Evaaluation of Prolonged Exposure Therapy

Exposure therapies are utilized to treat fear and other disorders under controlled situations. Exposure “is a key process in treating a wide range of problems associated with fear and anxiety.” (Corey, 2017, pg. 245) Controlled exposure is a systematic process between the client and a trained helping professional. During this exposure patients “confront the feared, but otherwise safe, objects, situations, thoughts, sensations, and memories with the goal of reducing fear and other negative reactions to the same or similar stimuli in the future.” (Foa, 2011) The specific kind of exposure therapy discussed in this paper is prolonged exposure therapy. (PE) In this paper I will discuss its proven scientific application making it an evidence-based practice through the details and methods used in two studies where PE is used as primary treatment. I also will discuss and how I would plan to find a connection to my own personal counseling practice as a future professional that could learn to use PE.

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Prolonged Exposure Therapy was developed by Edna Foa, PhD, the Director of the Center for the Treatment and Study of Anxiety (CTSA). The Center of the Treatment and Study for Anxiety’s website About Prolonged Exposure Therapy states that “PE has been empirically validated with more than 20 years of research supporting its use. PE is based on cognitive-behavioral principles and specially designed to help clients process traumatic events and reduce trauma-induced psychological disturbances.” (The Center of the Treatment and Study for Anxiety [CTSA], n.d.) The CTSA states that “this treatment produces clinically significant improvement in about 80% of patients with chronic PTSD. PE has been used to successfully treat survivors of varied traumas including rape, assault child abuse, combat, and motor vehicle accidents and disasters.” The CTSA website states “PE instills confidence and a sense of master, improves aspects of daily functioning, increases client’s ability to cope with courage rather than fearfulness when facing stress and improves their ability to discriminate safe and unsafe situations. In 2001, Prolonged Exposure for PTSD received an Exemplary Substance Abuse Prevention Program Award from the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA).

In describing the PE process for individuals with PTSD, The U.S Department of Veterans Affairs website Prolonged Exposure for PTSD describes that “people with PTSD will often try to avoid anything that reminds them of the trauma, but while this can help one feel better in the moment it does not provide relief in the long term.” PE is used to help one face one’s fears, by talking about the details of the trauma and confront safe situations that one has been avoiding. In laying out treatment the website states , one can expect a provider to start by giving you an overview and getting to know more about your past. A breathing technique is taught to help manage anxiety. Around second session, the provider has to make a list of people places or activities you have avoided since your trauma, which means you will gradually confront these situations. In this practice it is hoped that in time you will feel more comfortable in these situations enough not to avoid them anymore. Then will begin an imaginal exposure, talking about trauma which can help with emotions like anger and sadness. Records of imaginal exposure can be made and listened to between these sessions. By the confrontation of the details of this trauma, you may find less unwanted memories at other times. (VA National Center For PTSD, 2019)

The VA’s treatment plan has PE lasting for 8-15 weekly sessions which is around 3 months. These sessions are 1.5 hours in length. An individual may start to feel better after a few sessions, and the benefits of PE las long after the final sessions have been completed. The VA’s PE protocol (VA National Center For PTSD, 2019) recommends that homework is done out of session to practice some of the things you have avoided since trauma. Activities are begun that are manageable working up towards challenging activities…the risks of doing PE are mild to moderate discomfort when engaging in new activities and when talking about trauma related memories. These feelings are usually brief, and people tend to feel better as they keep doing PE…most people who complete PE find that the benefits outweigh an initial discomfort.” But in an opposing way The (American Psychological Association [APA], 2019) website Prolonged Exposure (PE) describes the PE beginning exposure period in more intense language, which is to be considered. The website states about PE exposure for PSTD “This is a very anxiety-provoking for most patients, the therapist works hard to ensure that the therapy relationship is perceived to be a safe space for encountering very scary stimuli. Both imaginal and in vivo exposure are utilized with the pace dictated by the patient.”

