Presentation on theme: "Prolonged exposure An Evidence-Based Psychotherapy for PTSD"— Presentation transcript:
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 CouncilEvidence-Based Psychotherapies Subcommittee
2 AcknowledgmentsSpecial 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
4 BackgroundIn 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
5 Goals of VA Training in EBPs To train VA staff from multiple disciplines in evidence-based psychotherapiesTo augment psychotherapies already being offered in VA medical centers
6 VA Dissemination and Training in EBPs Cognitive Behavioral Therapy (CBT) for DepressionAcceptance and Commitment Therapy (ACT) for DepressionCognitive Processing Therapy (CPT) for PTSDProlonged Exposure (PE) for PTSDSocial 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)
7 EBP Presentations for Interns and Postdoctoral Fellows VA EBP roll-out training has been focused on staffVA Psychology Training Council (VAPTC) developed a workgroup in 2009 to focus on developing EBP didactics for interns and postdoctoral fellows
8 Goals of this EBP Presentation To provide a basic working knowledge of each of the roll-out EBPsTo provide the foundation for trainees to seek out further training and supervision in the EBPs they intend to implement
9 LimitationsThis presentation will not provide equivalent training to the EBP roll-outsThis presentation will not provide the skills to implement the treatment without further training and supervision
11 2008 Institute of Medicine Report: PTSD Treatments Committee set high bar: evidence-based practiceOnly cited trauma exposure therapies as meeting this criteriaNo medications met criteriaReference: Institute of Medicine (IOM) (2008). Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.
12 EX therapy only 22 studies EX therapy + SIT and/or CR 25 studies Published Randomized Studies on Exposure Therapy (EX) Only and EX Plus SIT or CRChronic PTSD:EX therapy only studiesEX therapy + SIT and/or CR studiesAcute PTSD or ASDEX therapy only 1 studyEX therapy + SIT and/or CR 5 studiesSIT = Stress Inoculation Therapy (Meichenbaum); CR = Cognitive Restructuring
13 Study I With Female Assault Survivors Treatments:Prolonged Exposure (PE)Stress Inoculation Training (SIT)SIT + PEWaitlist ControlsTreatments included 9 sessions conducted over 5 weeksFoa et al.,1999
14 Comparison of PE, SIT, PE/SIT, and Waitlist With Female Assault Survivors PSS-I: PTSD Symptom Scale-Interview (Foa, Riggs, Dancu, & Rothbaum, 1993)Foa et al., 1999
15 Post-Rx Effect Sizes* of PE vs. SIT vs. PE/SIT: PTSD *Effect size compared to waitlist group at post-treatmentFoa et al., 1999
16 Study II With Female Assault Survivors Treatments:Cognitive Restructuring (PE/CR)Wait Exposure (PE) alonePE List (WL)Treatment includes 9 weekly sessions,extended to 12 for partial responders(< 70% improvement)Foa et al., 2005
17 Comparison of PE, PE/CR, and Waitlist With Female Assault Survivors Foa et al., 2005
18 Percent of Patients With PTSD Diagnosis Post-Tx Last FUFoa et al., 2005
19 Within-Group Effect Sizes PSS-I BDIFoa et al., 2005
20 Comparison of PE and PE/CR for Female Survivors of Rape, Physical Assault, and Childhood Sexual AbuseFoa et al., 2005Rape = PA = CSA
21 Comparison of 9 PE Sessions, 12 CPT Sessions, and Waitlist With Female Assault Survivors CAPS = Clinician Administered PTSD ScaleResick et al., 2002PE = CPT
23 The Efficacy of PE With 16 U. S The Efficacy of PE With 16 U.S. Veterans (PG, VN, OIF, WWII) Plus One EMTPSS-SR = PTSD Symptom Scale-Self-ReportVN = 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
24 The Efficacy of PE With 10 Veterans PDS = Posttraumatic Diagnostic Scale (self-report)Rauch et al., in press
25 CSP #494: Study Design Random Assignment 143 Total 141 Total 284 Female Veterans and Active-Duty Personnel with PTSD in 12 sites and 52 therapistsRandom AssignmentCSP = Cooperative Studies Program – multisite tx outcome research143 TotalComparison TherapyPresent CenteredTherapy (PCT)141 TotalProlonged Exposure (PE)TherapySchnurr et al., 2007
26 CAPS PTSD Scores Lower in PE Overall d =.27*Overall d =.46**p <.05Schnurr et al., 2007
27 CSP #494: Conclusions VA patients can benefit from PE PE more effective than PCT for treating PTSD in female veterans and active duty personnelVA patients are highly satisfied with PEVA therapists can deliver PESchnurr et al., 2007
28 SummarySeveral CBT programs are quite effective for PTSD, with exposure therapy receiving the most empirical evidence with a wide range of traumasPE is more effective than treatment as usualCBT can be successfully disseminated to community clinics with non-CBT experts as therapistsPE can be disseminated effectively over long distances and across culturesHowever, relatively few clinicians are using evidence based treatments for PTSD and other mental disorders in their practice
30 Emotional Processing Theory From Peter Lang (1977)Fear Structure - a program for escaping dangerIt includes information about:The feared stimuliThe fear responsesThe meaning of stimuli and responsesTiger ExampleTiger in zoo elicits different responses than tiger walking into this roomStimulus of tiger in zoo tends to not elicit fear responses; Stimulus of tiger in this room should elicit fear responses
