Irene Powch, Ph.D.Portland State University and

Mental Illness Research, Education and Clinical Center,

NorthwestJune 16, 2011

Knowledge, Perceptions, and Utilization PollHow many…

Know very little about PE—just curious?Know enough to fear PE?Know enough to be enthusiastic about PE?Know the evidence base but have little sense of

what the process of PE is like?Know enough to discuss PE with veterans in a

supportive, collaborative, engaging, and motivating way…and make good referrals?

Consider themselves competent practitioners of PE?

Goals of Today’s PresentationTo give you a sense of:

How the treatment rationale is discussed with veterans in a supportive, collaborative, engaging, and motivating way

What goes on in PE sessions How the therapeutic relationship is used in PE The evidence base that supports PE as an effective

treatment for PTSD What kinds of changes do real clients/veterans experience

(videos)? Where you can learn more

Practical applications would include: For anyone who works with veterans: Ability to help a

veteran consider if PE is a good treatment choice for him/her

For therapists: have a better sense of whether you may wish to take the intensive training to become a PE competent therapist.

OverviewBrief Introduction to PESummary of the Evidence Base Supporting PEWhen is PE indicated? Deepen understanding of PE through session by

session highlights and presentation of tx rationale

Video clips (PE sessions, Recovery Interviews)Resources for further learningQuestions/discussion

What is PE?Prolonged Exposure Therapy (PE) is a Cognitive-

Behavioral Treatment for PTSD, developed by Edna Foa, Ph.D., Director of the Center for the Treatment and Study of Anxiety

8 to 12 sessions of 1.5 hour duration, with 2 hours of daily practice and typically one phone contact between sessions.

In the context of a supportive therapeutic alliance, the trauma survivor intentionally approaches the trauma memory and reminders long enough and often enough to experience a reduction in anxiety that opens the door to new learning. The memory and reminders lose their power to elicit a trauma response.

Evidence for EffectivenessOver 20 years of research supports the effectiveness of

exposure therapy for PTSD.By 2000, 12 studies had tested exposure therapy. All

finding positive results; 8 of these received the highest AHCPR rating for methodological rigor. Based on this, the Practice Guidelines for the International Society

of Traumatic Stress Studies (Foa, Kean, & Friedman, 2000, p79) concluded that “exposure therapy shouldbe considered as the first line of treatment unless reasons exist for ruling it out”

A 2010 meta-analytic review of 13 published RCTs of PE for PTSD (675 participants) found that the average PE treated patient faired better than 86% of patients in control conditions at posttreatment on PTSD symptoms.

Real World and Beyond PTSDPE is effective in “real world” VA clinical

contexts, not only in pristine clinical trials. Turek et al., J Anx Disord 2010

PE results in clinical improvements on many dimensions in addition to PTSD symptoms, including decreased depression, increased quality of life, improved sleep, improvement in reported physical health symptoms, improved social function, and posttraumatic growth, including increased sense of new possibilities and personal strength.

Powers et al., Clin Psych Review, 2010; Hagenaars et al., JTS, 2010; Rauch et al. Depr & Anx 2009

How Does PE Work?Theoretical base: Emotional Processing Theory (Foa &

Kozak, 1986). PTSD emerges due to development of a pathological fear

structure concerning the traumatic event. (Includes representations about stimuli, responses, and their meaning)

Foa & Kozak, 1986; Steketee & Rothbaum, 1989

Attempts to avoid this activation result in avoidance sxs Fear reduction requires activation & integration of

corrective information. Repeated imaginal approach in the context of a therapeutic, supportive setting: 1. promotes habituation & corrects belief that anxiety lasts

forever 2. blocks the short term reward of avoidance 3. promotes realization that remembering is not dangerous 4. helps survivor differentiate the trauma from the rest of the

world 5. sense of personal incompetence becomes sense of mastery

How Does PE Work?Theoretical base: Emotional Processing Theory (Foa

& Kozak, 1986).

Reminders of the trauma trigger distressing thoughts and feelings, including a “fight/flight/freeze” response even when there is no current danger.

