In Vivo Exposure Therapy for PTSD: The Essentials

Barbara Rothbaum, Ph.D.

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

Highlights

  • We introduce in vivo exposure in session 2.
  • In in vivo exposure, the patient confronts safe situations in a therapeutic manner.
  • We teach them to communicate their level of anxiety with the SUDS scale.

 

Transcript

In video 5, we’ll discuss in vivo exposure, the essentials.
In vivo exposure just means that we’ll do things in real life, in vivo. We’ll help the patient confront situations that they’ve been avoiding because they’re fearful of them now or because they’re reminders of the traumatic event. We’ll help them confront these situations in a therapeutic manner so that something changes. That is very important to convey to the patient and very important for me to convey to you. Remember the example of the child who became fearful of dogs after a dog bite that we discussed earlier. If that child is presented with a dog and runs out of the room crying, it was not a therapeutic exposure. Nothing changed. We want to help them structure every exposure so that it is a therapeutic exposure.

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 that, they need to understand completely what we’re trying to accomplish and how. So we begin with the rationale for in vivo exposure.

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.

We explain that trauma-related fears are sometimes unrealistic or excessive. For example, if they used to think it was okay to go to a shopping mall but now avoid it, that might not be realistic. Their estimates of danger have increased following the traumatic event. Just a reminder here, I’m saying the traumatic event but you should use your patient’s words and call it whatever they call it, for example, the rape, the firefight in Iraq, when I was in the World Trade Center on 9/11. Also, sometimes, I refer to “he.” Sometimes, I refer to “she.” Sometimes, I refer to “they.” But obviously, you’ll individualize it for your patient.

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.

So, let me give you my five-cent lecture on behavior therapy and reinforcement. Remember that reinforcement is anything that increases the likelihood of a behavior. There’s positive reinforcement and negative reinforcement. In positive reinforcement, it increases the likelihood of a behavior by the addition of something positive. If I make delicious chocolate chip cookies and you’re coming to see me only for my chocolate chip cookies and I make them every Friday, you’re going to come on Friday and your attendance is going to be reinforced by my delicious chocolate chip cookies. Negative reinforcement increases the likelihood of a behavior but by the withdrawal of something negative. If I am anxious and I escape, that escape is reinforced because my anxiety goes down.

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.

We also explain as part of the rationale for in vivo exposure that by repeatedly putting yourself in these realistically safe situations over and over and staying in them long enough for your anxiety to decrease, the in vivo exposure will block negative reinforcement.
So by engaging in vivo exposure and in a therapeutic manner, it blocks negative reinforcement. In the example of the child, if the child is in the room with the dog, runs out crying, and feels better because he’s away from the dog, that’s negative reinforcement. We want to block that. We want them to stay with the animal and that’s why we might start with a cute little puppy that he’s not as scared of and stay with that animal long enough that his body and his brain register that there’s nothing to be scared of here.

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.

In vivo exposure also results in habituation so that the target situation becomes increasingly less distressing. Habituation is basically getting used to something. We’re not changing the stimulus but because we’re staying with it long enough, the response is decreasing.

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.

In vivo exposure fosters the realization that the avoided situation is actually safe. If I’m staying in the situation and nothing bad is happening, that’s registering maybe it’s not as dangerous as my body was acting like it was.

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.

In vivo exposure disconfirms the belief that anxiety and the feared situation will continue forever. If people get anxious and they escape, they run away and that makes their anxiety feel better. They never have the chance to learn that if they stay in the situation, their anxiety will decrease.

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.

In vivo exposure also enhances the sense of self-control and personal competence. So often when people come to see us, they feel incompetent. They feel like they’re not coping very well with life. They might say that they’re being a baby or being weak. And by engaging in the in vivo exposure, it will help them feel better and have a sense of mastery.

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.

After this discussion, we’re going to introduce the patient to the SUDS scale: Subjective Units of Discomfort or, as some call it, Subjective Units of Distress. This will take approximately five minutes. We’ll use the following explanation of the SUDS scale before beginning to construct a hierarchy of their feared and avoided situations. In order to find out how much discomfort or distress certain situations cause, we’ll use a scale that we call SUDS.

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.

It’s a 0 to 100 scale. A SUDS rating of 100 indicates that you’re extremely upset, the most you’ve ever been in your life, so panic level anxiety. And a 0 indicates no discomfort at all, maybe complete relaxation but it’s mainly a discomfort scale, so no discomfort.
Usually, when people say they have a SUDS of 100, they’re experiencing physical reactions such as sweaty palms, palpitations, difficulty breathing, feelings of dizziness, and anxiety. So 100 indicates extreme distress or anxiety. But because people are different, what makes one person feel 100 SUDS may not be troublesome at all for someone else. This is why we call it a subjective scale.

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, imagine that you and I are standing near a deep pool and someone pushes us both in the water. If I can’t swim, I may feel a SUDS level of 100 immediately. But if you can swim or aren’t afraid of deep water, you may be a 0. Have a discussion with the patient trying to get examples of different SUDS ratings. Ask if they can give an example of 100. Very often, that might be the time of the trauma. Can they give you an example of a 0? Can they give you an example of a 50? A 50 might be something unrelated to the traumatic event such as having to go see their child’s teacher at school or being called into a meeting with the boss at work. Ask, “What are you experiencing right now? Give me a SUDS rating right now in the session with me talking about this.” It’s really just a shorthand to be able to talk about the patient’s discomfort.

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.

Key points from this video. We introduce in vivo exposure in session 2 beginning with the rationale. In in vivo exposure, we help the patient confront realistically safe situations that they’ve been avoiding in a therapeutic manner so that something changes. We teach them to communicate their level of anxiety with the SUDS scale or Subjective Units of Discomfort on a 0 to 100 scale, in which 0 represents no anxiety and 100 represents panic level anxiety.

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