Had a fabulous staff meeting at our practice today given by fellow colleague, Marta MacDougall. Marta also works at the Philadelphia area VA. She presented an overview of Edna Foa’s Prolonged Exposure Therapy for PTSD. You can find the book here.
PE looks at trauma this way: PTSD is maintained by avoidance behaviors. One avoids memories, triggers, emotions, places of traumatic experiences. While avoidance works in the short-term, it exacerbates the symptoms over the long haul since they are not fully processed. In fact, the better able one can avoid these feelings, the more likely their PTSD will be worse later. Hence why you can have some very functional people become unable to function later in life. She used this illustration. For many Vietnam Vets, Vietnam is part of a book they keep trying not to read. They shove it away over and over but it has a habit of falling off the shelf and opening to the same page, even the same couple of very painful sentences. Thus, despite their attempt to avoid, the only thing they keep rereading is the same couple of sentences; thereby reinforcing and even rewriting the whole experience as if it were only those two sentences.
Thus, the goal is break the “phobic reaction” to painful thoughts and feelings. How? By two prongs: (a) imaginal exposure (memory encounters), and (b) in-vivo exposure to avoidant stuff in the present.
The therapy consists of 12-20 sessions (1.5 to 2 hours each). In the sessions, the person develops a current list of avoidance in their life or other subtle safety behaviors. They begin to daily pick easy to hard avoidant tendencies to expose themself to in order to break the fear pattern. Now, these are things that aren’t actually dangerous. Second, in session 3 they begin to recount the most salient trauma from the point in the story where they were safe to unsafe to safe again. So, it could be a story of waking up to a rape, going out for a particular traumatic battle, etc.). This portion of the story may only take 5-10 minutes to recount. That same memory is recounted, in the first person with eyes shut, repeatedly for up to 45 minutes. During the exposure, the therapist asks for their subjective units of distress level (0-100) every five minutes. This exposure to the same memory is repeated in each session with time to talk about and process at the end. The levels of distress are tracked over time (both from imaginal and in-vivo exposure experiences. On top the therapy intervention, the in office imaginal exposure experience is recorded and the client is to listen daily to that recording.
Sound like torture to you? It does to me. Here’s the reaction rationale. The avoidance of memories and emotions tied to them is causes even greater distress. Thus, getting the client to face that distress and process the emotions as well as uncover subtle lies believed about self and other is only dealing with reality directly.
You can imagine that many refuse this kind of therapy. Those who do it…about 80% see a significant reduction in PTSD.
Not sure I’m going to begin doing this kind of therapy as I’m not set up for it being in the office only 1 day per week. However, I will pay more attention to the ways avoidance behaviors or safety seeking behaviors accentuates PTSD and will be more likely to give daily homework to address this problem.
Musings on Faith and Psychology 
I just had my first “graduate” yesterday. Original Dx, Social Anxiety and Major Depression. We used Managing Social Anxiety. (also Oxford Press in the treatments that work series) Exposure is the main thrust of the therapy, with cognitive restructuring, avoidance of avoidance and safety seeking as the components.
This person was also my first client, given to me on the second day of practicum. When I confidently assured the client that there is a treatment that will help, I desperately hoped it was true! Please Lord, make up for my inexperience!
Well…, I am still skipping on the clouds! Gave the BDI-II, BAI and SPI (Jonathan & Davidson) at beginning and end. SPI 47 and 11, BAI 25 and 6 and BDI-II 29 and 1! Wow! Even doing well, I didn’t expect THAT good!
And…, another reply…..
Today, I was looking for info. on PTSD and depression comorbidity. Specifically if treating PTSD simultaneously treats depression. Didn’t find anything except that comorbidity of the two makes PTSD harder to treat.
I know a Marine who now admits that he has “some” PTSD. — 3 deployments, not on the front lines, but still in situations where he could be killed any moment — He also recognizes depression. But, he “deals” with it. I don’t know how he “deals.” — If it is avoidance and safety behavior, does this mean that at some point it is going to come out, and to a greater degree, and thus better to “deal” with it more appropriately now?
Anyone know of a good manualized group curriculum for PTSD in adolescents? I ran across “Seeking Safety” by Najavits, but I’ve not come across too much else.
The PTSD Workbook by Williams & Poijula is an excellent workbook with lots of techniques, exercises and worksheets. It simple and thorough and can be used with adolescents.
I will look that up and give it some attention! Thanks much!!!
Anyone ever try a book entitled “Out-of-Control: A Dialectical Behavior Therapy (DBT) –
Cognitive-Behavioral Therapy (CBT) Workbook
for Getting Control of Our Emotions
and Emotion-Driven Behavior” by Melanie Gordon Sheets, Ph.D? Ran across it on Amazon, but haven’t looked into it in depth yet.
Scott-
(First off, hey. Hope you’re doing well!)
I have heard some good things about Seeking Safety, have some ppl in my cohort who have implemented it. I have never used it myself so that is only second-hand. I’m not sure if its empirically-supported.
Thanks for the endorsement, Carmella! Hope you’re doing well at PCOM, as well! Drove by there 100’s of times on my way home from Belmont (working, not getting treated! 😛 ) My supervisor saw the “substance abuse” component of that program, and blanched…so I may have to put up the money and buy it myself…it’s more reasonable on eBay! Good to hear from you, you “Facebook bail-er out-er, you!
Admittedly I have fled Facebook. But its great to see you on here and I hope to keep in touch because I consider you a double-edged sword- a professional Christian colleague, and a friend!!
Thanks for this, Phil. And thanks for the summary of tackling a first session in the post above.