31 Trauma StructureSpecific form of fear structure; forms shortly after a traumaFeared stimuli – the sights, sounds, smells present at time of traumaFear/arousal Responses – the emotional/ physiological/behavioral responses at timeMeanings associated with stimuli & responses
32 Schematic Model of a Memory Shortly After Combat Trauma AfraidUncontrollableI - MeCombatIEDCrowdHelplessDrivingTrashFireDarkNoiseYellPTSDSymptomsScanOvals = Stimuli; Diamonds = Responses; Squares = Meaning of Stimuli or ResponsesSolid lines = reasonable connections (e.g., Fire is dangerous)Dotted lines = Excessive/Unrealistic connections (e.g., Trash on side of road in U.S. rarely hides IEDs)ConfusedIncompetentDangerousCourtesy of Melissa Polusny, Ph.D.32
33 Trauma Structures Very heavily sensory based Fragmented and poorly organizedOften contain unrealistic informationStimuli 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
34 Schematic Model of a Trauma Memory After Recovery AfraidUncontrollableI - MeCombatIEDCrowdHelplessDrivingTrashFireDarkNoiseYellScanThis can be natural recovery or treatment-aided recovery; Dotted lines gone – these stimuli and responses no longer have same meanings (“I am not incompetent just because I yelled”; “Crowds are rarely dangerous”)ConfusedIncompetentDangerous34
35 Rationale for PEPromotes emotional processing: Learn new, corrective information – trauma memories and related situations are not dangerousDiscriminate trauma memories from traumaReduce excessive fear and gain perspective on traumaPTSD 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”
36 Role of AvoidanceAvoidance reduces trauma reexperiencing and hyperarousal in short term but prolongs in long termAvoid trauma memories never challenge trauma- related beliefsAvoid public never challenge safety concernsMaintains trauma structuresAvoidance and negative reinforcement: Leaving or initially avoiding feared situation leads to relief, thus strengthening avoidance behavior
37 Rationale (continued) Two types of exposureImaginal exposureEmotional processing of trauma memoryLearning – Memory is painful but not dangerousIn vivo exposureDo real-life activities that are avoidedLearning – Many situations are safer than I thought
38 PE Protocol 9-15 sessions; averages 10 sessions 90-min sessions 1: Assessment, treatment overview, PTSD psychoeducation, breathing retraining2: In vivo Exposure (continue throughout)3-5: Imaginal exposure6-9: “Hot Spot” exposure10: Final imaginal exposure, wrap-up
39 Example of typical PE session (session 4 on) Review homework (10 min)In vivo exercises & trauma tape listeningConduct 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 practiceListen to trauma tape dailyComplete in vivo exercises
41 Rationale for In Vivo Exposure Introduces corrective information to trauma structures – disconfirms belief that feared situation is actually harmfulPrevents avoidance & thus negative reinforcementDisconfirms belief that anxiety will “last forever”Habituation – less & less distress with repeated exposuresIncreases sense of competencyUse a good metaphor:Little boy knocked over by wave, scared of water, parent gradually brings him closer & closer to water
42 Habituation Anxiety Time Anxiety increases Avoidance This situation is dangerous; I got out just in time; Something awful could have happenedAnxietyTimeCourtesy of Sally Moore, Ph.D.
43 Habituation Anxiety 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 betterAnxietyTimeCourtesy of Sally Moore, Ph.D.
44 Initiating In Vivo Exposure Anchor the SUDS (subjective units of distress scale)0-100 scale; 0 = most relaxed, 100 = most distressedDevelop a list of feared/avoided activities and rate the SUDSArrange into hierarchyCounteract stimulus overgeneralizationE.g., Are all Arabs really dangerous?Repeated practice necessary for habituation
45 In Vivo Exposure Hierarchy Construction Tips Types of activitiesTraumatic event dependent: Ask about sights, sounds, smells – e.g., avoiding Asians/Arabs, BBQs (smell of cooked meat), certain music/moviesGeneral hypervigilance: e.g., grocery store, Costco, sitting back to door at restaurantValued life activities/behavioral activation – the more valued the avoided activity, the stronger the motivation to doDo insure safetyE.g., Don’t encourage walking alone, at night, in dangerous neighborhoodSafety behaviors: anything that reduces anxiety – e.g., facing door, closing shades, carrying weapons – need to be systematically removed
46 Hierarchy Courtesy of Sally Moore, Ph.D. Grocery store with partner, not busy 30Restaurant with partner, back to wall 35Grocery store alone, not busy 45Grocery store with partner, moderately busy 50In line, facing sideways, wall to back 50Restaurant, whole family, back to wall 50Restaurant with partner, back to tables 60Elevator,1 or 2 people 60Movie with friends 60In line, facing forward or no wall at back 65Grocery store with partner, crowded 65Grocery store alone, moderately busy 65Feeling hot/sweaty 70Elevator, many people 75Mall alone, moderately busy 75GymRestaurant, whole family, back to tables 80Go to friend’s house 80Mall alone, crowded 95Grocery store alone, crowded 100Courtesy of Sally Moore, Ph.D.
