Some of us at Portland Psychotherapy have a new article that was just published in the September 2013 issue Journal of Contemporary Psychotherapy. This has been a 2-3 year work in progress, so we're super excited to see it in print.
It came to fruition from my ongoing interest in the use of exposure in Acceptance and Commitment Therapy.
Here's the Abstract:
Exposure is considered one of the most effective interventions for PTSD. There is a large body of research for the use of imaginal and in vivo exposure in the treatment of PTSD, with prolonged exposure (PE) therapy being the most researched example. Acceptance and commitment therapy (ACT) has sometimes been called an exposure-based treatment, but how exposure is implemented in ACT for PTSD has not been well articulated. Although support for the use of ACT in PTSD treatment is limited to a handful of case studies and open trials, research suggests ACT is particularly useful in flexibly targeting avoidance behavior—arguably the most important process in the continued maintenance of PTSD symptoms. The purpose of this paper is to explore the use of exposure within ACT in PTSD treatment. Through an overview of PE and ACT, and with the use of case examples, we describe how ACT principles and techniques may inform exposure-based treatments for PTSD in order to create more flexible approaches. In addition, understanding exposure within an ACT framework may also contribute to clarifying processes of change.
If you'd like a copy of the article, feel free to email me: bthompson [at] portlandpsychotherapyclinic [dot] com
Back when I was a psychology intern at the Portland VA Medical Center, I did my first rotation on the PTSD team. As part of the rotation, I helped out with or observed group-based treatments for PTSD. One of the cardinal rules of PTSD groups at the VA was: don’t let anyone describe their trauma, as it can trigger the other veterans.
This seemed like sound advice. Even talking abstractly about trauma was intense for many veterans. There were moments when I could feel the collective anxiety of the room rise when a veteran came close to talking about the details of his trauma. Even in a Cognitive Processing Therapy group I attended, the actual trauma narrative was only talked about with a therapist outside the group. No one talked about the details of the trauma. Describing a core trauma in a structured way is a form of exposure therapy (i.e., imaginal exposure), and this is typically done very carefully with an individual therapist.
For these reasons, I was intrigued when I came across a newly published study about an ongoing program at the Atlanta VA Medical Center that breaks this cardinal rule.
Group-Based Exposure Therapy
Talking about trauma in this group is not done lightly. In this program, 10 veterans with combat-related PTSD met for 3 hours twice a week for 16 weeks. The first 3 weeks involved building cohesion among group members. Group members learned about PTSD, practiced coping skills, and were required to give two 30 minute presentations on their lives before combat. They were also required to make telephone calls to each other outside of group, and were even supplied ice breaker questions, in order to build closeness.
The next 10 weeks involved talking about combat experiences and trauma in group. This was the exposure component. Veterans were required to give two presentations:
1.) a longer presentation on their war experiences from entering the war zone until the end of their tour;
2.) an hour-long presentation on their one or two most traumatic experiences.
The group leaders recorded these presentations and asked the veterans to listen to their own presentations at least 10 times each outside of group. In keeping with rapport building, one veteran signed up to present while another signed up to bring lunch to all the veterans.
The last 3 weeks (called “close the wound phase”) involved a number of techniques and activities to help bring some closure to the group.
How Well Did the Veterans Tolerate Treatment?
Perhaps the most impressive finding: out of three cohorts of 10 veterans—no one dropped out! Attendance was nearly 100% for the war trauma presentations, and no one indicated they found the presentation harmful. Although it’s worth noting that participants were carefully screened and asked to make a strong commitment, this is still pretty impressive. In the Discussion section of the article, the authors note that of the 267 people who have participated in the program so far, only 11 (4%) have dropped out, and these dropouts were largely due to health and financial reasons.
At the end the treatment, 73% of participants exhibited significant reductions in PTSD symptoms, and 36% no longer met PTSD criteria (at least according to a brief self-report measure). Additionally, 44% showed decreases in depression. Gains were maintained at a 7-9 month follow-up. The number of times group members listened to the audio recordings of their trauma presentations outside of group was positively related to improvements. Because of this latter finding, the authors write that they’ve increased the number of times they ask participants to listen to their recordings.
What About In Vivo Exposure?
As I mentioned above, talking about a trauma experience is what’s known as imaginal exposure. A common complement to imaginal exposure in exposure-based therapies for PTSD (e.g, Prolonged Exposure therapy) is in vivo exposure. In vivo exposure involves engaging experiences that tend to trigger PTSD symptoms (e.g., crowds, war movies). In Vivo exposure is absent in this particular program. This in itself is not a problem, but there is some evidence that in vivo exposure improves outcomes for PTSD above and beyond imaginal exposure alone (DeVilly & Foa, 2001; SalcIoglu et al., 2007).
