integrating acceptance-based behavior therapy into exposure-based therapy for ptsd

3. The third wave Behavior Therapy Cognitive Therapy Acceptance-based models Acceptance and Commitment Therapy (ACT) Mindfulness-based Cognitive Therapy (MBCT) Acceptance-based Behavior Therapy for GAD Dialectical Behavior Therapy (DBT) Integrative Behavioral Couple Therapy (IBCT) Behavioral Activation (BA) Functional Analytic Psychotherapy (FAP) Mindfulness-based Relapse Prevention (MBRP)

4. An etiological model of PTSD Generalized psychological vulnerability Generalized biological vulnerability Experience of trauma Developed by classical conditioning Maintained by operant conditioning Anxious apprehension Avoidance or numbing of emotional response Moderated by social support and ability to cope (Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)

5. Evidence-based psychological treatments for PTSD General aims Extinction of conditioned fear and anxiety responses through repeated, non-reinforced exposure to CS Development of alternative, competing responses to anxiety and fear Emphasis on symptom reduction through mastery experiences and internal control strategies

6. Evidence-based treatments Exposure Therapy Anxiety Management Training (AMT) Combination treatments (Foa, Keane & Friedman, 2000; Keane et al, 2006; Roth & Fonagy, 2005)

7. Exposure Therapy Patient is guided through a vivid remembering of the trauma until extinction occurs Goal is to reduce avoidance of anxiety and promote control/mastery over trauma-related cues (Foa and Rothbaum, 1998)

8. Anxiety Management Training Package of behavioral and cognitive strategies to reduce and control anxiety Progressive muscle relaxation Diaphragmatic breathing Cognitive restructuring Communication skills training Time management Anger management/assertion training (Meichenbaum, 1994)

9. Combination treatments Package of CT, exposure and emotion regulation skills Essential components of CT Self-monitoring Identification and labeling of thoughts and associated emotions Cognitive restructuring Changing the content of a �dysfunctional� cognition through logical analysis Hypothesis testing Conducting behavioral experiments to evaluate the validity of dysfunctional thoughts

10. Combination treatments Cognitive Processing Therapy (CPT) Written exposure trials cognitive restructuring of trauma related erroneous cognitions and schemas, particularly regarding safety, trust, power, control, self-esteem and intimacy STAIRS Emotion regulation and distress tolerance skills Prolonged exposure CSA related PTSD (Resick et al. 2002; Cloitre et al., 2002)

11. The good news about EBTs for PTSD Treatments are efficacious when compared to TAU, wait list control and active placebo treatments 67% of completers no longer meet criteria for PTSD 56% of intent-to-treat patients no longer meet criteria for PTSD Exposure and CBT are generally equally efficacious (Bradley, 2005)

12. Limitations of current treatments 44% of intent-to-treat patients continue to meet criteria for PTSD (Bradley, 2005) Using DSM criteria as treatment outcome may not be relevant to clinically significant change Generalization of findings limited by study exclusion rates averaging 30% Co-morbid Axis I disorder Current substance abuse Suicidal ideation or behavior

13. More limitations Relative lack of effectiveness research RCTs generally compare monotherapies and not multimodal therapies lack of evidence regarding long-term maintenance of gains Vast majority of community sample patients do not receive EBTs Due to lack of dissemination Due to lack of treatment acceptance by patients

14. And still more Lowest effect sizes for patients with combat-related PTSD compared to other traumas Focus on symptom reduction and not functional improvement Interpersonal relationships Vocational functioning General quality of life

15. Limitations specific to CBT Relatively difficult to train therapists to adherence (Kohlenberg, 2004; Dimidjian et al, 2006) Emphasis on control and mastery strategies can have paradoxical effect in anxiety disorders (Roemer & Borkovec, 1994)

16. Limitations specific to exposure Requires memory of a specific trauma event May have low acceptability to patients and providers PTSD patients have more negative attitudes toward emotional expression Exposure less effective for patients: High levels of anger at pre-treatment High levels of avoidance at pre-treatment Perpetrators of harm who experience guilt/shame as primary symptoms

