Learning Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians

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Last Updated Nov 7, 2022|

Self-Care for PTSD Therapists: Developing Tolerance for Patient Distress

Barbara Rothbaum, Ph.D.

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

Highlights

  • It is healing and liberating to say aloud the worst, and having another person witness and accept it.
  • Helping a patient to emotionally process traumatic events can be challenging and difficult.
  • Therapists need to increase their tolerance for patient distress.

 

Transcript

Video 8, Tips for the Therapist: Caring for Yourself.
Our experience as therapists, trainers, and supervisors has taught us that even experienced therapists are at times concerned about using PE procedures with highly distressed PTSD patients. My first session of exposure therapy with every PTSD patient, I’m a little bit anxious too because I don’t know how they’re going to respond. Once we have that first session and I know how they’re going to respond, my anxiety decreases. As any therapist who’s had to listen to painful and horrifying experiences can attest, helping a patient to emotionally process traumatic events can be challenging and emotionally difficult even when we’re rewarded by seeing the benefits of effective treatment.

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.

In order to conduct PE, therapists sometimes need to develop their own tolerance and increase their own tolerance for patient distress. These procedures trigger an intense emotional response and indeed that’s the purpose of the work. We want that. But how can therapists cope with these reactions in patients? How do you manage your own reaction to hearing such graphic and painful experiences?

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.

First and always, let the model guide you. At the same time that we’re helping patients to learn that intense anxiety and emotional engagement with painful memories can’t hurt them as their original trauma did and that anxiety does not last indefinitely, we also have to trust this fact for ourselves. Developing tolerance for patient distress requires that we accept, that the therapist accepts the rationale for treatment and especially the idea that memories can’t hurt the patient. It’s typical for the therapist to habituate to the trauma memory along with the client over the course of treatment. I have heard stories that at the beginning of treatment I thought, “Oh my gosh, could I have survived this? Is this patient going to get better,” and then it’s painful for me to hear their stories and the pain in the room is so palpable that it’s almost like I can feel their broken heart in my hands. And then they get better. And so I know the power of this technique. Nonetheless, conducting PE at times is emotionally challenging and can have difficult choices for the therapist. We always want to allow the model to guide these decisions.
We need to keep in mind that although emotional processing is painful work for most patients, it’s so beneficial. You might need to remind yourself this as often as you’re reminding your patient. We often talk when I’m training therapists about the parallel process. Just as I said, I’m a little anxious before I start PE with a new patient. Obviously, the patient is anxious. They feel better after that first session. I feel better after that first session. We need to remind them that emotional processing is painful, but that’s how they get to the other side of the pain. We might need to remind ourselves 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.

Some therapists new to PE have described being uncomfortable pushing their patients to recount these horrific events when they say they don’t want to. For example, one patient in a therapist I was supervising, the patient had survived incest. He said he wanted to stop the imaginal exposure. By the way, it’s very often that patients in the middle of exposure will say something like, “I can’t do this, I want to stop, I don’t like this.” And the therapist in this case struggled with whether it was appropriate, as the therapist said, to force him to continue just like his father did. This was such an important point for us to discuss in supervision. Our view is that the patient’s avoidance has not worked, that the patient consented to treatment with exposure with full informed consent and it’s the therapist’s responsibility to stay the course and help him do what he hasn’t been able to do on his own. The therapist agreed, encouraged the patient to continue the exposures, and the patient thanked him at the end of treatment saying that was exactly what he needed.

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.

We’ve also heard some novice therapists say that they feel voyeuristic pushing for intimate details and pushing for all of the gory details. But we’ve also had patients tell us that this is the first time that they’ve been able to say exactly what happened. I’ve had a number of rape survivors tell me that even though they went to rape crisis centers afterwards that this is the first time that they’ve been able to tell someone exactly what happened to them. And I think there’s something inherently healing and liberating about saying aloud the worst, most shameful moments of one’s life and having another person witness and accept it for what it is. We encourage you to give your patients this gift.

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.

Decision making should also be guided with the goal of promoting the patient’s sense of control. While our job is to make recommendations, we never try to compel or pressure unwilling patients to do exposures. A difficult decision we sometimes have to face is whether to encourage the patient to continue therapy or to help him terminate therapy if he’s not ready to confront the trauma-related fears and avoidance. If the patient isn’t engaging in trauma-focused treatment, my opinion is it’s better to have him stop early rather than have him fail to get better and leave treatment thinking that PE didn’t work and didn’t decrease his symptoms, or that he failed treatment, or that he’s hopeless and nothing can help. We’ll often tell the patient that PE is very effective for most people, so we would rather them stop now and know that he hasn’t finished and invite him to come back when his circumstances change now that he knows what will be required.

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.

Supervision with an expert or consultant with peers can be beneficial and can provide technical and emotional support. What we usually recommend is learning PE and then having someone supervise, or a consultant, on the first two full cases of PTSD. Ideally, having a team or supervision group that meets regularly to discuss trauma-related cases is very helpful. Regular consultation provides opportunities for input from colleagues regarding difficult decisions and how to proceed with these often complex and challenging cases.

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.

The key points from this video are that there’s something inherently healing and liberating about saying aloud the worst, most shameful moments of one’s life and having another person witness and accept it for what it is. We encourage you to give your patients this gift. As any therapist who has listened to a patient and their horrifying experience can attest, helping a patient to emotionally process traumatic events can be challenging and emotionally difficult even when we’re rewarded by seeing the benefits of effective treatment. In order to conduct PE, therapists sometimes need to develop or increase their own tolerance for patient distress.

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