Prolonged exposure An Evidence-Based Psychotherapy for PTSD

1. Prolonged exposureAn 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 Scott.michael@va.gov

3. VA Training in Evidence-Based Psychotherapies

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. 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

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 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 Percent 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 Resick et al., 2002 PE = CPT

22. PE with Veterans

23. The Efficacy of PE With 16 U.S. Veterans (PG, VN, OIF, WWII) Plus One EMT 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 Rauch et al., in press

25. CSP #494: Study Design 284 Female Veterans and Active-Duty Personnel with PTSD in 12 sites and 52 therapists Random Assignment 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

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. PTSD Symptoms Schematic Model of a Memory Shortly After Combat Trauma Afraid Uncontrollable I - Me Combat IED Crowd Helpless Driving Trash Fire Dark Noise Yell Scan Incompetent Dangerous Confused Courtesy of Melissa Polusny, Ph.D.

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 Incompetent Dangerous Confused

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 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 • 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 • 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.

47. Hierarchy • 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 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 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)

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