR WL Pre Post FU

Percent of Patients With PTSD Diagnosis

Foa et al., 2005 Post-Tx Last FU

Within-Group Effect Sizes

Foa et al., 2005 PSS-I 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

90 60 30 0 PE

Resick et al., 2002

CPT Pre Post FU WL

PE = CPT

PE with Veterans

The Efficacy of PE With 16 U.S. Veterans (PG, VN, OIF, WWII) Plus One EMT

40 30 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.

Pre Post

Albrecht, unpublished

The Efficacy of PE With 10 Veterans

VV (n =5) OEF/OIF (n = 5) 40 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* Overall d =.46*

*p

<.05

Schnurr et al., 2007

CSP #494: Conclusions

 VA patients can benefit from PE – PE more effective than PCT for treating PTSD in female veterans and active duty personnel  VA patients are highly satisfied with PE  VA therapists can deliver PE Schnurr et al., 2007

Summary

• • • • • 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

 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

 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 Helpless Combat Driving Dark Crowd IED Fire Noise Trash Yell Scan PTSD Symptoms Confused Incompetent Courtesy of Melissa Polusny, Ph.D.

Dangerous

Trauma Structures

 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 Helpless Combat Driving Dark Crowd IED Fire Noise Trash 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

     Avoidance reduces trauma reexperiencing and hyperarousal in short term but prolongs in long term Avoid trauma memories  related beliefs Avoid public  never challenge trauma 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)

• 1.

2.

▫ ▫ ▫ ▫ Two types of exposure 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

    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)  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)  Continue breathing practice  Listen to trauma tape daily  Complete in vivo exercises

In Vivo Exposure

Rationale for In Vivo Exposure

      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

Time   Anxiety increases  Avoidance

This situation is dangerous; I got out just in time; Something awful could have happened

Courtesy of Sally Moore, Ph.D

.

Habituation

Time    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

Courtesy of Sally Moore, Ph.D

.

Initiating In Vivo Exposure

 Anchor the SUDS (subjective units of distress scale)  0-100 scale; 0 = most relaxed, 100 = most distressed  Develop a list of feared/avoided activities and rate the SUDS    Arrange into hierarchy Counteract stimulus overgeneralization  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  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

15.

16.

17.

18.

19.

20.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

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 65 65 65 70 75 75 80 80 80 95 100 30 35 45 50 50 50 60 60 60 Courtesy of Sally Moore, Ph.D

.

Hierarchy

15.

16.

17.

18.

19.

20.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

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 80 95 100 50 60 65 75 70 80 60 80 30 35 45 50 50 65 60 65 75 Themes: Crowds Enclosed areas Heat Socializing Courtesy of Sally Moore, Ph.D

.

Selection of Initial In Vivo Exposures

      Initial exposures: 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 100 70 80 35 60 50 80 75 95 60 80 30 50 65 50 65 40 75 45 65

How to do In Vivo Exposure

      Select activity w/ moderate SUDS (e.g., 30-40) Ideally: stay in exposure activity until SUDS decreases 50%  This may not occur initially, but should stay until SUDS drops some Stay for at least 30 minutes & until SUDS decrease from peak levels Systematically remove safety behaviors  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  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 2 nd trauma after 1 st done; do so if patient wants to and/or PTSD symptoms not decreasing

Conducting Imaginal Exposure

         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 1 st time; 30-45 min subsequently Tape record – assign

daily

listening as homework Avoid “failure” experiences – try to not let them stop mid way

Therapeutic Stance in Imaginal Exposure

       Initially stay out of their way – let patient tell story without much prompting 1 st 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

       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

    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  Foa: ideally daily but at least 4-5 times per week Listens to tape while…..

 Doing housework, driving, keeping busy, etc.

Drinks during exposure exercises  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  What is the ultimate fear: Go crazy, lose control, feel sad forever, never be able to turn it off Review rationale Remind why patient came to treatment   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  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

 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 over engaged 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?