Learning Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians

Learn the fundamentals of prolonged exposure and help your PTSD clients overcome trauma. Earn 7 CE/CME credits.

PTSD Treatment with Exposure Therapy and Virtual Reality: Tips for Therapists

Barbara Rothbaum, Ph.D.

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

Highlights

  • The patient should remain in the exposure long enough for the distress to decrease.
  • Patients should be encouraged to use as much detail as possible.
  • Praise patients for this difficult but worthwhile work.
  • Virtual reality exposure therapy is a new effective medium for conducting exposure therapy.

 

Transcript

Video 6: Tips for Exposure Therapy
The first tip has to do with the treatment schedule and the rationale. We are presenting this program as weekly sessions. And probably around the world, that is the most frequent way that all psychotherapy is conducted—in weekly sessions. For PE, for prolonged exposure, we recommend at least 90-minute sessions to allow enough time to get into the exposure, to do the processing, to assign homework. I also really like seeing patients more frequently than that. In our veterans program, we have an IOP, an intensive outpatient program, and we’re able to see patients. We bring people in from all over the country and we see them every day for two weeks. We do an hour and a half of individual imaginal exposure and then two hours of group in vivo exposure. And people move very quickly through the memory and it’s difficult but we’re seeing great responses. And one of the best things about it is we have a very low dropout rate by doing it that frequently. Even if you can’t do it that frequently, if you can see patients twice a week or three times a week, it really helps to minimize the avoidance that some of the patients will engage in between sessions and it works to move them quickly up the hierarchy.

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.

As we’ve said before, the therapist should make appropriate comments during the exposure and encourage continued exposure until anxiety has habituated. Many of us have the things that we tend to say all the time, but we only want to say them if it’s appropriate. So, for example, if a lot of people tend to say, “See, with continued exposure, your anxiety decreases,” if that hasn’t happened to your patient, don’t say that. You want to say something that reflects reality and shows your patient that you’re really paying attention to what’s going on for them. So, if their anxiety hasn’t decreased, you might say something like, “I know you were so scared of doing this and I can see that it is hard for you and it has remained hard for you and you tolerated it. You were scared that something terrible would happen and it hasn’t. I know that it causes you a lot of distress, but you’re tolerating it and nothing bad has happened. And that’s terrific. And I do think that if we stay with this, it will get easier.” So, you want to make appropriate comments.

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.

Some guidelines for exposure therapy.

Patients should remain in the exposure situation long enough for their anxiety to decrease. I can’t emphasize this one enough. The biggest rookie mistake that I see in therapists new to exposure therapy: patient gets anxious, therapist gets anxious, and they stop the exposure. It is very common for patients when they’re doing imaginal exposure—and especially early on in treatment and sometimes throughout treatment—they will say, “I don’t want to do this. I hate this. Can I stop now?” Or when they’ve gone through one iteration and we’re asking them to go back to the beginning and start again, they say, “Really?” And they’ll open their eyes and look at us and say, “I don’t want to do that.” It’s important (1) not to engage in a discussion with the patient during exposure and (2) to encourage them to continue exposure. You can acknowledge that this is difficult, that you say this is exactly what you need to do to help it be easier for you. Don’t let them off the hook. That is not the kind thing to do. They can avoid all on their own. They’re coming to you to help stop avoiding, to help do something differently, to help make this an easier memory for 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.

The therapist should encourage the patient to use as much detail as possible—especially for the worst parts of the trauma. Some therapists I’ve worked with that are new to exposure, they feel voyeuristic and they feel almost cruel and very uncomfortable asking for this level of detail. But in the example I gave earlier, if a rape victim glosses over it and says, “And then he raped me,” that’s not doing her any favors to let her get away with that. We need to slow it down and say describe everything that he’s doing to you, describe everything that you’re feeling in your body. Use the appropriate words and whatever her words are. They can be penis and vagina. They can be dick. They can be whatever word she uses. But encourage her to describe everything that she’s feeling. I’ve had several people tell me that this is the first time that they have ever been able to go through in detail what happened to them. And I think that it is so powerful to have a human in the room with you trying to be helpful, someone who’s handling the details of what you’re saying. They’re not shocked. They’re not abhorred. And they’re letting you air it all out and say it. One of our other analogies is that it’s like mold. And when they keep the details and these memories in the dark, the mold festers. And one way to get rid of the mold is expose it to the sunlight.

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.

