Constructing the In Vivo Exposure Hierarchy for PTSD Therapy

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.

Highlights

  • The in vivo hierarchy should be representative, but not exhaustive.
  • Choose items that the patient can stay in long enough for their anxiety to decrease.
  • Do not include anything realistically dangerous.

 

Transcript

Video 6: Constructing the in vivo hierarchy.
There’s an art and a science to constructing the in vivo hierarchy. We want it to be representative, but it does not have to be exhaustive. We want items on it that, ideally, the patient can stay in long enough for their anxiety to decrease and/or repeat frequently enough that their anxiety decreases. We don’t want to include anything realistically dangerous. We can tweak items to achieve the desired anxiety-provoking level.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

For example, going to the mall alone might be rated as a SUDS of 80. But we might be able to break it up as follows: a SUDS of 50 might be driving to the mall with their friend, Judy, eating together at the food court. A SUDS of 60 might be Judy stays at the food court in the mall while I walk to the other end and back. A SUDS of 70 might be Judy stays in her car in the mall parking lot while I go in and shop for at least 45 minutes. And then, as we said, a SUDS of 80 is going to the mall alone.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Constructing the in vivo hierarchy. To do this, we might need to remind them of the treatment rationale. What do we want them to learn? We want to give them daily life examples of in vivo exposure and habituation. I like the example of the child being scared of the water. Say a mother and a child are on a beach vacation. They’re in the water. A wave knocks them over. The child goes underwater and it’s very scary. The child wants to get out of the water. And the next day, the child doesn’t want to go in the water because he’s scared. So a smart mama is going to not force it and do it very gradually. A smart mama might say, “Okay, that’s fine. Let’s build a sandcastle.” And then eventually for a sandcastle, you need a little bit of water. So, do you want to take this pail and get a little bit of water? So then the child only needs to go up, say, to their ankles in the water. And then after they build the sandcastle, now we need to wash off a little bit. And so the mama will take the child in, not too deep, maybe up to their knees, and just to wash off. Have fun. Play in the water. And gradually, do it like this until the child feels comfortable going back in the water.
We want to remind our patients of the Subjective Units of Distress or Discomfort Scale (the SUDS scale) and develop a list of situations that the patient has been avoiding since the trauma. You’re going to know many of these from the assessment of their PTSD, the avoided situations, and the earlier common reactions to trauma discussion. Sometimes, people don’t immediately say—if you ask them if they’re avoiding, they don’t say yes. They’ll say, “No, I’m not avoiding.” And then you can ask specific questions. How often are you going outside by yourself after dark? Are you comfortable sitting with your back to the door in a restaurant? So you can ask very specific questions. Ask the patient to rate the intensity of their anxiety, give you the SUDS level that she or he imagines would result from confronting each of the situations and staying in it long enough, so not just walking in and walking back out.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Arrange the situations in a hierarchy according to their SUDS level. I usually start with items around a SUDS of 50 and aim for increments of 10 up to 100. If the patient can’t identify circumstances, suggest some typically avoided situations or what you know about them from their assessment. You can also ask what a spouse or a close friend wishes that they could do or wants to do with them. Inquire about the actual safety of the situations. You can ask about the crime rate in their neighborhood or a trusted friend or neighbor who they think has good judgment. And if this is an issue, I’ll ask them, “Who would that be? Who’s a trusted friend or neighbor that you think has good judgment?” They’re not too foolhardy. They’re not whatever words they would use, too restrictive or too scared. Would they think this is an okay thing to do? When you’re trying to compare, some patients will bunch items together. So, for example, everything is 100. Then what you need to do is try to help them tease things apart. So, is going to the mall by yourself easier or more difficult than sitting with your back to the door in a restaurant? And you could just keep doing that comparison almost like they do at the eye doctor. Is this one easier or more difficult than this one? And then you can get a little spread.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

Items that go on the in vivo exposure hierarchy include situations, activities, places, objects… anything the person is avoiding because he perceives them as dangerous because he sees the world as dangerous. You also want to include situations that are avoided because they trigger trauma-related distressing memories or feelings. And this can be certain odors, clothing, watching the news. Usually, these are objectively safe. I think I mentioned I had a patient who was assaulted when she was wearing a yellow sweater and never wanted to wear a yellow sweater again. So that was a good item to include on the hierarchy. I had someone who wouldn’t wear white tennis shoes because she was assaulted. Many of our veterans don’t like doing things socially. They don’t like certain odors. They don’t go to barbecues because of that smell of burning meat. We also want to include activities that function as behavioral activation exercises or provide opportunities for increased social interaction, things that will help them get back into life, especially for those patients with comorbid depression whose lives have become very narrow.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press.
 
Rothbaum, B. O., Foa, E., Hembree, E. A., & Rauch, S. (2019). Reclaiming your life from a traumatic experience: Client workbook (2nd ed.). Oxford University Press.

The key points from this video. That there is an art and a science to constructing the in vivo hierarchy. We want it to be representative, but it does not have to be exhaustive. We want items on it that, ideally, the patient can stay in long enough for their anxiety to decrease and/or repeat frequently enough so that their anxiety decreases. And we don’t want to include anything that’s realistically dangerous.

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