1. 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)

2. 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

3. PTSD Diagnosis

4. 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

5. 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

6. 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)

7. Diagnostic Symptoms of PTSD (cont.) Criterion F:  Symptoms must persist for more than 1 month Criterion G:  Symptoms cause significant distress or impairment Criterion H:  Not induced by substances and/or medical conditions

8. Treatment Rationale and Myths

9. 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).

10. 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.”

11. 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

12. 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

13. 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 (%) Exposure51%71% Cognitive Behavioral Therapy22%58% Psychodynamic16%38% Sertraline9%24% Thought Field Therapy3%7% My Buddy Therapy1%2% EMDR0%

14. Becker et al. (2009). Law enforcement preferences for PTSD treatment and crisis management alternatives. Behaviour Research and Therapy. N=379 Top Choice (%)Top 2 (%) Exposure26%59% Cognitive Behavioral Therapy37%57% Psychodynamic13%29% Sertraline9%22% Brief eclectic psychotherapy9%21% EMDR2%6%

15. 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

16. Myths regarding exposure therapy Foa 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

17. 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

18. 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) Age33.7 (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 dependence98.3% 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 severity79.26 Total Criterion A events9.6 (2-22)

19. 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

20. Myths regarding exposure therapy Hembree et al. (2003). Do Patients Drop Out Prematurely From Exposure Therapy 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)

21. Session Descriptions

22. 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

23.  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

24. 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

25. 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

26. 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

27. 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

28. https://www.youtube.com/watch?v=2CTWhYRwy2 Q Through minute 13 Clip from Session 1

29. Facilitating the Therapeutic Alliance  The 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

30. 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.

31. Treatment Components

32. Format of Treatment Program  Behavioral program  9-12 sessions  60 or 90 minute sessions  Weekly homework assignments  Importance of weekly attendance

33. Primary Treatment Components 1. Psychoeducation What is PTSD Rationale 2. Breathing Retraining 3. Common Reactions 4. SUDS Development 5. In-Vivo Exposure Hierarchy development Homework assignment 6. Imaginal Exposure

34. Psychoeducation & Breathing

35. 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

36. 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 Conversation  Focus on not reading  Gains valuable info for hierarchy  Be sure to follow-up to gather further information if the person says “yes, I’ve experienced this thing”

37. 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

38. In Vivo Exposure

39. 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

40. 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

41.  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

42. 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

43. Session 2B Video https://www.youtube.com/watch?v=rZgsYs1xO5I -from minute 24-31 is explanation about avoidance -from min 34.30-53:30min Hierarchy Construction

44. 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/http://www.myvaapps.com/

45. 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!

46. 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

47. Role of Safety Behaviors  Validating the initial development of safety behaviors  Safety 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 phone You (therapist = safe person) Water bottle

48. Imaginal Exposure

49. 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

50. If multiple traumas  Collaboratively choose the most intrusive and distressing memory currently  “Which would you remove/get rid of, if possible?” Implementing Imaginal Exposure

51. 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

52. 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

53. 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

54. Timing Your Session 60-minute session  Set agenda as the person walks in the door  5 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)

55. 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

56. 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

57. DON’T MAKE A ROOKIE MISTAKE! THE MOST COMMON MISTAKE NEW PE THERAPISTS MAKE IS FOCUSING ON HOT SPOTS TOO SOON!

58. DON’T MAKE A ROOKIE MISTAKE! THE MOST COMMON MISTAKE NEW PE THERAPISTS MAKE IS FOCUSING ON HOT SPOTS TOO SOON!

59. Therapist-Client Alliance During Imaginal Express support and empathy with client’s distress Periodically 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

60. https://www.youtube.com/watch?v=YZbJZMm oLwUhttps://www.youtube.com/watch?v=YZbJZMm oLwU Session 3 Video - Imaginal

61. https://www.youtube.com/watch?v=9aTDIiTr99 Yhttps://www.youtube.com/watch?v=9aTDIiTr99 Y Video Clip - Foa

62. Factors that Impair Engagement

63. Factors that Impair Effective Emotional Engagement in Imaginal Exposure  Avoidance  Under-engagement  Over-engagement

64. Avoidance

65. 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

66. 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

67. 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*!!

68. 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

69. Under-engagement

70. 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”

71. 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

72. 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

73. Over-Engagement

74. 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

75. 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

76. 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

77. 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

78.  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

79. Session Descriptions Review

80. 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

81.  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

82. 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

83. 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

84. 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

85. 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

86. Questions??