Patients should be allowed to progress at their own pace. And this is true, but also with an asterisk. Their pace is one of avoidance and so they’ve come to us for help out of that avoidance. So, it’s like a dance we do with our patients. As I’ve said before, I tell them I will push them outside of their comfort zone, but not outside of their safety zone. You don’t want to push them too far or too fast because then they might drop out of therapy. But you want to keep them moving because this is a pretty short-term therapy. And that’s one of the advantages. I tell people, “This is hard, but it’s best described in weeks really rather than even months. And it’s worth the investment. If you push yourself hard for these few weeks, you’re going to be able to take your life back from PTSD.”

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.

Patients should be praised for exposures completed and encouraged to push themselves further. I’ve said it before. I’m like a cheerleader in there, really getting excited when they’re doing exposures and celebrating with them when they’re able to do something that they’ve been avoiding maybe for years. And I want them to feel how happy I am for them. And also, that helps me push them because I want to help them get to that point.

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 clinician should acknowledge how difficult exposure therapy is for the patient. And you should really understand that even if some level the patient knows that it’s not as dangerous as their bodies make them feel like it is, it still feels that dangerous. It feels that scary. And they are doing it anyway. And so, we do want to let them know that we can appreciate how difficult this is. They have set their lives up to avoid this memory, to avoid these reminders. And we are asking them to do this on purpose.

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.

Therapists should gauge their responses according to the patient’s reactions to exposure. And this is similar to what we talked about earlier. It’s similar if you know about the concept of mirroring. So, we want to mirror what the patient’s experience is. If they’re doing great, we want to say they’re doing great. If they’re having difficulties, we want to acknowledge the difficulties and problem solve them with 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.

I’m going to switch now and talk very briefly about virtual reality. First, what is virtual reality exposure? Because this is a term that’s used a lot these days. It is an interactive computer environment, but it’s more than just this multimedia environment because the user experiences a sense of presence in this environment. They are immersed in this environment. So, for example, if I took a picture of a room I was in and sent it to you, you could get a sense of that room. If I took a video of that room, you could get a little bit better sense of that room. If I had that room rendered in virtual reality, you would feel present in that room. And so for that reason, that sense of presence and immersion, we thought that virtual reality would be good for exposure therapy.

References

Rothbaum, B. O., Price, M., Jovanovic, T., Norrholm, S. D., Gerardi, M., Dunlop, B., Davis, M., Bradley, B., Duncan, E. J., Rizzo, A., & Ressler, K. J. (2014). A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan war veterans. American Journal of Psychiatry, 171(6), 640-648.. https://doi.org/10.1176/appi.ajp.2014.13121625
 
Rothbaum, B. O., Hodges, L., Smith, S., Lee, J. H., & Price, L. (2000). A controlled study of virtual reality exposure therapy for the fear of flying. Journal of Consulting and Clinical Psychology, 68(6), 1020-1026. https://doi.org/10.1037/0022-006x.68.6.1020
 
Rothbaum, B. O., Anderson, P., Zimand, E., Hodges, L., Lang, D., & Wilson, J. (2006). Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavior Therapy, 37(1), 80-90. https://doi.org/10.1016/j.beth.2005.04.004
 
Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Graap, K., Zimand, E., Hodges, L., & Davis, M. (2004). Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Archives of General Psychiatry, 61(11), 1136-1144. https://doi.org/10.1001/archpsyc.61.11.1136

The hardware that we use. We ask the users to put on what’s called a head-mounted display or HMD. And that is like a helmet with straps with a television screen in front of each eye and earphones and a position tracker that just as my view changes in reality when I move my head, so it does in the virtual reality in real time. For some environments, we have a handheld sensor or joystick that allows the user to manipulate things in the virtual environment or move around. So, for example, they can push a virtual button on a virtual elevator and go up. They can drive a virtual Humvee and steer it. There’s obviously the computer and the monitor, so the therapist can see everything on the monitor that the patient is seeing in the head-mounted display, so we can comment appropriately. For many environments, we will also use something like what’s called a thunder chair. For our environments where I work, we have a raised platform and a woofer, a base speaker, a shaker, embedded underneath that platform, so they also feel the vibrations. So, for example, in the virtual airplane, they can feel turbulence. They can feel the landing gear coming up. In the virtual Iraq, they can feel the engines on of the Humvee. They can feel the explosions.