A Qualified Success
What’s most impressive about this study is that it shows how a group treatment that breaks the rule about openly talking about trauma can be not only effective, but can have incredible rates of attendance when carefully and sensitively structured. At 32 total sessions total—twice a week meetings for 4 months—and outside assignments (e.g., listening to the trauma recording, preparing presentation), Group-Based Exposure Therapy is quite a time-commitment. Whether the outcomes justify it compared to briefer group treatments for PTSD (e.g., Cognitive Processing Therapy for groups) is another question. Regardless of the answer, I think the design of this group is an extremely inspiring achievement.
This post is the first part of a series on using exposure in Acceptance and Commitment Therapy
Within the Acceptance and Commitment Therapy (ACT) literature, there’s a core concept called experiential avoidance. Experiential avoidance was arguably the lynchpin in ACT theory in the early days of ACT. The theory has been broadened since then.
Experiential avoidance is a basic umbrella terms for all sorts of avoidance behavior that people use to deal with all sorts of private experiences (e.g., thoughts, emotions, bodily sensations). Attempts to block out, reduce, or change these experiences are all forms of experiential avoidance. Behaviors associated with experiential avoidance include disputing thoughts, using substances (e.g., alcohol), and escaping or avoiding uncomfortable situations.
Everyone engages in some experiential avoidance on a daily basis. Less problematic examples include putting on sweater when it’s cold, turning on a light switch when we enter a dark room, or mindlessly perusing the internet when we feel listless. Experiential avoidance becomes a problem when it is applied rigidly and inflexibly, and when it gets in the way of what’s important to us.
One of the clearest examples of experiential avoidance is how it functions in people with posttraumatic stress disorder (PTSD).
Experiential Avoidance and PTSD
As you might imagine, people with PTSD engage in a lot of experiential avoidance. In fact, avoidance behaviors are one of the core cluster (C) of symptoms for a PTSD diagnosis. There’s a large body of research suggesting that experiential avoidance plays a big role in maintaining PTSD symptoms over time. For example, experiential avoidance predicts PTSD in adult survivors of childhood sexual abuse more than the severity of the abuse itself (Batten, Follette, & Aban, 2002; Rosenthal, Hall, Palm, Batten, & Follette, 2005).
Here are some possible reasons experiential avoidance may result in PTSD symptoms.
Reason 1: Avoidance leads to more of what the person wants avoid
Dostoevsky famously challenged his brother to not think of a white bear.
Can you do that? Can you not think of a white bear?
As you can imagine, trying not to think of something is really hard. Decades of research on thought suppression (e.g., Wenzlaff & Wegner, 2000) have shown that the very strategy of suppressing a thought tends to lead to more of the very thought the person is trying to avoid.
For people with PTSD, the result is that avoiding trauma-related internal experiences results in more of those very experiences over time. For example, in survivors of motor vehicle accidents, those who attempted to avoid thinking about the accident showed greater PTSD symptom severity (Mayou, Ehlers, & Bryant, 2002; Steil & Ehlers, 2000).
Part of what maintains this tendency to avoid PTSD-related thoughts and feelings is probably a momentary sense of relief that comes from suppressing those thoughts and feelings. Unfortunately, this moment of relief becomes increasingly insignificant when compared against the long-term consequences of avoiding trauma reminders. As trauma reminders recur, avoiding them becomes a major focus on the person’s life. Other life goals and values get neglected and avoidance gains more and more influence of the person’s life.
Additionally, as people begin to avoid more and more experiences, even neutral stimuli can become reminders of the trauma. For example, a person may avoid a particular alley in which he was attacked. Over time, the person may avoid all alleys. Features of the alley, such as red brick, similar to what lined the alley, or even the experience of closed spaces, may become linked to the trauma if they are continually avoided. Only through maintaining contact with these stimuli can one learn or re-learn that these stimuli (e.g., bricks, enclosed spaces) do not need to be avoided.
Reason 2: Some avoidance behaviors increase the risk of further painful experiences
The potential for danger increases significantly when a person spends time abusing drugs and alcohol, having unprotected sex with people they hardly know, or engaging in daredevil activities. People with PTSD often do things like this to block out the trauma, putting them at risk for further harm (Chapman, Gratz, & Brown, 2006; Polusny & Follette, 1995). Actions such as substance use, overeating, and staying home from work can lead to painful consequences in the short-term and across time.
