Prolonged Exposure - a treatment for PTSD

We go through the treatment protocol for Prolonged Exposure, an evidence-based therapy used to treat post-traumatic stress disorder (PTSD).

Transcript

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Welcome to the Inner Solutions Podcast. We are your hosts, Donna Hughes and Jessica Heil. We own and operate Inner Solutions, a private practice clinic located in Calgary, Canada. We seek to understand and help our clients by providing empirically supported treatments and evidence-based practices with compassion and expertise. This podcast will provide you with information regarding complex psychological conditions as well as treatments that are available. I am Jessica Heil, and today I'm going to be talking about prolonged exposure, which is a type of treatment that we use for trauma symptoms. It is considered to be the gold standard for treating post-traumatic stress disorder or PTSD because it has so much research to back it. Prolonged exposure is a treatment that was developed in the 1980s by a person named Ednafoa. And it has been shown to be very effective at treating all sorts of different PTSD symptoms, ranging from having really heightened emotions when facing triggers of the trauma to treating different intrusive thoughts that a person might have, and certainly in treating avoidance behaviors that show up after a traumatic event. Prolonged exposure is a 12-session model, though I can tell you that when applying it in the moments, sometimes that can range. I'd like to talk about what a person would experience going into prolonged exposure, how the structure of the therapy looks, so that if anybody is interested in potentially looking into this therapy, that you just know what it is that you'd be walking into. So prolonged exposure, really there's two parts to the therapy. There's something that's called imaginal exposure, and there's something called in vivo exposure. And both of them are really important to be applied in order for us to be able to get full recovery from the PTSD symptoms. If you listened to my podcast last episode, you would have heard me talking about how the brain will internalize a traumatic event and create symptoms of PTSD, which a lot of the underpinning of PTSD is due to the tendency to avoid the cues or the triggers that remind us about the traumatic events. So if we were in a car accident and then we avoid going into a car, we try to avoid thinking about a car, we do everything we can to not have to face the distress that we feel when we are in the surroundings of a car. That can be the thing that will start to create PTSD symptoms because it reinforces this belief that cars are dangerous. And we know that, yeah, while cars can sometimes be dangerous, it's not the car itself that's dangerous. It's getting into the accident that's dangerous. So we need to have corrective experiences and be able to get back in cars and see that nothing bad happens like 99.9% of the time in order for our anxiety to start to come down. Prolonged exposure is a treatment that is very good at getting a person to expose to those triggers so that they can start to have corrective experiences. So we do this in the two ways. So as I mentioned, we've got in vivo exposure and imaginal exposure. Let's dive into what both of those mean. In vivo exposure means real life exposure. If you're in therapy doing prolonged exposure, the therapist would sit down with you and figure out what is it that you are actively avoiding? What are you avoiding behaviorally and cognitively in terms of your thinking? And they're going to strategically begin to expose to these things, these variables that you're avoiding, for long enough for the distress to begin to decrease. Let's come back to our car example. A person got in a car accident, they're afraid now to get back in the car. What we might start with with an in vivo exposure, rather than saying to them, get back in the car and start driving right away. That may not be realistic because perhaps as soon as they try to do that, their anxiety is reaching like a nine out of 10, 10 out of 10, they're panicking. This is not effective. Instead, we need to start slowly and with stimuli that are going to create less of an intense reaction. So maybe the first step would be just getting them to look outside their window from their house at cars and tolerate the anxiety that that's going to bring up. We need people to sit in the anxiety for long enough for those emotions to start to come down. And whether you believe it or not, if you sit there for long enough, the emotions will come down because the brain will start to realize, oh, nothing bad is happening. I'm not actually in danger. And the anxiety will start to habituate. It'll start to decrease. Now, as a therapist, the thing I'm watching out for when I'm asking my clients to sit in these in vivo exposures is I'm telling them that it's really important that they do not give in to the urge to avoid right at the peak of that anxiety. If they're looking at the cars and they're getting uncomfortable and right at the peak of how bad they're feeling, how how heightened that anxiety is, they're like, I can't, I can't do this anymore. I can't stand this. And they leave, then what they have just done is that they've taught their brain that looking at cars is in fact dangerous. The brain will internalize that as this is too dangerous for me to do it. I need to avoid. And it's going to make the anxiety worse the next time that a person is looking at a car. So we really need to be able to tolerate that anxiety through the height of that peak and wait for the anxiety to come back down before we move on with our exposure and go do different things. In therapy, we create an exposure hierarchy where we're going to ask people to rate how intense their anxiety is towards the things that they're afraid of. And we're going to start by getting them to expose to things that are maybe a little bit anxiety provoking, but they're not terribly anxiety provoking. So things that on a scale of zero to 10, maybe it's like your threes out of tens, your fours out of tens, and we're going to get them to do that for long enough that the anxiety starts to come down. It starts to habituate. So eventually those threes and fours out of tens are going to feel more like ones and twos out of tens. Once a