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 Scott.michael@va.gov

VA Training in Evidence-Based Psychotherapies 3

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.

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 CR Chronic PTSD: EX therapy only 22 studies EX therapy + SIT and/or CR 25 studies Acute PTSD or ASD EX therapy only 1 study EX therapy + SIT and/or CR 5 studies SIT = Stress Inoculation Therapy (Meichenbaum); CR = Cognitive Restructuring

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 PSS-I: PTSD Symptom Scale-Interview (Foa, Riggs, Dancu, & Rothbaum, 1993) Foa et al., 1999

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 Foa et al., 2005

Percent of Patients With PTSD Diagnosis Post-Tx Last FU Foa et al., 2005

Within-Group Effect Sizes PSS-I BDI Foa et al., 2005

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 = Clinician Administered PTSD Scale Resick et al., 2002 PE = CPT

PE with Veterans

The Efficacy of PE With 16 U. S The Efficacy of PE With 16 U.S. Veterans (PG, VN, OIF, WWII) Plus One EMT PSS-SR = PTSD Symptom Scale-Self-Report 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 PDS = Posttraumatic Diagnostic Scale (self-report) Rauch et al., in press

CSP #494: Study Design Random Assignment 143 Total 141 Total 284 Female Veterans and Active-Duty Personnel with PTSD in 12 sites and 52 therapists Random Assignment CSP = Cooperative Studies Program – multisite tx outcome research 143 Total Comparison Therapy Present Centered Therapy (PCT) 141 Total Prolonged Exposure (PE) Therapy Schnurr et al., 2007

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 Stimulus of tiger in zoo tends to not elicit fear responses; Stimulus of tiger in this room should elicit fear responses

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 Combat IED Crowd Helpless Driving Trash Fire Dark Noise Yell PTSD Symptoms Scan Ovals = Stimuli; Diamonds = Responses; Squares = Meaning of Stimuli or Responses Solid 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) Confused Incompetent Dangerous Courtesy of Melissa Polusny, Ph.D. 32

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 Combat IED Crowd Helpless Driving Trash Fire Dark Noise Yell Scan This 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”) Confused Incompetent Dangerous 34

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  never challenge trauma- related 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 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 Anxiety Time Anxiety increases  Avoidance This situation is dangerous; I got out just in time; Something awful could have happened Anxiety Time Courtesy of Sally Moore, Ph.D.

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 better Anxiety Time 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 Courtesy of Sally Moore, Ph.D. Grocery store with partner, not busy 30 Restaurant with partner, back to wall 35 Grocery store alone, not busy 45 Grocery store with partner, moderately busy 50 In line, facing sideways, wall to back 50 Restaurant, whole family, back to wall 50 Restaurant with partner, back to tables 60 Elevator,1 or 2 people 60 Movie with friends 60 In line, facing forward or no wall at back 65 Grocery store with partner, crowded 65 Grocery store alone, moderately busy 65 Feeling hot/sweaty 70 Elevator, many people 75 Mall alone, moderately busy 75 Gym 80 Restaurant, whole family, back to tables 80 Go to friend’s house 80 Mall alone, crowded 95 Grocery store alone, crowded 100 Courtesy of Sally Moore, Ph.D.

Hierarchy Themes: Crowds Enclosed areas Heat Socializing Grocery store with partner, not busy 30 Restaurant with partner, back to wall 35 Grocery store alone, not busy 45 Grocery store with partner, moderately busy 50 Restaurant, whole family, back to wall 50 Grocery store with partner, crowded 65 Restaurant with partner, back to tables 60 Grocery store alone, moderately busy 65 Mall alone, moderately busy 75 Restaurant, whole family, back to tables 80 Mall alone, crowded 95 Grocery store alone, crowded 100 In line, facing sideways, wall to back 50 Elevator,1 or 2 people 60 In line, facing forward or no wall at back 65 Elevator, many people 75 Feeling hot/sweaty 70 Gym 80 Movie with friends 60 Go to friend’s house 80 Themes: Crowds Enclosed areas Heat Socializing Notice 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 week Courtesy of Sally Moore, Ph.D.

Selection of Initial In Vivo Exposures Grocery store with partner, not busy 30 Grocery store with partner, moderately busy 50 Grocery store with partner, crowded 65 In line, facing sideways, wall to back 50 In line, facing forward or no wall at back 65 Elevator,1 or 2 people 40 Elevator, many people 75 Grocery store alone, not busy 45 Grocery store alone, moderately busy 65 Grocery store alone, crowded 100 Feeling hot/sweaty 70 Gym 80 Restaurant with partner, back to wall 35 Restaurant with partner, back to tables 60 Restaurant, whole family, back to wall 50 Restaurant, whole family, back to tables 80 Mall alone, moderately busy 75 Mall alone, crowded 95 Movie with friends 60 Go to friend’s house 80 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)

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 File 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 more Undigested Food: trauma is like poisoned food that’s been eaten – needs to be digested and passed Boil: trauma = infected boil, needs to be drawn to surface, lanced, squeeze out pus, then do again repeatedly until heals as a healthy scar Unread 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

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 2nd trauma after 1st 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 1st 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 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 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?