Issue # 3

• Can Reassurance Make a Difference?
  
  
• How Do You Sell Clients on the Purpose and Benefits of Prolonged Exposure (PE)?
  
  
• How Do You Conduct Effective Exposure?
  
  
• The Protocol for Imaginal Exposure with PTSD
  
  
• Spacing Out or Becoming Overwhelmed during Exposure or Avoiding Stimuli between Sessions
  

Can Reassurance Make a Difference?

The cognitive model suggests that catastrophic beliefs about bodily sensations contribute to nocturnal panic more than biology does. The authors hypothesized if they reassured panic patients that the fluctuations in their physiological state were normal, those patients would be less fearful of such arousal than patients who were led to believe that the same signals were abnormal.

Thirty patients who reported regular nocturnal panic and were also free from medications were randomly assigned to 1 of 3 conditions: expected, unexpected, and a control group. Participants were “wired up” and led to believe that auditory tones would occur during their sleep in response to any large physiological changes. However, the signal was experimenter-controlled so as to pair the critical tone with false physiological feedback. Those in the expected group were told that large fluctuations were normal. Those in the unexpected group were given instructions that implied large fluctuations were abnormal and possibly indicative of nocturnal panic.

After participants were asleep, up to 10 progressively louder tones were presented until the participant woke up by the sounds or was awakened by the technician. The expected and unexpected groups were equally likely to report abrupt waking in response to the tones, but the unexpected group reported the most anxiety and dread on awakening, and 60% of the unexpected group met criteria for a panic attack on waking as compared with about 10% for the expected group.

This result supports the cognitive model that it is the patient’s negative interpretation, not the actual event, which contributes to the panic attack, whether in the middle of the night or not.  This should reinforce therapists’ intentions to attack panic disorder at the level of belief and prediction. 

More specifically, patients can use a big dose of reassurance that the panic symptoms themselves are not dangerous.  (Remember, this study only provided “feedback” that there was elevated physiological arousal, not panic.)  We can do this in a psychoeducational model, explaining the physiology of panic.  Or, we can do it through interoceptive exposure, where they actually provoke the symptoms in the office.  A good guide (OK, I wrote it) to both approaches is in the 80-page self-help book Facing Panic, which is sold in our online store here.

It will walk the reader through a logical system about how the mind and body work together to generate the panic state, and how to use the mind and body to get out of it.  The reader also gets clear and simple instructions for interoceptive exposure practice.

Craske, M. G., Lang, A. J., Rowe, M., DeCola, J. P., Simmons, J., Mann, C., Yan-Go, F., & Bystritsky, A. (2002). Presleep attributions about arousal during sleep: nocturnal panic. Journal of Abnormal Psychology, 111, 53–62.

There is a wonderful set of articles published in Volume 10 (2003) of Cognitive and Behavioral Practice, written by senior researchers and clinicians, describing what they have learned over the decades.   They specifically focus on concepts that are not articulated in the books on treatment protocols.  I want to share some of the information from the article on prolonged exposure for post-traumatic stress disorder in this issue, and I’ll cover some others in later issues.

How Do You Sell Clients on the Purpose and Benefits of Prolonged Exposure (PE)?

Prolonged exposure is hard!  Some clients will have no part in it, and others will drop out prematurely.  But PE is extremely effective.  One of our jobs is to be as persuasive as necessary to help clients engage in effective treatment.

Here is the basic rationale for PE:

1. avoidance interferes with learning;

2. facing, rather than avoiding, painful but safe memories and situations will result in an eventual decrease in anxiety; and

3. successful handling of distressing situations and memories is powerfully reinforcing and promotes a sense of competence.

But clients are going to be skeptical, because it is prior to them experiencing any benefits from the treatment and (have I mentioned?) the treatment is threatening! 

Sometimes, metaphor and analogies can reinforce the point.  One analogy is to describe

“the mind as a file room and the trauma as a collection of loose papers and bits of information that are scattered around in different places because the information does not seem to fit into any of the drawers in the mind.  Through PE, a mental drawer is built where the trauma (and the associated stimuli) can be organized and filed away.”

Another analogy is viewing the trauma “as a wound, and healing it thoroughly so that, while it may leave a scar, it will not hurt when something touches it.”

Elizabeth A. Hembree, Sheila A. M. Rauch and Edna B. Foa (2003). Beyond the manual:  the insider’s guide to prolonged exposure therapy for PTSD. Cognitive and Behavioral Practice 10, 22-30.

How Do You Conduct Effective Exposure?

Edna Foa and Michael Kozak wrote a landmark article in Psychological Bulletin in 1986, called “Emotional Processing of Fear”.  This is one of the most widely referenced articles in the field of anxiety.  In it they delineated how the goal of exposure is to modify pathological fear structures.  Two conditions are needed for treatment to be effective.

1. Exposure should activate the fear structure that is targeted by the treatment.  This is a critical piece that often therapists don’t get, whether treating PTSD, panic disorder or any other form of anxiety associated with threat.  The client needs to go toward the threatening event, not way from it as through relaxation training.  She/he needs emotional engagement with the trauma memory.  We want to call up the fear structure in the moment--have it alive and present in the room--as the best way to modify it.

2. Exposure should lead to corrective information that will be incorporated into the fear structure.  When a client repeatedly recounts her trauma over several sessions and experiences a progressive decrease in her distress, she learns that thinking and talking about the trauma is not dangerous.  She also learns that the distress associated with such thoughts will not last forever.

