Irene Powch, Ph.D.
Portland State University and
Mental Illness Research, Education and
Clinical Center, Northwest
June 16, 2011
Knowledge, Perceptions, and
Utilization Poll
 How many…
 Know very little about PE—just curious?
 Know enough to fear PE?
 Know enough to be enthusiastic about PE?
 Know the evidence base but have little sense of what the
process of PE is like?
 Know enough to discuss PE with veterans in a supportive,
collaborative, engaging, and motivating way…and make good
referrals?
 Consider themselves competent practitioners of PE?
Goals of Today’s Presentation
 To give you a sense of:
 How the treatment rationale is discussed with veterans in a
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supportive, collaborative, engaging, and motivating way
What goes on in PE sessions
How the therapeutic relationship is used in PE
The evidence base that supports PE as an effective treatment for
PTSD
What kinds of changes do real clients/veterans experience (videos)?
Where you can learn more
 Practical applications would include:
 For anyone who works with veterans: Ability to help a veteran
consider if PE is a good treatment choice for him/her
 For therapists: have a better sense of whether you may wish to take
the intensive training to become a PE competent therapist.
Overview
 Brief Introduction to PE
 Summary of the Evidence Base Supporting PE
 When is PE indicated?
 Deepen understanding of PE through session by
session highlights and presentation of tx rationale
 Video clips (PE sessions, Recovery Interviews)
 Resources for further learning
 Questions/discussion
What is PE?
 Prolonged Exposure Therapy (PE) is a Cognitive-Behavioral
Treatment for PTSD, developed by Edna Foa, Ph.D., Director of
the Center for the Treatment and Study of Anxiety
 8 to 12 sessions of 1.5 hour duration, with 2 hours of daily
practice and typically one phone contact between sessions.
 In the context of a supportive therapeutic alliance, the trauma
survivor intentionally approaches the trauma memory and
reminders long enough and often enough to experience a
reduction in anxiety that opens the door to new learning. The
memory and reminders lose their power to elicit a trauma
response.
Evidence for Effectiveness
 Over 20 years of research supports the effectiveness of exposure
therapy for PTSD.
 By 2000, 12 studies had tested exposure therapy. All finding
positive results; 8 of these received the highest AHCPR rating for
methodological rigor.
 Based on this, the Practice Guidelines for the International Society of
Traumatic Stress Studies (Foa, Kean, & Friedman, 2000, p79) concluded
that “exposure therapy shouldbe considered as the first line of treatment
unless reasons exist for ruling it out”
 A 2010 meta-analytic review of 13 published RCTs of PE for
PTSD (675 participants) found that the average PE treated
patient faired better than 86% of patients in control
conditions at posttreatment on PTSD symptoms.
Real World and Beyond PTSD
 PE is effective in “real world” VA clinical contexts, not only
in pristine clinical trials.
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Turek et al., J Anx Disord 2010
 PE results in clinical improvements on many dimensions in
addition to PTSD symptoms, including decreased
depression, increased quality of life, improved sleep,
improvement in reported physical health symptoms,
improved social function, and posttraumatic growth,
including increased sense of new possibilities and personal
strength.
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Powers et al., Clin Psych Review, 2010; Hagenaars et al., JTS, 2010; Rauch et al. Depr &
Anx 2009
How Does PE Work?
 Theoretical base: Emotional Processing Theory (Foa & Kozak,
1986).
 PTSD emerges due to development of a pathological fear structure
concerning the traumatic event. (Includes representations about
stimuli, responses, and their meaning)
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Foa & Kozak, 1986; Steketee & Rothbaum, 1989
 Attempts to avoid this activation result in avoidance sxs
 Fear reduction requires activation & integration of corrective
information. Repeated imaginal approach in the context of a
therapeutic, supportive setting:
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1. promotes habituation & corrects belief that anxiety lasts forever
2. blocks the short term reward of avoidance
3. promotes realization that remembering is not dangerous
4. helps survivor differentiate the trauma from the rest of the world
5. sense of personal incompetence becomes sense of mastery
How Does PE Work?
 Theoretical base: Emotional Processing Theory (Foa & Kozak,
1986).
 Reminders of the trauma trigger distressing thoughts and
feelings, including a “fight/flight/freeze” response even when
there is no current danger.