person has had some progress on some of those lower end pieces of the hierarchy, then we'll move on to some more intense types of ratings. So now maybe we're working with our fives out of tens and then our sixes out of tens. And then those will start to come down over time. And eventually we're moving on to the items on the hierarchy that are causing a lot of distress. But at this point, because we've had success with getting the anxiety down for those lower items, what we start to find is that the whole list of things that we're avoiding starts to become a little less scary, a little less intense. And we become capable of tolerating a lot more than we thought that we would have been at the beginning. And eventually we're able to expose to everything on our in vivo hierarchy list and no longer avoid. So that's part of the therapy. That is called our in vivo exposure hierarchy. We're doing that, and at the same time, concurrently, we are going to be doing a marginal exposure in our individual sessions. So a person will be meeting with a therapist ideally once a week. And during the session, what they would be doing is choosing the memory that we are working on. So that really it's usually the memory that is causing the most distress related to the traumatic incident. And the person is going to repeat the story of what happened during the traumatic event over and over and over and over, generally within a 90-minute session. So it's a pretty long session where the client and the therapist are just sitting there with the client sharing the story over and over again. And what happens over time is eventually the person's emotions start to habituate, just like it would in the in vivo exposure hierarchy. So people start off as feeling like really quite intense. There's a lot of anxiety, there's a lot of emotion. And over time, that is going to start to subside. Now, it may not subside within the first session of doing the imaginal exposure. It may take a series of sessions to get there before you start to notice that your emotions are starting to decrease. But usually around, I would say, maybe session like five, six, seven, we're starting to notice that the emotions are no longer going as high as they were originally. And eventually towards the end of those 12 weeks, we're finding that the emotions are just about totally regulated when sharing the story of what happened during that traumatic event. So it's really neat watching that progress because we go from people experiencing very heightened emotions. It is not abnormal for me to see people sitting in high, high distress, like nine out of 10, 10 out of 10. It can be quite distressing during the sessions. But then towards the end of those 12 weeks, they're sitting there telling their story as if it's just old news. It's kind of like, okay, I'm done with this. I'm ready to move on with my life. So really amazing progress that can happen. And when you think about it, 12 weeks, as much as it's like kind of a brutal 12 weeks while you're doing the protocol, 12 weeks is not a lot of time in the grand scheme of your life. And it can take those 12 weeks before you're able to just really get your life back and go on and live a life that is significantly better because your PTSD symptoms have been all but resolved. At the end of the sessions, there's always an opportunity to process any insights that came from the session. This might include the client's insights on just what they experienced during the session. And sometimes the therapist will also share what their insights might have been, like what did they pick up on? So, for example, they might highlight that perhaps there are certain self-judgments that became really apparent to the therapist, and they want to highlight that to their client so the client becomes more aware of them. The therapist may give them a gentle encouragement to reframe certain thoughts in a way that might be a little bit more effective. So, this is where we're pulling in a little bit of our cognitive behavior strategies, where we're looking at the way people think and seeing if we can just do subtle modifications to that thinking in order to get a person to be able to move closer to recovery. Prolonged exposure has also been adapted by dialectical behavior therapy in order to be able to treat pervasive traumatic events. When we pair prolonged exposure with DBT, we call it DBT PE, so DBT prolonged exposure. And it's a nice addition to DBT after our stage one targets are done. So stage one DBT is about treating behavioral dysregulation. Once we're getting some progress with that, then we move into stage two, which is about reprocessing past experiences or doing our trauma work. The difference between DBT PE and regular PE is that we've just taken a lot of time in that DBT stage one to make sure that somebody has the appropriate emotion regulation skills before diving into doing prolonged exposure. Sometimes we get clients who will come to Inner Solutions and they will have tried to do a trauma treatment before doing DBT and they found that the trauma treatment actually made them worse, not better. And usually, if that's the case, it's because they didn't have enough emotion regulation skills to pull on prior to trying to do the trauma work. And the trauma work opened up kind of like a wound. It opened up these, uh, well, it opened the trauma back up again. And if those emotion regulation skills are not in place, then it can be very difficult for people to know how to get those emotions to come back down naturally on their own. And they find that they just can't seem to regulate after doing the trauma work. So DBTPE just we really take our time to make sure those skills are in place first, and then we pivot into doing the trauma treatment. And DBTPE has a particular protocol that we use for anybody who has experienced pervasive invalidation and they're finding themselves having trauma symptoms because of that experience of invalidation. If you listen back to my episode on how with BPD, sometimes we can feel like our relationships have caused trauma. That really links into why we would use the DBTPE protocol. Okay, well, I think that's it for today. I hope that this was helpful. Next session, I'm going to talk about another evidence-based practice for treating trauma. It's going to be on EMDR. So stay tuned for that. See you then.ca