Escape and avoidance behaviors develop to obtain temporary relief that serves to maintain PTSD.

By intentionally approaching instead of avoiding safe reminders—and staying long enough for anxiety to decrease, new learning happens: The memory is not dangerous! The reminders are not dangerous! Anxiety does not last forever! I can conquer the memory! I am competent!

When Is PE Indicated?Before First Session: Assessment

Is PTSD the primary problem? PCL, CAPS, BDI, PCI, chart review & psychiatric

interview

Are there significant more urgent or treatment interfering problems that need to be addressed first or simultaneously?Any current situation or condition that poses

imminent danger or interferes with ability to engage reliably in outpatient treatment.

Fine Tuning: PE vs. CPT/CPTC?Both therapies have a strong evidence base. There is

not yet sufficient research to guide treatment matching.

Considerations that may favor PE:Client resonates strongly with the rationale behind PE

and believes PE is the more direct approach that s/he needs

Therapist is more comfortable/competent with PEFear (fight/flight/freeze) is the predominant emotion that

is triggered by trauma reminders.Client has enough memory of one of the traumas that

causes their PTSD symptoms to form a narrative.Client is highly motivated to “de-commission” triggers

that are avoided and get in the way of enjoying highly valued activities.

Fine Tuning: PE vs. CPT/CPTC?Considerations that may favor CPT:

Client resonates strongly with the rationale behind CPT and believes that s/he needs to change his/her thinking before changing behavior.

The client has complete amnesia for the event.Therapist is more comfortable/competent with CPT The distress is driven by something other than

fear/horror/helplessness (for example, overwhelming shame at the thought of exhibiting fear; guilt about perpetration or other complications that block fear.)

Session 1

Engagement through Trauma InterviewTreatment Rationale round one (general)

Skill-the gift of breathPractice assignment—breathing, listen to

tape

Session 2Supportive and motivating review of practice

(breath)Engagement through discussion of common

reactions to trauma Treatment rationale round 2 (in vivo)Collaborative setting up SUDS & in vivo

hierarchyCollaborative planning of in vivo practice;

continue practice breathing, listen to tapeBetween session planned check-in call

Session 3Reassuring & helpful review of in vivo practiceEngagement through treatment rationale round 3

(imaginal)First Imaginal Exposure (clinician is a reassuring

presence, does not interfere with processing)Reassuring and affirming debriefPractice assignment—continue practice breathing,

in vivo exposure, and add imaginal exposure, listen to tape

Between session planned check-in calls as needed

Intermediate SessionsReassuring & helpful review of in vivo &

imaginal practiceSupportive, socratic questions regarding “gaps”

or other puzzling incongruencies; collaboratively identify “hot spots”

Gradually move imaginal exposure in on “hot spots”

Practice assignment—continue practice breathing, in vivo exposure, and add imaginal exposure, listen to tape

Between session planned check-in call

Final Session (usually near 10)

Celebratory review of in vivo and imaginal exposure work and progress madeDrop in SUDS and PCL scoresReview and celebrate addition of many

enjoyable activities that veteran previously was unable to do at all

Make suggestions for continued practice; plans for future

Videos10 minute segment of PE10 minute segment of PE recovery interview

More from Our Clinic

PrePost (change on the PCL)

62 38 (24) * From almost completely isolated to going back to72 32 (45) school to become a paramedic; faced a situation54 24 (30) similar to major trauma (burn victims) and slept55 26 (29) like a baby the following night.56 33 (23)80 40 (40) * From unable to stand out on back porch at night40 27 (13) to enjoying walks at night in safe neighborhood.65 45 (20)60 42 (18) * From almost completely isolated to going out70 25 (45) to concerts with friends. 42 19 (23) 60 32 (28) * Finally able to enjoy grandkids, wife, travel.

Resources for Further LearningHandout

References for clinical manuals and patient manuals for PE and related evidence-based treatments.

References for reviews of the evidence base and key studies.

Websites for continuing education related to effective treatments for PTSD

DiscussionQuestions and discussion from the audience