In the first study I will discuss “Prolonged Exposure Therapy for Older Veterans With Posttraumatic Stress Disorder: A Pilot Study.” (Thorp, Stein, Jeste, Patterson & Wetherell, 2012) The purpose of this study was “to assess feasibility and efficacy of PE in older Veterans with PTSD”. Exposure Therapy had “not been studied systematically in older adults due to the published concern that these older individuals would not tolerate treatment”. Eleven men were recruited from a Veterans Affairs PTSD Clinical Team program and after assessment, eight completed prolonged exposure therapy. Study criteria included, 1) PTSD due to a military event; 2) age 55 years or older; and 3) no change in type or dosage of psychotropic medications in the past 2 months. The participants were measured on by using clinician-administered PTSD Scale 7, PTSD Scale (CAPS), The FI/12 method of categorical scoring, and summated dimensional scoring (for PTSD severity 10).

In the portion of PE therapy is this study, an author or one other psychologist provided PE14 to participants. Each of the veterans then received 90-minute sessions, twice a week totaling 6 weeks of PE. The patients were taught breathing retraining, and then created a list in hierarchical fashion of their avoided activities and other situations that were associated with the trauma. The patients were also encouraged to engage in feared activities in a systematic way outside of session and then to recount this later aloud in session. Patients listened to records of these trauma narratives between sessions. Final sessions focused on reviewing skills and creating plans to maintain treatment gains. (VA National Center For PTSD, 2019)

 In the conclusion of the study, the veterans who had completed 6 weeks of PE showed a significant reduction in clinician-rated and self-reported PTSD Symptoms. The study relays using the interpretation of CAPS scores suggested by Weathers et al.,10 as a group Veterans receiving PE showed a clinically significant decline in severity (from the extreme range to the moderate range) whereas Veterans receiving TAU (TAU consisted of medication appointments or physicians appointments to monitoring treatment and offer general support, averaging one appointment each during the 6 weeks.) did not demonstrate a clinical significant decline in severity (from the extreme range to the moderate range.) Indeed, 100% of the PE sample showed a clinically significant decline in severity whereas 40% of the veterans in the TAU sample made such a change. As the study hypothesized, that veterans with traumatic events which occurred on average 40 years earlier, still showed a significant decrease in symptoms of PTSD (clinician and self-reported) following exposure therapy.

The second study I would like to discuss about PE to demonstrate its evidence based practice is “Prolonged Exposure Therapy with Veterans and Active Duty Personnel Diagnosed With PTSD and Traumatic Brain Injury” (Wolf, Kretzmer, Crawford, Thors, Wagner, Strom & Vanderploeg, 2015) which was a study done on clinical data to analyze the effectiveness of prolonged exposure (PE) for PTSD among the veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. These veterans all besides having PTSD had histories of mild to severe traumatic brain injury. (TBI) The data used in the study was collected from two inpatient and outpatient programs at the Department of Veteran Affairs.

In (Wolf et al., 2015) it is stated “that studies estimate that 12.0% of 17.0% of returning soldiers experience symptoms of PTSD (Seal, Bertenthal, Miner, Sen, & Marmar, 2007) and a review of Veterans Affairs (VA) health care utilization covering the last 10 years indicates PTSD was the most prevalent psychiatric disorder with approximately 217,000 cases (Seal et al., 2010). It is also estimated that of the 2.6 million soldiers deployed, approximately 253,330 experienced a TBI during their military service (U.S. Department of Defense, 2012)” The study then highlights that mental health professionals frequently encounter comorbid PTSD and TBI. (Taylor et al., 2012) Evidence based psychotherapy such as PE and cognitive processing therapy have been designated at the first line interventions for comorbid PTSD with mild TBI. (U.S. Department of Veterans Affairs and U.S. Department of Defense, 2009)

The method of this study 69 individuals received PE as part of routine care at Tampa and Durham VA medical centers. These veterans were not offered PE if they presented “psychosis, unstable bipolar disorder, imminent suicidal or homicidal ideation, and recent aggressive behavior, self-harm, or severe substance” then other mental health treatment was provided. When veterans were enlisted in inpatient treatment the average length of stay being 6 to 8 weeks, these participants completed twice weekly PE sessions. In the residential program veterans with an average length of stay of 3 to 6 months and participants were seen weekly also for PE sessions. Other forms of treatment in concurrence to PE were concurrent psychiatric medication, physiatry, cognitive rehabilitation, physical therapy and vocational rehabilitation services.