 Escape and avoidance behaviors develop to obtain temporary
relief that serves to maintain PTSD.
 By intentionally approaching instead of avoiding safe
reminders—and staying long enough for anxiety to decrease,
new learning happens: The memory is not dangerous! The
reminders are not dangerous! Anxiety does not last forever! I
can conquer the memory! I am competent!
When Is PE Indicated?
 Before First Session: Assessment
 Is PTSD the primary problem?
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PCL, CAPS, BDI, PCI, chart review & psychiatric interview
 Are there significant more urgent or treatment
interfering problems that need to be addressed first or
simultaneously?
 Any current situation or condition that poses imminent
danger or interferes with ability to engage reliably in
outpatient treatment.
Fine Tuning: PE vs. CPT/CPTC?
 Both therapies have a strong evidence base. There is not
yet sufficient research to guide treatment matching.
 Considerations that may favor PE:
 Client resonates strongly with the rationale behind PE and
believes PE is the more direct approach that s/he needs
 Therapist is more comfortable/competent with PE
 Fear (fight/flight/freeze) is the predominant emotion that is
triggered by trauma reminders.
 Client has enough memory of one of the traumas that causes
their PTSD symptoms to form a narrative.
 Client is highly motivated to “de-commission” triggers that
are avoided and get in the way of enjoying highly valued
activities.
Fine Tuning: PE vs. CPT/CPTC?
 Considerations that may favor CPT:
 Client resonates strongly with the rationale behind CPT
and believes that s/he needs to change his/her thinking
before changing behavior.
 The client has complete amnesia for the event.
 Therapist is more comfortable/competent with CPT
 The distress is driven by something other than
fear/horror/helplessness (for example, overwhelming
shame at the thought of exhibiting fear; guilt about
perpetration or other complications that block fear.)
Session 1
 Engagement through Trauma Interview
 Treatment Rationale round one (general)
 Skill-the gift of breath
 Practice assignment—breathing, listen to tape
Session 2
 Supportive and motivating review of practice (breath)
 Engagement through discussion of common reactions
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to trauma
Treatment rationale round 2 (in vivo)
Collaborative setting up SUDS & in vivo hierarchy
Collaborative planning of in vivo practice; continue
practice breathing, listen to tape
Between session planned check-in call
Session 3
 Reassuring & helpful review of in vivo practice
 Engagement through treatment rationale round 3
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(imaginal)
First Imaginal Exposure (clinician is a reassuring presence,
does not interfere with processing)
Reassuring and affirming debrief
Practice assignment—continue practice breathing, in vivo
exposure, and add imaginal exposure, listen to tape
Between session planned check-in calls as needed
Intermediate Sessions
 Reassuring & helpful review of in vivo & imaginal
practice
 Supportive, socratic questions regarding “gaps” or other
puzzling incongruencies; collaboratively identify “hot
spots”
 Gradually move imaginal exposure in on “hot spots”
 Practice assignment—continue practice breathing, in
vivo exposure, and add imaginal exposure, listen to
tape
 Between session planned check-in call
Final Session (usually near 10)
 Celebratory review of in vivo and imaginal exposure
work and progress made
 Drop in SUDS and PCL scores
 Review and celebrate addition of many enjoyable
activities that veteran previously was unable to do at all
 Make suggestions for continued practice; plans for
future
Videos
 10 minute segment of PE
 10 minute segment of PE recovery interview
More from Our Clinic
PrePost (change on the PCL)
62 38
72 32
54 24
55  26
56 33
80  40
40 27
65 45
60 42
70  25
42  19
60 32
(24)
(45)
(30)
(29)
(23)
(40)
(13)
(20)
(18)
(45)
(23)
(28)
* From almost completely isolated to going back to
school to become a paramedic; faced a situation
similar to major trauma (burn victims) and slept
like a baby the following night.
* From unable to stand out on back porch at night
to enjoying walks at night in safe neighborhood.
* From almost completely isolated to going out
to concerts with friends.
* Finally able to enjoy grandkids, wife, travel.
Resources for Further Learning
 Handout
 References for clinical manuals and patient manuals for
PE and related evidence-based treatments.
 References for reviews of the evidence base and key
studies.
 Websites for continuing education related to effective
treatments for PTSD
Discussion
 Questions and discussion from the audience