Myths, Misconceptions, and Moving Forward: Successful Implementation of Prolonged Exposure
I was eager to write this blog when Ryan Van Wyk asked if I would be willing to contribute a post on Prolonged Exposure (PE) to the Minnesota Trauma Project website. As I’ve attended trauma conferences and talked with colleagues, it has amazed me the misconceptions in the field of mental health when it comes to exposure-based therapies. As a PE therapist and trainer myself, I have seen first hand the amazing changes that patients can undergo in 8-12 sessions; I’ve literally seen lives change and success maintained for years afterwards. It’s from this place of the incredible honor and fulfillment that I’ve experienced in providing this therapy that I write this post. While there is a lot that could be written about PE, the first step is to debunk some myths and misconceptions about PE. My hope here is to help demonstrate how this treatment is implemented in a manner that can help individuals struggling with Posttraumatic Stress Disorder (PTSD) in some very dramatic and enduring ways.
Before I explain some of the myths and misconceptions about PE, I think it would be useful to provide a somewhat brief overview of PE. PE is a cognitive-behavioral therapy (CBT) that is comprised of four essential elements: Education about trauma related symptoms and recovery processes; confronting real world situations that have been avoided since the trauma (i.e., in-vivo exposure); re-visiting/re-telling of the trauma narrative (i.e., imaginal exposure); and discussion of in-session emotions and thoughts following trauma re-visiting. A standard course of PE lasts, on average, between 9 and 12 sessions. There are a few specific contraindications for PE among individuals with PTSD: clients with unstable bipolar disorder or psychosis, imminent suicidal or homicidal intent, recent and severe violent behavior, active self-harm, or severe substance use disorders. Generally, it is important to delay PTSD treatment until such clinical risks can be sufficiently mitigated. The Institute of Medicine (IOM) reviewed the literature on successful PTSD treatments and concluded that exposure based treatments like PE were the only treatments that have a solid enough research base to be considered effective. Further, the most recent VA/Department of Defense (DoD) Clinical Practice Guidelines identified exposure therapy as one of four evidence-based psychotherapies for Veterans with PTSD (along with several other treatments including Cognitive Processing Therapy and EMDR).
Perhaps the most prevalent myth related to PE is that it is an unsafe treatment. Despite evidence to support it’s effectiveness across populations, many clinicians express concerns about client safety and acceptability of PE, typically based upon “what they have heard.” However, it has been my experience, and that of many other clinicians, that PE tends to be highly effective for the majority of patients (research has found around 80% show significant improvement), and in those cases where PE does not yield benefit, treatment yielded no noticeable reduction in symptoms (as opposed to a worsening). In the latter case, it is common that they struggle with confronting avoidance symptoms, and therefore, do not receive a full dose of the treatment. While the experiences of clinicians is useful in these discussions, the research literature allows us to examine these questions in a more systematic manner, and with larger numbers of patients. The research literature on PE has also supported its safety and acceptability. For example, one study examined whether clients experienced a worsening of symptoms while completing PE, and found that a minority (~11%) of patients showed an initial, temporary increase in PTSD symptoms, but this initial increase did not affect overall treatment outcomes and did not increase drop-out rates. Relatedly, a more recent study found that 0% of patients in PE showed worsening of PTSD by the end of treatment.
One commonly held misconception about PE relates to the desired outcome following exposure. Perhaps drawing from early writings on exposure principles, many clinicians unfamiliar with PE hold the belief that de-sensitization or habituation to the trauma memory and associated feared situations is the primary desired outcome. However, through decades of clinical intervention and research, habituation or de-sensitization is now understood to be a byproduct of changes in trauma-related cognitions. Changes in beliefs (e.g., “The world is a dangerous place”, “The event happened because of the way I acted”) are achieved through confronting trauma-related situations and discussing/processing the trauma memory. This allows the individual to incorporate more realistic views about safety and their own competence.
Ways to Enhance Outcomes
While a comprehensive review of the PE protocol is beyond the scope of the present post, I thought it would be useful to provide some general comments on ways to enhance outcomes when implementing PE. These comments are based on my experience as well as consultation with other providers learning to implement PE. In my experiences, one of the best ways to enhance outcomes is to ensure that a thorough initial assessment is completed. This is necessary to make sure that the patient has the symptoms that PE treats, and that their goals line up with what PE has been shown to accomplish.
First, when considering PE, I’ve always felt that successful treatment begins during the initial intake assessment. Before initiating PE, and I would argue any trauma-focused treatment, it is also essential to conduct a thorough diagnostic evaluation that incorporates a structured diagnostic interview for PTSD, such as the clinician administered PTSD scale (CAPS), or the PTSD symptom severity interview (PSS-I). These interviews allow clinicians to gather some basic information about trauma history, and also get a sense for the frequency, intensity, and nature of ongoing symptoms (e.g., content of re-experiencing symptoms). While a full diagnosis of PTSD is not required to initiate PE, it is required that the individual have clinically relevant levels of re-experiencing (e.g., nightmares about the trauma) and behavioral avoidance symptoms (e.g., avoiding situations that remind them of the trauma) in order to proceed. As the Minnesota Trauma Project website highlights, there is a range of treatments that can successfully assist our clients in reclaiming their lives, therefore, if the clients’ symptom presentation does not include significant re-experiencing and avoidant symptoms, PE should not be the chosen treatment. Also useful within the initial interview is determining whether the presence of ongoing major life stressors (e.g., unstable housing) or co-morbid psychiatric conditions will prevent successful implementation of PE.
Finally, as with any good therapy, there needs to be a firm match made between the selected treatment, the client’s presenting concerns/symptoms, and their goals for treatment. The initial intake is an opportunity to elicit the client’s goal for care and gauge whether these goals align with the outcomes expected from a trauma focused treatment such as PE. In order to determine this, information gathered during the CAPS or PSSI can be evaluated against the client’s self-stated goals for treatment. It is reasonable to find that an individual has not heard that they have PTSD, or they don’t fully appreciate how these pernicious symptoms have crept into all aspects of their lives. At this point in treatment it is important for the clinician to provide some brief education about addressing PTSD symptoms that may improve multiple aspects of their lives. Additionally, asking questions such as “what would you like to be doing more of at the end of treatment” or “what has PTSD prevented you from doing, that you would like to?” will provide the clinician with behavioral targets to include in future in-vivo exposure activities, as well as providing motivation and a “big picture” perspective when the client is pulled to avoid.
In conclusion, PE is a very effective treatment for reducing PTSD (and associated comorbid) symptoms. In addition to evidence supporting it’s effectiveness, studies have demonstrated its safety and acceptability across multiple populations. However, in order for any trauma-focused treatment to be effective, it is incumbent upon the treating clinician to ensure that they are effectively matching the selected treatment to the client’s goals and presenting symptoms. When this match is made and the treatment occurs in the context of a trusting therapeutic relationship, PE has demonstrated itself to be among the most effective treatments for PTSD.