References

Rothbaum, B. O., Price, M., Jovanovic, T., Norrholm, S. D., Gerardi, M., Dunlop, B., Davis, M., Bradley, B., Duncan, E. J., Rizzo, A., & Ressler, K. J. (2014). A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan war veterans. American Journal of Psychiatry, 171(6), 640-648. https://doi.org/10.1176/appi.ajp.2014.13121625
 
Rothbaum, B. O., Hodges, L., Smith, S., Lee, J. H., & Price, L. (2000). A controlled study of virtual reality exposure therapy for the fear of flying. Journal of Consulting and Clinical Psychology, 68(6), 1020-1026. https://doi.org/10.1037/0022-006x.68.6.1020
 
Rothbaum, B. O., Anderson, P., Zimand, E., Hodges, L., Lang, D., & Wilson, J. (2006). Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavior Therapy, 37(1), 80-90. https://doi.org/10.1016/j.beth.2005.04.004
 
Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Graap, K., Zimand, E., Hodges, L., & Davis, M. (2004). Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Archives of General Psychiatry, 61(11), 1136-1144. https://doi.org/10.1001/archpsyc.61.11.1136

And virtual reality exposure therapy, or VRE, has been found to be effective for specific phobias, including the fear of heights, the fear of flying, the fear of public speaking, for substance use disorders, for PTSD, and for many others.

References

Rothbaum, B. O., Price, M., Jovanovic, T., Norrholm, S. D., Gerardi, M., Dunlop, B., Davis, M., Bradley, B., Duncan, E. J., Rizzo, A., & Ressler, K. J. (2014). A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan war veterans. American Journal of Psychiatry, 171(6), 640-648. https://doi.org/10.1176/appi.ajp.2014.13121625
 
Rothbaum, B. O., Hodges, L., Smith, S., Lee, J. H., & Price, L. (2000). A controlled study of virtual reality exposure therapy for the fear of flying. Journal of Consulting and Clinical Psychology, 68(6), 1020-1026. https://doi.org/10.1037/0022-006x.68.6.1020
 
Rothbaum, B. O., Anderson, P., Zimand, E., Hodges, L., Lang, D., & Wilson, J. (2006). Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavior Therapy, 37(1), 80-90. https://doi.org/10.1016/j.beth.2005.04.004
 
Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Graap, K., Zimand, E., Hodges, L., & Davis, M. (2004). Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Archives of General Psychiatry, 61(11), 1136-1144. https://doi.org/10.1001/archpsyc.61.11.1136

For PTSD, virtual reality exposure therapy is basically PE with their eyes open and the therapist matches what the patient is describing in the VR. So, for example, for a combat veteran who might be describing, “I’m driving the Humvee back to base. Jones is next to me. Smith is in the back seat. Rivera is in the turret as the gunner. We hit an IED on the right front. Everything fills with smoke,” we can reproduce all of that in the virtual reality. We first tried VRE for PTSD in the late ‘90s and that was with Vietnam veterans and it was helpful. And now, many people around the world are using VR for PTSD. They’re using it for World Trade Center survivors. They’re using it in Israel for terrorist survivors. As I mentioned, we use it for combat survivors.

References

Rothbaum, B. O., Price, M., Jovanovic, T., Norrholm, S. D., Gerardi, M., Dunlop, B., Davis, M., Bradley, B., Duncan, E. J., Rizzo, A., & Ressler, K. J. (2014). A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan war veterans. American Journal of Psychiatry, 171(6), 640-648. https://doi.org/10.1176/appi.ajp.2014.13121625
 
Rothbaum, B. O., Hodges, L., Smith, S., Lee, J. H., & Price, L. (2000). A controlled study of virtual reality exposure therapy for the fear of flying. Journal of Consulting and Clinical Psychology, 68(6), 1020-1026. https://doi.org/10.1037/0022-006x.68.6.1020
 
Rothbaum, B. O., Anderson, P., Zimand, E., Hodges, L., Lang, D., & Wilson, J. (2006). Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavior Therapy, 37(1), 80-90. https://doi.org/10.1016/j.beth.2005.04.004
 
Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Graap, K., Zimand, E., Hodges, L., & Davis, M. (2004). Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Archives of General Psychiatry, 61(11), 1136-1144. https://doi.org/10.1001/archpsyc.61.11.1136

I like VRE for several reasons. For example, we can exactly control the stimuli. So, actually, one of my favorite virtual reality programs is the virtual airplane for the fear of flying. And prior to VR, I kind of hated treating the fear of flying because it was such a pain to go to the airport. And if I actually had to fly with the patient, it took a lot of time. It was expensive for the patient. It was difficult feasibly to arrange. And a virtual airplane is so easy, feasibly. I can exactly control the stimuli. If my patient is not ready for turbulence, I can guarantee there wouldn’t be turbulence. When my patient is ready for turbulence, I can guarantee there will turbulence. We can take off and land as many times as we need to—all within my 45-, 50-minute therapy session and without leaving my office. In our studies, it has worked just as well as going to the airport and using a real airplane. And it’s just so much easier. It’s so much more feasible.