Describing the used PE treatment in all of the veterans cases the following major PE components which are listed as “(a) psychoeducation (b) repeated in vivo exposure to commonly avoided trauma-related situations and cues (c) repeated imaginal exposure to traumatic memories and (d) subsequent discussion after imaginal exposures to facilitate emotional process and corrective learning.” (Foa, et al., 2007) Which are consistent with the VA treatment manual, and no other therapy components were included. Patients that were in inpatient or residential settings completed assigned in vivo exposure independently or during community outings. Baseline measures were collecting within one week of treatment but no longer than two weeks.

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Measures used in the study were the PTSD Checklist, (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993) which monitored PTSD symptom severity at the initiation of PE and was used for every other session during the duration of treatment. The Beck Depression Inventory (2^nd ed.; BDI-II) was also used “to measure severity of depression at the initiation of PE and every session across the course of the treatment. In results of treatment in the study there was significant and reliable clinical change. In the sample, 75.4% of the participants demonstrated reliable reduction in PTSD symptoms of 10 points or more on the PCL…and 71.6% demonstrated a reliable reduction on depression of 5 points or more on the BDI-II during treatment. The study demonstrated that these analyses show the effective ness of PE with comorbid PTSD and TBI. Due to these documented successes” (Wolf et al., 2015) noted “The findings should contribute to dispelling the notion that comorbid TBI and its associated problems represent a barrier to successful treatment of PTSD in active duty service members and veterans.”

Now I will discuss how PE may be used in my own practice as a future counselor. When I make a consideration of a serious, evidence-based practice such as PE I know it isn’t about my interpretation it is about the correct implementation. I understand that my use of it only could come through after my own professional training and then understanding. In my own theory alignment, though very much developing I want to focus on a personal empathetic connection but also, basing my practice out of evidence-based practices and methods. This would be to tailor my methods specifically to the issues I am seeing (specifically mental health.) The evidence-based treatments for specific mental illness (in whatever theory it may be based, be it CBT or Behavioral) are where I will seek more knowledge and training.

In this paper I have worked to show that PE is an evidence-based treatment for PTSD. As a noted limitation/practical issue I would keep in mind this is not the appropriate treatment for all clients with PTSD, (psychosis, unstable bipolar disorder, imminent suicidal or homicidal ideation, and recent aggressive behavior, self-harm, or severe substance) (Wolf et al., 2015) As I may see cases of PTSD in my practice, when possible I would like to see training in PE. I would especially seek this training if it was working with the veteran community or the within the VA specifically where I have considered applying for my internship. Training is offered at University of Pennsylvania Center for the Treatment and Study of Anxiety with PE’s founder Dr. Edna B. Foa, there a continuing education credit that would come with this training. Personally, I would do that if it something I could do to build my practice, I really hope to be open to learning experiences and continuing my education as a counselor always.

 The role of the counselor in this relationship performing PE I see as the helping professional. The counselor is not experiencing  the intense feelings of trauma and anxiety that the client will be facing but can only offer a genuine presence of concern and empathy. It is the counselor’s responsibility to be trained and knowledgeable about the PE process before trying it on a client as that would be very dangerous. I think there is a level of trust that needs to be built before any exposure can be started given that this will be a difficult and potentially scary process for the client. Coming back to what the APA states on their website (American Psychological Association [APA], n.d.) “This is a very anxiety-provoking for most patients, the therapist works hard to ensure that the therapy relationship is perceived to be a safe space for encountering very scary stimuli.” So, I think as a counselor it is my job to try to create that safe space. This would be by outlining the method well, talking about what may be experienced, creating an environment that is soothing.

 It would be important for me to let the client know that I am here for the duration of this journey, and together we can enable the client to discover they can face the trauma they may not have been able to until the exposure therapy process. Relationship issues that may be encountered are this would be an increased time of need for the client where I may have to be more open to outside communication, if they are doing out of session exposure. I would also have to consider the workload and relationships of my other clientele and being present for them. This exposure time and the increased anxiety/emotional component that may come out of clients may need to be a time of greater self-care out of work for myself.  