17. Potential limitations of standard therapies for OIF/OEF veterans Stigma associated with mental health care Reluctance to participate in exposure Presence of co-morbid conditions Lack of a single traumatic event Associated feelings of guilt, loss, anger, sadness, grief Potential for iatrogenic effects of exposure

18. The challenge in treating OIF/OEF veterans How do we provide secondary prevention? Proper treatment may help prevent the development or progression of symptoms, or the underlying mechanisms leading to pathology (Zatzick et al. 2004) what are these mechanisms? What is the natural course of resilience, remission and recovery? (Bonanno 2004) How can we use current treatments in secondary prevention? How can we adapt or elaborate on these treatments for use with recently returned veterans?

19. Spectrum of Post-Deployment Mental Disorders (N = 46,571) Disorder N % PTSD 20,638 44% Drug Abuse 17,768 38% Depression 14,317 31% Neurotic Disorders 11,481 25% Affective Psychosis 7,460 16% Alcohol Dependence 3,116 7% Acute Stress Reaction 1,327 3% VHA Office of Public Health and Environmental Hazards, February 14, 2006 Rates of VHA enrolled veterans who have PTSD have been consistently rising since 2003. The overall percentage of patients with PTSD seeking VA care more than doubled between February 13 and December 9, 2004 (Kang & Hyams, 2005). Reserve component troops were as likely to develop PTSD as were Active Duty personnel (in VA utilization data). Total number of OIF/OEF vets Dx with PTSD represents about 5% of VA�s total PTSD workload (as of 2005 NEPEC report for FY04) Rates of VHA enrolled veterans who have PTSD have been consistently rising since 2003. The overall percentage of patients with PTSD seeking VA care more than doubled between February 13 and December 9, 2004 (Kang & Hyams, 2005). Reserve component troops were as likely to develop PTSD as were Active Duty personnel (in VA utilization data). Total number of OIF/OEF vets Dx with PTSD represents about 5% of VA�s total PTSD workload (as of 2005 NEPEC report for FY04)

20. The cautionary tale of Critical Incident Stress Debriefing (CISD) Intervention intended as secondary prevention for occupational trauma exposure (Mitchell 1983;1993) Proprietary; dramatic claims of effectiveness Basic assumptions Exposure to traumatic stressor is sufficient to cause symptoms that can escalate to a pathological condition Early and proximal intervention involving emotional catharsis (exposure) is prophylactic

21. CISD procedures Format Group administration Delivered by a mental health provider assisted by non-professional peers Conducted in one 2-3 hour session within 24-72 hours of traumatic event Mandatory attendance customary Non-attendees or drop-outs typically retrieved by peer facilitator

22. CISD treatment protocol Introduction of the debriefing Statement of facts regarding the traumatic event Disclosure of thoughts regarding the event Disclosure of emotional reactions, with focus on strong negative affects Specification of possible symptoms Education regarding consequences of trauma exposure Planned re-entry to social environment (Mitchell & Everly, 1993)

23. CISD outcome research No clinically significant improvement for participants at long-term follow-up Slight but statistically significant worsening on outcome measures for those accepting debriefing Preference for informal sources of support and assistance correlated strongly with improved outcome Those with highest levels of both avoidance and intrusive recollection deteriorated most after debriefing; recovery better among those not receiving treatment (Mayou et al. 2000) �CISD is inert at best and iatrogenic at worst� (Lohr et al. 2003)

24. An etiological model of PTSD Generalized psychological vulnerability Generalized biological vulnerability Experience of trauma Developed by classical conditioning Maintained by operant conditioning Anxious apprehension Avoidance or numbing of emotional response Moderated by social support and ability to cope (Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)

25. Approaches to providing secondary prevention Watch and wait Respect the natural course of recovery among the resilient Support naturally occurring restorative factors in patient�s life Provide supportive treatments that do not interfere with natural resilience and are not iatrogenic Wellness Provide treatments that enhance naturally occurring restorative factors Example: Behavioral Activation (BA)

