Using PE to Overcome Fear: 4 Cornerstones

Barbara Rothbaum, Ph.D.

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

Highlights

  • Using PE to help patients overcome their fear successfully is rooted in several cornerstones:
  1. A firm grounding in the conceptual model of treatment.
  2. A strong, collaborative therapeutic alliance.
  3. A clear and convincing rationale.
  4. An effective implementation of exposure techniques.

 

Transcript

Welcome to video 7, Laying the Groundwork for Treatment.
It’s difficult, really difficult for people with PTSD to confront situations that provoke fear. Usually, prior to seeking professional help, they have tried to face their fears and failed, or they avoid to the point that their lives have become very narrow. I had one veteran who said he moved a little mini fridge into his bedroom. He said now he doesn’t even have to leave his room to eat.

Reference

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.

Using PE to help patients overcome their fear successfully is rooted in a foundation that has several cornerstones. And that’s what we’ll discuss in this video.
One is a firm grounding in the conceptual model of treatment underlying exposure therapy. Two is a strong collaborative therapeutic alliance. Three is a clear and convincing rationale for treatment. And four, effective implementation of the exposure techniques, which is addressed throughout the PE manual and throughout this course.

Reference

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 conceptual model: we’ve mentioned that that’s emotional processing theory. We’ve talked about that. And a clear understanding of this model is extremely important when implementing this therapy. This understanding will aid the therapist in anticipating the course predicting how the patient is going to respond and make more progress during treatment. It’ll help guide the therapist in making decisions when they’re presented with choice points or new and unusual problems and allow the therapist to track the patient’s progress and determine when the work is done.

The therapeutic alliance is a critical component of any therapy. And in PE, it can be promoted in a number of ways.
It’s important for the therapist to acknowledge the patient’s courage in choosing a therapy designed to help them face and overcome strong negative emotions and avoidance. I use courage and I tell patients about it. I don’t use it loosely. Courage is doing something in the face of fear, being scared and doing it anyway. It’s important for the therapist to align themselves with the patient in supporting this effort. We align with our patients; that it’s me and you against the PTSD. It’s not me trying to force you into something. It’s not you trying to talk me out of it. It’s us working together against the PTSD. We want to help them take their lives back from PTSD.

Reference

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.

It’s important for the therapist to be nonjudgmental and comfortable when the patient is describing his or her traumatic experience. We’ve had patients express such relief at being able to tell someone, to tell the therapist their stories and being met with calmness, acceptance, and support. I always try to teach my therapists no puppy dog eyes. Our patients don’t need us to look at them with pity. No shock, no disgust, no boredom. We want to be real humans. We want to respond compassionately, but we don’t want our patients to worry about our responses. It’s important to listen closely to the patient, to use specific examples, and always use the patient’s own words when they’re describing their fears and symptoms and when we’re presenting the education and treatment rationale. This helps the patient to feel that he or she is understood and you’re tailoring the treatment to his or her unique situation.

Reference

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.

It’s important to demonstrate knowledge and expertise about PTSD and its treatment and express confidence in the efficacy of PE and in your ability to implement it effectively. They need to know that we can handle it, we can handle everything they say, and that if they do what we say, it’s going to get easier.
For a lot of new therapists to PTSD, they don’t have the experience. They haven’t seen it work as many times, for example, as I have. And so we encourage you to channel our confidence and the power of the technique in you and your patient’s ability to be successful.

Reference

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.

You always want to be active and positive in encouraging the patient to attend sessions, learn these skills, and practice them for homework. It’s important to be truly collaborative in constructing the in vivo hierarchy, selecting trauma memories for imaginal exposure, and making decisions about the focus and pace of treatment. You guide the patient and make recommendations, but you should always incorporate what the patient is telling you. It’s a dance. Maybe the therapist is leading it, but it’s a delicate dance.
Finally, through all stages of therapy, it’s so important to provide abundant support, encouragement, and positive feedback. Good PE therapists are cheerleaders for their patients and help their patients feel proud of their efforts and accomplishments.

Reference

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.

Key points from this video include using PE to help patients overcome their fear successfully is rooted in a foundation that has several cornerstones, and these include a firm grounding in the conceptual model of treatment underlying exposure therapy, a strong collaborative therapeutic alliance, …

…a clear and convincing rationale for treatment, and an effective implementation of the exposure techniques.

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