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OVERVIEW OF THE TREATMENT PROTOCOL

FOR PROLONGED EXPOSURE

(from Foa & Rothbaum, 1998)

Research protocol is based on nine weekly sessions of 90 minutes each.  Clients who do not show substantial improvement (at least a 70% reduction in symptoms severity from pretreatment) are offered three additional sessions

·         If clients have not benefited substantially from 12 sessions of the PE protocol, it is not likely that continuing with CBT will yield additional benefits (Foa & Rothbaum, 1998).

o        At that point, consider thorough reevaluation or referral for multisystemic treatment

·         Many clients prefer to vary from the 9 session protocol, and may request some sessions that are not focused on PE.  Researchers including Foa and Resick have stated that when they are providing treatment that is not part of a research study they tend to be flexible rather than strictly adhering to a 9-12 session model.

Basic assumptions to keep in mind

·         the fear structure must be activated in order to be altered, and new information must be provided that is incompatible with the existing structure

·         Repeated imaginal reliving of the trauma promotes habituation and corrects the idea that anxiety will stay forever unless one avoids it or escapes from it

·         To facilitate this process, it is necessary to deliberately block negative reinforcement caused by avoidance

·         Client also learns competence and mastery in coping with exposure to prior, feared CS

Preparation for Exposure

·         Clinical Interview and Baseline measures:

o        With regard to psychometrics, the Posttraumatic Stress Diagnostic Scale (PDS) and Impact of Events Scale (IES) are brief, self-report measures that may be helpful in gathering baseline information.  The Clinician Administered PTSD Scale (CAPS) is an excellent interview measure, but is time consuming to administer.

·         Education and Informed Consent

o        Provide information on the treatment process, as well as a basic explanation of available outcome research, risks and benefits, etc.  Also, basic information on Mowrer’s two factor theory and how it pertains to the treatment process.

o        Anticipate some of the common assumptions people may have:

o        “First, there is the concept that anxiety will persist until escape is realized.  Secondly, the fear stimuli and/or the fear responses are associated with unrealistically high probability for either causing psychological (e.g., going crazy, losing control) or physical (e.g., cardiac arrest, sickness) harm.  Thirdly, the threat has an extremely high negative valence for the individual” (Foa and Kozak, 1986).

o        Warn that anxiety and Sx may increase at first, and that during the time between sessions the person may initially experience increased symptoms.  Make explicit that it is important to continue exposure until the client habituates, but also make sure that the client is aware that if needed she or he can stop the session.

o        Some clients have reported feeling sick before coming to exposure sessions due to anticipatory anxiety.  We warn people of this possibility and encourage them to come in anyway and offer the option of a low key, non-PE session

·         Initiate breathing retraining (client to practice breathing retraining at home)

·         Construct SUDS (Subjective Units of Distress Scale) hierarchy and a hierarchy of situations that the client is avoiding.

Initiating prolonged exposure

·         90 minute sessions, usually structured so that there is a 10 minute check in at the start of the session and at the end.  The rest of the time is focused on repeating back-to-back trials of exposure to the feared stimulus (with PTSD, usually the client visualizes and recites what happened at the time of the trauma, trying to picture the event as if were happing right in front of them)

·         Track SUDS at the end of each trial (usually asking the client for a subjective rating of 1-10)

o        Tape record the exposure portion of the session and ask the client to listen to it once during the interval between sessions

·         Continue repeating trials of exposure during a session until there is at least a 50% SUDS reduction

o        Exposure may focus on “hot spots” as it progresses

After the initial sessions of exposure, begin to phase in in vivo exposure homework assignments

·         construct a hierarchy of situations associated with the trauma that the client is avoiding, and gradually encourage the client to practice approaching them. 

o        Example: if the client fears going to a store, begin with her or him first going to the parking lot with a friend and staying until s/he habituates.  Next, go in to the store with the friend and repeat habituation.  Then, go into the store without the friend.  Each step may take several trials.

The “golden rule” of PE is to

continue exposure until the person habituates

while also preventing avoidance or distraction.

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The information posted on this site reflects our understanding of peer-reviewed research and generally accepted principles in psychology.  It is not intended to be used for self-treatment or as a substitute for individualized assessment and treatment by a licensed professional, and should not be construed as professional advice.

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