26. Secondary prevention approaches Rehabilitation Support naturally occurring curative factors in patient�s life + Provide treatments that prevent or inhibit pathological mechanisms implicated in the development and maintenance of psychological distress Experiential avoidance Co-morbid conditions that serve the function of experiential avoidance, especially SUDs and rumination

27. Acceptance-based Behavior Therapy (ABT) Standard therapies Based on a conditioning model of PTSD Aim is to reduce fear and anxiety through extinction Coupled with strategies to change trauma-related thought content An alternative model PTSD can be understood as a disorder of experiential avoidance (Hayes et al. 1999) Aim is to improve quality of life Coupled with strategies to change the process of cognition rather than the content (Orsillo & Batten 2005; Batten et al. 2005; Follette et al. 2004)

28. Experiential avoidance Attempts to change the form or frequency of internal events (thoughts, feelings, memories, sensations) (Hayes et al. 1996) EA contributes to the development and maintenance of various forms of psychopathology, particularly anxiety disorders Anxiety disorders develop when individuals are unwilling to experience anxiety (and associated thoughts, images, distressing emotions)

29. A variety of external and internal control strategies are utilized to alleviate distress via escape and avoidance Behavioral avoidance of situations and cues (CS) that elicit unwanted internal states (CR) Cognitive control strategies to avoid unwanted states Thought suppression Worried rumination Distraction Internal and external control strategies are negatively reinforced External control strategies generalize lead to disengagement with the naturally rewarding contingencies in the environment Internal control strategies generalize Become rigid and inflexible Lead to narrowing of attention Control strategies maintain distress / cause rebound

30. Thought suppression Effortful suppression of thoughts Initially relieves distress Has paradoxical long-term effect with rebound of avoided imagery Leads to escalating efforts to control and master thoughts and imagery Thought suppression associated with negative tx outcome (CSA, rape, MVA, Gulf War, urban violence) Behavioral therapies have been adapted to specifically target experiential avoidance as a core feature of pathology (Borkovec et al. 2004)

31. Acceptance-based Behavior Therapies (ABT) Acceptance and Commitment Therapy (ACT) (Hayes et al. 1999, 2004; Eifert & Forsyth, 2005) Mindfulness-based Cognitive Therapy (MBCT) (Segal et al. 2002) Acceptance-based Behavior Therapy for GAD (Roemer& Orsillo, 2004, 2005) Dialectical Behavior Therapy (DBT) (Linehan, 1993) Integrative Behavioral Couple Therapy (IBCT) (Jacobson & Christensen, 1996) Behavioral Activation (BA) (Jacobson et al. 1996; Dimidjian et al. 2006) Functional Analytic Psychotherapy (FAP) (Kohlenberg & Tsai, 1991; Kohlenberg et al. 2004) Mindfulness-based Relapse Prevention (MBRP) (Marlatt et al. 2005)

32. Acceptance-based Behavior Therapy (ABT) Basic assumptions Treatment components Treatment strategies and techniques

33. ABT assumptions Emotions are just emotions; thoughts are just thoughts; memories are just memories Emotions are information; not good or bad Control of internal events is not an option Control is the problem, not the solution

34. Similarities to Exposure/CBT Both consider avoidance to be a core feature of pathology Both advocate approach as an integral treatment strategy

35. Differences from Exposure/CBT Approach and avoidance Approach behaviors are inherently valuable Approach behaviors are pragmatically valuable in order to reengage with natural reinforcers and expand domains of functioning Emphasis on clinically valued change rather than symptom reduction

36. Differences Attention CBT emphasizes directing attention toward stimuli associated with disorder (or distract from) ABT emphasizes directing attention broadly toward flow of experience

37. Differences Cognition � radically different understanding of the role of cognition in development and treatment of disorders Cognitions are causal vs. cognitions are responses Importance of content vs. importance of function Goal to change content vs. goal to change relationship to one�s own thoughts and feelings

38. Differences Control within the CBT framework Lack of perceived control and unpredictability strongly associated with distress (Mineka et al. 2006) Control/predictability can be increased by Attending to thoughts and associated emotions Changing thoughts from irrational to rational Through process of logical analysis and behavioral experimentation