47 Hierarchy Themes: Crowds Enclosed areas Heat Socializing Grocery store with partner, not busy 30Restaurant with partner, back to wall 35Grocery store alone, not busy 45Grocery store with partner, moderately busy 50Restaurant, whole family, back to wall 50Grocery store with partner, crowded 65Restaurant with partner, back to tables 60Grocery store alone, moderately busy 65Mall alone, moderately busy 75Restaurant, whole family, back to tables 80Mall alone, crowded 95Grocery store alone, crowded 100In line, facing sideways, wall to back 50Elevator,1 or 2 people 60In line, facing forward or no wall at back 65Elevator, many people 75Feeling hot/sweaty 70GymMovie with friends 60Go to friend’s house 80Themes:CrowdsEnclosed areasHeatSocializingNotice the themes for this patient; can conceptualize hierarchy as occurring in multiple domains at same time – patient will be doing in vivo exercises in each domain each weekCourtesy of Sally Moore, Ph.D.
48 Selection of Initial In Vivo Exposures Grocery store with partner, not busy 30Grocery store with partner, moderately busy 50Grocery store with partner, crowded 65In line, facing sideways, wall to back 50In line, facing forward or no wall at back 65Elevator,1 or 2 peopleElevator, many peopleGrocery store alone, not busy 45Grocery store alone, moderately busy 65Grocery store alone, crowded 100Feeling hot/sweatyGymRestaurant with partner, back to wall 35Restaurant with partner, back to tables 60Restaurant, whole family, back to wall 50Restaurant, whole family, back to tables 80Mall alone, moderately busy 75Mall alone, crowdedMovie with friendsGo to friend’s houseInitial exposures:Goal: Success experienceRelatively low SUDS (30-40)Collaboratively selectedIf possible, things patient already doing with some successDon’t pick big unknown (e.g., going to potentially dangerous neighborhood)
49 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 someStay for at least 30 minutes & until SUDS decrease from peak levelsSystematically remove safety behaviorsExample: 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 theaterWork your way up the hierarchy – goal is to complete hardest items at top by end of PEIdeally they’ll do daily in vivo exposure!
51 Rationale for Imaginal Exposure Repeated trauma reexperiencing indicates “unfinished business”Use a good metaphorFile cabinet Undigested Food Boil Unread BookAvoidance works in short term to alleviate distress but functions to maintain distress over long termServes good survival function butPrevents emotional processingFile Cabinet: trauma file is disorganized mess; springs open and dumps papers on ground, quickly stuff back in – we need to open file, take papers out and re-organize into more orderly form, file will tend to stay closed moreUndigested Food: trauma is like poisoned food that’s been eaten – needs to be digested and passedBoil: trauma = infected boil, needs to be drawn to surface, lanced, squeeze out pus, then do again repeatedly until heals as a healthy scarUnread book: Trauma story – book on shelf that flings open on ground to worst scene, quickly put back on shelf, but keeps flinging itself out b/c it needs to be read – via PE you read it all the way through and put it back, will tend to stay on shelf more often
52 Goals of Imaginal Exposure Emotionally process & organize trauma memoryDifferentiate between “revisiting” & “reliving”While memory is painful, isn’t dangerous – won’t lose control or sanityHabituate to anxiety in trauma memoryPromote competence and mastery
53 Selecting the Index Trauma Many patients will have multiple traumasSelect the “worst” trauma firstMost prominent in reexperiencingMost 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 selectedIf PTSD scores do not fall by completion of trauma processing, indicates possible “hidden” trauma they did not initially reportMay opt to work on 2nd trauma after 1st done; do so if patient wants to and/or PTSD symptoms not decreasing
54 Conducting Imaginal Exposure Use present tenseClose eyesMonitor SUDS every 5 minutesAsk for sensory info, be very detail-orientedBe aware of cognitive avoidanceBe very supportive; gently encourage patient to complete storyCompletes as many accounts as possible in time allotted45-60 min 1st time; min subsequentlyTape record – assign daily listening as homeworkAvoid “failure” experiences – try to not let them stop mid- way
55 Therapeutic Stance in Imaginal Exposure Initially stay out of their way – let patient tell story without much prompting 1st timeWill have numerous opportunities: Patient likely to complete ~ 20 times with youOrient toward details of memory in order to increase engagementSensory info is powerful engagerBe aware of “editing”: overly analytic, abstract, staying disengagedDo not attempt to foster insight during imaginalProcessing – Do attempt to foster insight