References

Rothbaum, B. O., Price, M., Jovanovic, T., Norrholm, S. D., Gerardi, M., Dunlop, B., Davis, M., Bradley, B., Duncan, E. J., Rizzo, A., & Ressler, K. J. (2014). A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan war veterans. American Journal of Psychiatry, 171(6), 640-648. https://doi.org/10.1176/appi.ajp.2014.13121625
 
Rothbaum, B. O., Hodges, L., Smith, S., Lee, J. H., & Price, L. (2000). A controlled study of virtual reality exposure therapy for the fear of flying. Journal of Consulting and Clinical Psychology, 68(6), 1020-1026. https://doi.org/10.1037/0022-006x.68.6.1020
 
Rothbaum, B. O., Anderson, P., Zimand, E., Hodges, L., Lang, D., & Wilson, J. (2006). Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavior Therapy, 37(1), 80-90. https://doi.org/10.1016/j.beth.2005.04.004
 
Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Graap, K., Zimand, E., Hodges, L., & Davis, M. (2004). Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Archives of General Psychiatry, 61(11), 1136-1144. https://doi.org/10.1001/archpsyc.61.11.1136

For PTSD, I like the virtual reality because it’s such a potent stimulus that I think it’s harder for the patient to avoid. And as I mentioned, we use a lot of sensory input. They can feel the vibrations. For some environments, we have the smells. The sounds are really what get people as well. So, even if they’re emotionally avoidant, it’s really hard to avoid such a potent stimulus.

References

Rothbaum, B. O., Price, M., Jovanovic, T., Norrholm, S. D., Gerardi, M., Dunlop, B., Davis, M., Bradley, B., Duncan, E. J., Rizzo, A., & Ressler, K. J. (2014). A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan war veterans. American Journal of Psychiatry, 171(6), 640-648. https://doi.org/10.1176/appi.ajp.2014.13121625
 
Rothbaum, B. O., Hodges, L., Smith, S., Lee, J. H., & Price, L. (2000). A controlled study of virtual reality exposure therapy for the fear of flying. Journal of Consulting and Clinical Psychology, 68(6), 1020-1026. https://doi.org/10.1037/0022-006x.68.6.1020
 
Rothbaum, B. O., Anderson, P., Zimand, E., Hodges, L., Lang, D., & Wilson, J. (2006). Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavior Therapy, 37(1), 80-90. https://doi.org/10.1016/j.beth.2005.04.004
 
Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Graap, K., Zimand, E., Hodges, L., & Davis, M. (2004). Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Archives of General Psychiatry, 61(11), 1136-1144. https://doi.org/10.1001/archpsyc.61.11.1136

And if you’re using it in studies, I love it for the precise methodological control. When we used it for some of the studies studying medication in addition to exposure therapy, we can make sure that every patient gets exactly the same dose of exposure therapy, that we can replicate it by patient by session. So, it offers precise methodological control.

References

Rothbaum, B. O., Price, M., Jovanovic, T., Norrholm, S. D., Gerardi, M., Dunlop, B., Davis, M., Bradley, B., Duncan, E. J., Rizzo, A., & Ressler, K. J. (2014). A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan war veterans. American Journal of Psychiatry, 171(6), 640-648. https://doi.org/10.1176/appi.ajp.2014.13121625
 
Rothbaum, B. O., Hodges, L., Smith, S., Lee, J. H., & Price, L. (2000). A controlled study of virtual reality exposure therapy for the fear of flying. Journal of Consulting and Clinical Psychology, 68(6), 1020-1026. https://doi.org/10.1037/0022-006x.68.6.1020
 
Rothbaum, B. O., Anderson, P., Zimand, E., Hodges, L., Lang, D., & Wilson, J. (2006). Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behavior Therapy, 37(1), 80-90. https://doi.org/10.1016/j.beth.2005.04.004
 
Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Graap, K., Zimand, E., Hodges, L., & Davis, M. (2004). Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Archives of General Psychiatry, 61(11), 1136-1144. https://doi.org/10.1001/archpsyc.61.11.1136

Key points from this video: The patient should remain in the exposure long enough for the distress to decrease. Patients should be encouraged to use as much detail as possible.

Therapists should praise patients for this difficult but worthwhile work. And virtual reality exposure therapy or VRE is a new medium for conducting exposure therapy that’s been found effective and engaging for patients.

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