39. Differences Control within the ABT framework Efforts to exert internal control maintain distress Thoughts and emotions are transitory experiences of the mind and body Treatment provides experiential learning of acceptance rather than control Distress naturally wanes as a consequence of not being escalated by control strategies (e.g., MBCT)

40. ABT treatment components Overarching goals Target experiential avoidance and expand experiential acceptance Target associated behavioral restrictions and expand engagement with valued life goals and activities 1. Psychoeducation 2. Assessment 3. Experiential acceptance 4. Valued action

41. 1. Psychoeducation Role of emotions as information (Linehan 1993) Limits and costs of control strategies (Roemer & Orsilllo 2004) Importance of approach and emotional engagement in therapy sessions (Jaycox et al. 1998)

42. 2. Assessment General assessment Symptom review and diagnostic assessment Self-report measures PTSD Anxiety depression Self-report functional measures Life satisfaction Valued life domains (Roemer & Orsillo, 2004; Orsillo & Batten, 2005)

43. 2. Assessment Avoidance and suppression Self-report measures of experiential avoidance and thought suppression (Hayes et al. 2006; Eifert & Forsyth, 2005) Acceptance and Action Questionnaire (AAQ) White Bear Suppression Inventory Thought Control Questionnaire Values assessment Self-report measures to identify idiographic treatment outcomes (Hayes et al. 1999, Eifert & Forsyth, 2005) Generate values Rate values to establish priorities Identify intermediate steps, actions and barriers

44. 3. Experiential acceptance Mindfulness Targets identification of thoughts/feelings as �reality� Willingness Encourages approach behaviors Distress tolerance skills Targets avoidance due to inability to tolerate emotion Emotion regulation skills Targets avoidance due to inability to modulate emotion

45. Key concepts in Mindfulness Decentering Experiencing thoughts and feelings as mental events and not reality Early problem recognition Intentional awareness allows �turning toward� difficulties Anti-ruminative Experience is of current awareness, not elaborate thinking about implications, meaning, etc. Generic skill Daily practice competes with development of avoidance, escape and control strategies (Segal et al, 2002)

46. Steps in Mindfulness training Practice attention to a single sense Practice attention to the flow of experience Practice attention to thoughts, feelings, images as part of the flow of experience Practice attention to the flow of experience during activities

47. Mechanisms of Mindfulness Exposure to previously avoided classes or categories of emotional experience, leading to decreased distress via extinction Self-monitoring associated with improved appraisal of actual contingencies, leading to increased flexibility in responding State of relaxation (response prevention) Change in attitude toward internal experiences leads to decreased volatility (Baer, 2003; Teasdale et al. 2002; Segal et al. 2002)

48. 4. Valued action Assessment questions What is important to the patient? To what extent are they living life in accordance with their values? How do their symptoms interfere with the pursuit of their values?

49. 4. Valued action Intervention techniques Writing exercises to clarify values Self-monitoring to assess degree to which life is spent in valued activities (and/or degree to which patient is emotionally engaged in valued activities) Goal setting Identify concrete steps intermediate to valued activities Commit to plan Identify potential barriers Review previous goals (Roemer & Orsillo, 2004; Eifert & Forsyth, 2005; Orsillo & Batten, 2005)

50. Integrating Exposure Therapy Exposure sessions for specific events as well as classes of emotion Goal is acceptance rather than extinction Therapist must be practiced in approaching emotional experience, and mindful of not colluding with patient in experiential avoidance Therapist must be capable of achieving the metacognitive state of �engaged observation�

51. Summary Acceptance-based therapies are useful extensions of exposure-based in secondary prevention of PTSD and co-morbid disorders Empirical support in treatment of anxiety, depression, SUDs, couples, BPD Acceptable to patients Accommodates exposure for emotions other than fear & anxiety, or in absence of Criterion A Teaches cognitive and behavioral skills that may prevent development of avoidant and controlling strategies associated with the exacerbation of anxiety, depressive relapse, substance use, conflict, and intimacy problems Goal is broad functional improvement