1. Prolonged exposure An Evidence-Based Psychotherapy for PTSD
Scott Michael, Ph.D., Dana Holohan, Ph.D., Gia Maramba, Ph.D., & Thad Strom, Ph.D.
VA Psychology Training Council
Evidence-Based Psychotherapies Subcommittee

2. 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

3. VA Training in Evidence-Based Psychotherapies3

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. Prolonged Exposure
Empirical Research

11. 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.

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 CR
Chronic PTSD:
EX therapy only studies
EX therapy + SIT and/or CR 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

13. 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

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-treatment
Foa et al., 1999

16. 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

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 FU
Foa et al., 2005

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

20. Comparison of PE and PE/CR for Female Survivors of Rape, Physical Assault, and Childhood Sexual Abuse
Foa et al., 2005
Rape = PA = CSA

21. 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

22. PE with Veterans

23. 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

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 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

26. CAPS PTSD Scores Lower in PE
Overall d =.27*
Overall d =.46*
*p <.05
Schnurr 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 personnel
VA patients are highly satisfied with PE
VA therapists can deliver PE
Schnurr et al., 2007

28. 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

29. Prolonged Exposure
Theoretical Underpinnings

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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”

36. 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

37. 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

38. 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

39. 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

40. In Vivo Exposure

41. 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

42. 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.

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 better
Anxiety
Time
Courtesy 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 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

45. 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

46. 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
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.

47. 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
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.

48. 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
Elevator, many people
Grocery store alone, not busy 45
Grocery store alone, moderately busy 65
Grocery store alone, crowded 100
Feeling hot/sweaty
Gym
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
Movie with friends
Go to friend’s house
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)

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 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!

50. Imaginal Exposure

51. 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

52. 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

53. 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

54. 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; min subsequently
Tape record – assign daily listening as homework
Avoid “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 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

56. 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

57. 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 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 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?

60. 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

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 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

62. 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

63. 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

64. 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

65. 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

66. 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

67. 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

68. 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

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 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?