Preparing Clients for PE: First Steps

Barbara Rothbaum, Ph.D.

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

Highlights

  • The main components of PE are imaginal exposure and processing and in vivo exposure.
  • PE takes 9 to 12 sessions.
  • Enhance motivation and help the patient anticipate what therapy might be like.

 

Transcript

Hello. Welcome to our second module on Exposure Therapy Overview in Session 1. In our first video, we’re going to talk about preparation for therapy.
Prolonged exposure therapy, or PE, for PTSD includes the following treatment components: Breathing retraining for a few minutes in session 1; education about common reactions to trauma; imaginal exposure, which is the reliving and imagination to the trauma memory; in vivo exposure, which is in real life exposure to trauma reminders in between sessions; processing of themes and emotional material that emerge during 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, USA.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press, USA.

And our schedule is about 9 to 12 weekly, or twice-weekly 90-minute sessions.

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, USA.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press, USA.

In imaginal exposure, which is the primary component, patients recount the traumatic memories during the sessions out loud and repeatedly, and listen to the tape-recorded recounting between sessions. In vivo exposure involves patients confronting realistically safe trauma-related situations and reminders in real life between sessions beginning with less fearful situations and moving on up to more fearful situations.

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, USA.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press, USA.

When we’re preparing the patient for PE therapy, an important area is to enhance their motivation. Remember—and I am going to keep reminding you—that PTSD is a disorder of avoidance. So we really have to pay attention to their motivation.

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, USA.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press, USA.

One way is to identify areas of the person’s life that have been disrupted or are unsatisfying as a result of the trauma. If the trauma was recent enough that the patient can remember life before and after it, then you can assess the discrepancy between these two times of life. For example, you can ask, “What kinds of things did you use to enjoy that you can’t do anymore or that you can’t do without a lot of anxiety?” or, “Tell me about the life you want to reclaim. We will talk a lot about taking your life back from PTSD. What are some areas of your life that you want to take back from PTSD?” It’s important to identify potential gains or positive changes that will result from therapy or from reducing PTSD and the related interference. So you can ask, “What do you hope that you can do at the end of therapy or six months from now?”
We want to identify and problem solve any likely obstacles to successful therapy. So for example, difficulties attending therapy sessions, finding time to do homework. For example, if people have childcare responsibilities, finding a private time and a private place that they can practice their homework will be important. We might need to problem solve with them. For example, asking a partner or a spouse or a friend to watch their kids or identify what’s the best time of day to do homework. We don’t want people doing the homework right before they go to sleep. And I’ll keep reminding you of that 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, USA.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press, USA.

Some of the issues to discuss in preparation for PE: We want to tell people that some people may feel worse before they feel better and that these symptoms may increase before decreasing. The good news is that this is usually temporary. It’s not associated with worse outcome or even dropout. If it happens, how will it be for you? Is there anything I can do to help you tolerate this temporary worsening? Sometimes, especially if it’s a woman and they’ve had children, I’ll use the analogy that in early pregnancy when people will say, “It’s great that you’re feeling sick, it’s great that you’re feeling nauseous because that means your hormones are at the right level.” I might use that analogy that all of these feelings you’re having mean that you’re accessing what we need to access. So that’s great. But you want to find out, one, you want to anticipate it for them. And two, how’s it going to be? How can I help you through that?

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, USA.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press, USA.

We also want to have the discussion, sometimes there are aspects of people’s lives that actually change for the better after trauma. Is this true for you? If so, what do you feel you’ve gained from experiencing the trauma? And conversely, what might you lose if you get better? I’ve had a few cases, for example, in working with rape survivors that someone came into their lives. I refer to it as the white knight on a horse coming in. And very often, that might be their husband now and that they came in and kind of rescued them after the assault. But their entire relationship has been based on the patient having symptoms. And so very often, it will change the relationship if the patient has fewer symptoms or no symptoms or gets stronger in some areas. So sometimes, that’s something that needs to be discussed.

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, USA.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press, USA.

The key points from this video are that the main components of PE include imaginal exposure and processing and in vivo exposure. PE usually takes anywhere from 9 to 12 90-minute sessions and can be delivered weekly, twice-weekly, or up to daily. We advise having conversations to enhance motivation and helping the patient anticipate what therapy might be like and how to get the most out of therapy.

More PE presentations