From a diversity perspective on PE  (Corey, pg. 259, 2017) lists exposure therapy as a behavior therapy and in which “behavior therapists need to become more responsive to specific issues pertaining to all forms of diversity. Because race, gender, ethnicity, and sexual orientation are critical variables that influence the process and outcome to therapy…it is essential for therapists to conduct a thorough assessment of the interpersonal and cultural dimensions of the problem.” I think a lot of this would come in the investigative part of this therapy, where and when the trauma developed. How others in this individual’s home and other areas such as their partners and family may need to be involved in the treatment. It is possible that sessions would have to be done not just with the individual but having other family come into talk about the process. Coming out of Feminist Theory how one’s own formed cultural identity, and gender role messages (such as if the client identified as a man thinking he should be tough and bury trauma) play into part. Investigating any societal messages related to how one is supposed to behave after experiencing trauma if it is something to hide or be open about in one’s specific cultural household.

In conclusion I hope to have properly introduced prolonged exposure therapy (PE) and inform how it is indeed an evidence-based practice with a strong history and evidence of support. Its method is impactful and proven successful, with its 20 plus years of application in those with traumatic events and traumatic induced mental illnesses, and specifically addressed in this paper example studies veterans working with PTSD. As a future counselor I hope to learn PE’s correct methodology and implication though proper training and have PE something I can offer my clients. It was engaging and informative to learn about the details of this evidence-based practice and I hope to learn more about exposure therapy in the future.

References

• American Psychological Association. (2019). Prolonged Exposure (PE). Retrieved from https://www.apa.org/ptsd-guideline/treatments/prolonged-exposure
• Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory Manual. San Antonio TX: The Psychological Corporation.
• Center for the Treatment and Study of Anxiety. (n.d.) About Prolonged Exposure Therapy. Retrieved from https://www.med.upenn.edu/ctsa/workshops_pet.html
• Corey, G. (2017). Theory and practice of counseling and psychotherapy. Boston, MA: Cengage Learning.
• Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences, therapist guide. Oxford, England: Oxford University Press.
• Foa, E. B. (2011). Prolonged exposure therapy: past, present, and future. Depression and anxiety.
• Seal, K.H., Bertenthal, D.S., Miner, C.R., Sen, S., & Marmar, C.R. (2007). Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of internal medicine, 167 5, 476-82 .
• Seal, K. H., Maguen, S., Cohen, B., Gima, K. S., Metzler, T. J., Ren, L., . . . Marmar, C. R. (2010). VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. Journal of Traumatic Stress, 23, 5–16. doi:10.1002/jts.20493
• Taylor, B. C., Hagel, E. M., Carlson, K. F., Cifu, D. X., Cutting, A. B., Douglas, E., & Sayer, N. (2012). Prevalence and cost of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq war Veteran VA users. Medical Care, 50, 342–346. doi:10.1097/MLR.0b013e318245a558
• The U.S Department of Veterans Affairs National Center For PTSD. (2019) Prolonged Exposure for PTSD. Retrieved from https://www.ptsd.va.gov/understand_tx/prolonged_exposure.asp
• Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson, T. L., & Wetherell, J. L. (2012). Prolonged exposure therapy for older veterans with posttraumatic stress disorder: A pilot study. The American Journal of Geriatric Psychiatry, 20(3), 276-280.
• U.S. Department of Veterans Affairs and Department of Defense (VA/DoD). (2009). VA/DoD clinical practice guideline for management of concussion/ mild traumatic brain injury. Washington, DC: Author. Retrieved from http://www.healthquality.va.gov/mtbi/concussion_mtbi_full_1_0.pdf
• U.S. Department of Defense. (2012). U.S. military casualty statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. Washington DC: Author. Retrieved fromhttp://www.fas.org/sgp/crs/natsec/RS22452.pdf
• Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist: Reliability, validity, and diagnostic utility. Paper presented at the Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.
• Wolf, G. K., Kretzmer, T., Crawford, E., Thors, C., Wagner, H. R., Strom, T. Q., … & Vanderploeg, R. D. (2015). Prolonged exposure therapy with veterans and active duty personnel diagnosed with PTSD and traumatic brain injury. Journal of Traumatic Stress, 28(4), 339-347.