56 Processing Always start with validation Provide containment and supportFollow patient’s lead – ask for reactions, insights, “How was that for you?”Normalize reactions during and following traumaIn early sessions, do not begin to challenge beliefsAs imaginal exposure progresses, may lightly challenge faulty beliefs but use open-ended questionsIf need be, increase challenges but remain in Socratic questioning mode – allow patient to come to own insights
57 Hot Spots Procedure Sessions 6 – 9 Chose the “Hot Spot” – the worst part of the eventDiscuss with patient, offer your thoughts, but let him/her chooseTrauma may have several hot spots – work on worst one for several sessions until habituates, then move to nextRepeat as many times as possible in min
58 Special Issues Treating PTSD Avoidance Under-Engagement Over-Engagement
59 PE is a treatment for PTSD While PE focuses on trauma, it is specifically designed to treat PTSDNot everyone who experienced trauma has PTSDPE will not be (as) effective for those who do not meet diagnostic criteria for PTSDPotential ProblemsLack of/low reexperiencing – poor target for imaginalLow avoidance – few avoided situations for in vivoNot sufficiently distressed to adhere – distress motivates exposure therapy; if patient not very distressed, why would s/he bother?
60 Recognizing Avoidance No show! Or cancelling oftenNot completing homeworkFoa: ideally daily but at least 4-5 times per weekListens to tape while…..Doing housework, driving, keeping busy, etc.Drinks during exposure exercisesSeveral drinks at dinner; drinking during tape listeningIn vivo: does not stay long enough; uses safetiesUnder-engaged in imaginal workEdits during imaginal
61 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 offReview rationaleRemind why patient came to treatmentAvoidance reduces anxiety in short-term but impedes meaningful activities in long-termKnow your patient’s values and goals – what do they want more of?Schedule phone calls during weekProblem-solve impediments to therapyEx: Can’t afford to eat out often – go to mall food court and have coffee, sit in middle with back to crowdStay focused on PELife happens, but PE is short-termDo your best to not deviate or suspend protocol if possible
62 Under-EngagementLess feared by clinicians than over-engagement but far more commonEngagement is a continuumMany are low engagers; under-engagers are qualitatively differentMany patients begin on less engaged side, then become more engaged as PE progressesDon’t jump to conclusion patient is an under-engager too soon
63 Identifying Under-Engagement Provides a “military report” version (strictly factual)Reports low SUDSBehaviorally seems un-engaged in emotions/storyMoves quickly through storyJumps 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 memoryReports high SUDS but seems un-engaged
64 Addressing Under-Engagement During ImaginalAlways 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, soundsFocus on bodily sensations that occurred during traumaCan use external stimuli to prime: e.g., chopper sounds
65 Addressing Under-Engagement, cont’d During Processing or prior to ImaginalValidate effortsReiterate rationaleRemind them of personal reasons to engage in PEExplore feared consequences of engagement: Go crazy, lose control, sadness will never stopRole-play proper procedures - show how effective imaginal work looks like
66 Over-Engagement More feared by clinicians but quite uncommon Engagement is a continuumMany are high engagers; over-engagers are qualitatively differentDo not jump to conclusion that patient is over- engaged if they are highly engaged and emotiveReporting “100” SUDS does not immediately indicate over-engagement
67 Identifying Over-Engagement Hysterically sobs and cannot keep speakingThis persists for more than one sessionDissociates strongly during session and not responsive to your voiceShows signs of reliving trauma in the therapy room; behaviors mimic what actually happened
68 Addressing Over-Engagement Validate and reiterate rationale – emphasize goal is to revisit, not relive, memoryRemind that memories are upsetting but not dangerousIf necessary, modify imaginal instructionsEyes open and/or use past tenseIf dissociative, can use grounding, but preferably not during account (try in between accounts)If stuck – help move along to next stepCan use hierarchy of memories and start with less distressful memoryCan have patient write trauma narrative; try in beginning and attempt to move toward verbal recounting if possible
69 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 scoresHave SUDS levels routinely decreased ~ 50% for both in vivo and imaginal exposures?Look for other signs of improvement; PCL isn’t everythingSee signs of habituation during imaginal?Tells story with less intense affect, shows behavioral signs of being more relaxedReports that it seems more like a memory, less like relivingIs patient more engaged with life?Doing more; being more spontaneous; greater emotional range and engagement?