So... in summary... we need to call up the trauma memory, help the client feel it as fully as is reasonably possible without further traumatizing him/her (there are protocols to help with this, too), and do this sufficiently and frequently enough that the fear structure is modified.  And a big part of that modification is that the original trauma is in the past, and reminders of it will not overwhelm him/her.

Edna Foa and Michael Kozak (1986). Emotional processing of fear: exposure to corrective information. Psychological Bulletin, 99, 20-35.

The Protocol for Imaginal Exposure with PTSD

Elizabeth A. Hembree, Sheila A. M. Rauch and Edna B. Foa (2003). Beyond the manual:  the insider’s guide to prolonged exposure therapy for PTSD. Cognitive and Behavioral Practice 10, 22-30.

Back to our article called “Beyond the Manual.”  Here is the protocol for imaginal exposure:

1. The client is instructed to describe and vividly visualize the trauma as though it is happening now. During this time, she is to keep her eyes closed, use the present tense, and include the thoughts, feelings, physical sensations, and behaviors that she experienced during the traumatic event. 

2. The therapist prompts for details that are not spontaneously included (feelings, thoughts, sensory details) and monitors the client’s distress level. 

3. In the ideal session, the client is close enough to the experience to access all of its important, fear-related elements, but is also safely grounded in the present.  The authors sometimes give this message to the client: “While it is necessary to connect to the memory on an emotional level, it is also important to remind yourself that you are safe and that the memory cannot hurt you.  I want you to process this memory with one foot in the past and the other in the present - safely grounded here, but reliving the past.”

4. The therapist can audiotape the session and ask the client to listen to that tape repeatedly for homework.

Spacing Out or Becoming Overwhelmed during Exposure or Avoiding Stimuli between Sessions

Two ways that this work can lead to less than optimal results are when the client either becomes overengaged or underengaged. 

Underengaged client

With underengagement, the client has difficulty accessing the emotional components of the trauma memory.  If this persists, then the authors recommend that the therapist revisit the rationale for exposure.

Then the therapist should:

1. attempt to discover what is interfering or preventing her from engaging with the memory,

2. explore any feared consequences the client might have of connecting with the memories, and validate any feelings that come up, and, at the same time

3. help her realize that being distressed is not dangerous.

During sessions with the underengaged client, the therapist can ask questions about sensory experience, feelings and thoughts (e.g., “Describe what you see...”  “Describe the room...”  “How does it smell...?”  “What are you wearing...?”  “What are you feeling...?”  “What are you thinking...?”)   But don’t engage in conversation during the exposure, since that will further distance them from the work at hand.

If the client begins relating the trauma in a conversational manner, suggest that she look at something other than the therapist (the wall, floor)

If the client continues to have difficulty, you as the therapist can role-play the way that trauma reliving should be done.  Closes your eyes, use present tense, and recount the client’s trauma, using all of the relevant elements of the memory.

Anger can also be a defense against engagement.  The therapist can express empathy for the anger but explain that focusing on this anger during exposure may prevent her from engaging with the fear and anxiety associated with the trauma memory.  So, during exposure session, anger can interfere with progress.

Overengaged client

The overengaged client has difficulty maintaining a sense of safety and grounding in the present moment. In this situation, the therapist first reiterates the rationale for exposure and can offer the metaphor of keeping one foot in the present and one in the past (“memories can’t hurt you”).

Other options include:

1. For the client to keep her eyes open during the imaginal exposure, or if closed, to open them periodically

2. For the client to use past rather than present tense in describing the trauma.

3. If she becomes stuck in an especially upsetting or horrifying part of the memory, the therapist can suggest that the client move forward in time, skipping over that point for now.

4. Physical touch might also be helpful but should always be discussed.

5. Teach the client slow, paced breathing and encourage her to use it as needed during the session. 

6. If the client is agitated or physically restless during imaginal exposure, you can offer her something to manipulate such as a stress ball or a towel.

7. If a client is overwhelmed by engaging with the traumatic memory, you can have her begin by recounting the traumatic memory conversationally while maintaining eye contact with the therapist.

8. Or, if necessary, the client can begin with a written narrative of the event instead of a conversation about it.  She should still try to include thoughts, feelings, actions, and sensations.  The therapist may ask the client to read the narrative aloud and gradually increase the client’s engagement with her feelings over multiple readings.

Responding to avoidance

It is natural for clients to want to continue to avoid any reminders of the trauma memory, and it seems to be the most common impediment to completing the exposure process.  Clients need to know that to finish their work, they need to confront their avoidance and reclaim their world.  It prevents them from learning that the avoided situations and the memories they elicit are not dangerous.

One analogy is that avoidance is like “a cave where the client retreated to heal from the trauma.  While this safe cave has allowed her to function on some level, it has also significantly restricted the client’s life.  Exposure involves increasingly longer and more extensive journeys outside of the cave, and that feels risky and dangerous.  However, in order to completely heal from the trauma, the client must learn to deal with the risks outside the cave.”

Elizabeth A. Hembree, Sheila A. M. Rauch and Edna B. Foa (2003). Beyond the Manual:  The Insider’s Guide to Prolonged Exposure Therapy for PTSD. Cognitive and Behavioral Practice 10, 22-30.