Increasing Emotional Engagement in PE Therapy for PTSD: Addressing Under-Engagement and Homework

Barbara Rothbaum, Ph.D.

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

Highlights

  • Under-engagement is one of the biggest obstacles to exposure therapy.
  • Procedures to increase engagement include keeping their eyes closed, using the present tense, and probing for details.
  • Anger can get in the way of effectively processing trauma.
  • Homework completion and compliance are associated with better outcomes.

 

Transcript

Welcome to Video 5: Under-Engagement, Anger, and Homework Compliance.
There are a few ways that you can recognize and identify under-engagement.
If the patient has difficulty accessing the memory. And one way to see this is if they are consistently reporting low SUDS, Subjective Units of Discomfort or Distress, if they seem emotionally disconnected or detached from the memory, if they report difficulty visualizing the event, and if they rush through their revisiting.

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.

You can also identify under-engagement if there’s a discrepancy in the reporting of their SUDS and what you’re observing. For example, if they describe the trauma in detail but report low SUDS during the revisiting or if they report high SUDS during imaginal revisiting, but they appear not so distressed. So, their appearance is discrepant with the high rating. You also want to be on the lookout for under-engagement if their narrative sounds like a police report—that basically they go into what I call reporting mode. It’s kind of a flat, affect-less reporting of the incident that would be similar to how a police report would read.

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.

There are several ways to address under-engagement. We usually start with reiterating the rationale, why it’s essential that the patient understand why he or she is being asked to confront this painful memory. Explore the feared consequences of engagement with the memory. For example, I’ve had some people tell me they feel like if they start crying that they may never stop. I’ve also had people tell me that they feel like—especially if someone died—that if they get over it and it gets less distressing that they feel like that wouldn’t be honoring the person’s memory. So, it’s important to address any of these feared consequences of engagement with the memory.

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 want to validate the patient’s feelings, but at the same time, help him or her realize that being distressed is not dangerous. Always we want to avoid conversations during the revisiting. Conversations reduce the emotional engagement with the memory and it reinforces avoidance. So, when they’re doing the imaginal exposure, keep them in the imaginal exposure. And if you really need to say, “We can talk about that after exposure,” you can say that much.

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.

There are a couple of ideas and procedures that can increase the emotional engagement. This is why we ask people to keep their eyes closed and use the present tense because this increases emotional engagement.

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 therapist can probe for details about bodily sensations, feelings, and thoughts with brief questions using the present tense. For example, “How does it smell?” “What are you feeling?”

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.

Keep these probe questions very brief, infrequent, and directed only at what the patient is describing at that moment. You want to enhance it, not distract them. If needed, you can role-play the proper procedure for the patient to demonstrate the way trauma recounting should be done, what it should look like. Remember they don’t know what they’re doing. They don’t know what you’re asking of them.

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.

What about anger? We see a lot of anger with PTSD.

And in addressing that, first, we want to validate the valid. Most people with PTSD obviously have been in a dangerous situation. They have been in a situation that probably should never have happened and maybe in which they were wronged. You want to normalize anger in the context of PTSD and as a reaction that comes up during emotional processing of trauma. I often see people go through different emotions as they move through exposure and processing, much like the grief reaction of denial, anger, bargaining, depression, acceptance, but obviously not always in that order or all of them.

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.

You can discuss the usefulness of anger, how it helps, how it protects, how it propels us to act, but also discuss the ways that anger may be unhelpful, how it gets in the way, hinders, keeps the patient stuck, keeps them from getting what they want. For some people, it’s easier to feel anger than fear.

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.

And explain that anger, although it’s valid and maybe justified, can get in the way of effectively processing the trauma. It can keep the person from accessing the fear and the vulnerability.

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.

I sometimes see anger as a round room with no way out and I’ll use that analogy with patients. In that case, I’ll ask if they want to feel less angry. Sometimes, they don’t. Then I’ll ask, what would they need to decide to feel less angry? I might suggest that the person put aside or step around the anger or try to use it to allow themselves to emotionally process the trauma. And explain that if they decide to let go of the anger, it doesn’t mean that what the person did was okay or not bad. It just means that they recognize that the anger they’re carrying isn’t useful to them. It’s costing them. It’s a burden to carry. And now, it’s getting in the way of getting better.

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.

You can work on ways to do this as needed. Feel free to get creative. Sometimes, I’ll use metaphors or if the patient already has a metaphor. Sometimes, we’ll have a wall and we can knock out bricks in the wall. Anything that seems to work and get the message across.

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.

Now, let’s talk about homework, homework compliance, and outcome.

There’s been a meta-analysis of homework in cognitive behavior therapy studies that showed that homework assignments are related to better treatment outcome and high homework compliance is related to better treatment outcome. Other studies have found that patients of more experienced exposure therapists do more homework than patients of less experienced therapists.

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.

Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7(2), 189-202. https://doi.org/10.1093/clipsy.7.2.189

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.

Bottom line: the more they practice for homework, the better they’ll get and the faster they’ll improve.

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.

Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7(2), 189-202. https://doi.org/10.1093/clipsy.7.2.189

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.

What are some things you can do to facilitate the homework compliance? One is you can reiterate the rationale. Again, they must understand why they’re being asked to do homework. Find out what’s getting in the way. Is it organization? Did they lose their sheet or forget? Are they practical issues? Do they have no time or no privacy? Or is it avoidance? And your intervention will be guided by the nature of the compliance problems and what’s getting in their way. I will often ask them if they use the calendars on their phones or computers and enter the homework into their calendars to remind them. And I ask them to put in reminders as well.

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.

Ask about their homework at the beginning of every session. If you don’t ask about it, they’ll stop doing it. If they’ve done it but didn’t record it on the homework sheets, I’ll ask them to recreate it at the beginning of the session filling out the homework sheets. I also remind them that the more homework they do, the faster they can stop seeing me.

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: Under-engagement is one of the biggest obstacles to exposure therapy. Procedures to increase engagement include keeping the eyes closed and using the present tense and probing for details.

Anger, although valid and justified, can get in the way of effectively processing trauma. Keep emphasizing homework completion and compliance throughout treatment. It’s associated with a better outcome.

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