Please be clear: I don’t mean that people should be blamed for this pattern. The horrifying images involved in PTSD and painful feelings can easily overwhelm people’s ability to cope and people understandably turn to behaviors that bring relief. Unfortunately, strategies that decrease pain in the short term (such as those above) may actually lead to more suffering in the longer term.
Reason 3: People may lose out on helpful experiences
In addition to avoidance leading to harmful experiences, someone who chronically avoids may lose contact with experiences that are potentially helpful. The more time people spend avoiding events, memories, feelings, and thoughts, the smaller and narrower their lives become. This reduces contact with positive experiences over time, and it stymies valued and meaningful living. As behavioral activation research for depression has suggested (e.g., Kanter, Busch, & Rusch, 2009), it’s very important for people to be engaged in a variety of enjoyable and personally meaningful activities.
When avoidance becomes the norm, people lose contact with sources of positive reinforcement and reward. This might include relationships, exercise, hobbies, and other interests. Over time, someone’s life may become increasingly narrow (e.g., staying inside much of them time). In the absence of other enjoyable and meaningful experiences, someone’s range of activity may become so small, that all she has left is what is being avoided (e.g., trauma).
ACT and Experiential Avoidance
Nowadays, it’s more common to hear ACT therapists talk about “increasing psychological flexibility,” but in the not-so-distant past, the focus was on decreasing or undermining experiential avoidance. ACT theory and technology were specifically developed to target experiential avoidance.
ACT has a number of interventions and techniques that focus on helping people contact stimuli that are typically avoided: thoughts, emotions, bodily sensations, meaningful goals, and activities. ACT has been called an exposure-based treatment (e.g., Luoma, Hayes, & Walser, 2007); however, you could also consider exposure as one technique among many used by ACT therapist to reduce experiential avoidance and expand behavioral repertoires.
ACT is less procedural than other treatments, and, therefore, harder to manualize. Because ACT has so many methods for targeting experiential avoidance, though, ACT offers therapists an array of tools to use for conditions (e.g., PTSD) where exposure-based approaches remain the gold standard.
At this writing, there is little written guidance about how to use exposure in an ACT. People are talking about it, and giving workshops about using exposure in ACT, but it remains new territory.
This series of posts focuses on how therapists can use exposure in an ACT context to undermine experiential avoidance in people with PTSD.
I will mainly organize the posts according to ACT-specific processes. My hope is that the series will offer clinicians some practical guidance on using exposure-based interventions in an ACT-influenced way. Additionally, it is my aspiration that even non-ACT clinicians will find these posts helpful in expanding their understanding of clinically significant processes of change and range of potential clinical interventions.
When I was delving into the trauma literature for my dissertation several years ago, I noticed a study that—while not particularly relevant to my needs at the time – offered an intriguing finding. Bodkin, Pope, Detke, and Hudson (2007) found equivalent rates of PTSD symptoms between individuals who did (78%) and did not (78%) report a history of trauma. That is, a significant portion of their sample (who had major depression) similarly exhibited symptoms for PTSD, regardless of whether they had had been exposed to a trauma or not.
This was the first time I became aware of an ongoing controversy relating to how PTSD is diagnosed. In our current nosology (as defined in the DSM-IV), a PTSD diagnosis requires a person to have experienced a traumatic event--Criterion A, defined as threat of injury or death to self or others. However, some data seem to indicate that people can can experience PTSD-like symptoms even in the absence of an identifiable Criterion A trauma (as defined by the DSM-IV). There is a large group of proponents who think this reveals a deep flaw in our diagnostic critera for PTSD.
For a brief summary of this controversy, check out, Rosen, Spitzer, & McHugh (2008; click on this link for the full pdf). As I’ve written about in a previous post, the current task force is considering tightening up the criterion A definition of what is considered a traumatic event.
I bring all this up now because the controversy has reached the popular press. In an April issue of Scientific American (reprinted online in May), Scott Lilienfeld and Hal Arkowitz provide a brief, readable summary of these concerns in their article, “Does Post-Traumatic Stress Disorder Require Trauma?”
This is an issue that can be easily misinterpreted by the public. Critics of diagnostic criteria of DSM are not suggesting that PTSD does not exist; rather, the concern is that our understanding of PTSD and the criteria we use to diagnose it are seriously flawed.
I look forward to watching how this debate plays out in the revision process for the DSM-V.
Back when I was a psychology intern at the Portland VA Medical Center, the majority of the veterans I worked with were Vietnam era. Veterans from the wars in Afghanistan and Iraq were trickling in, but were not a large presence yet. I’ve heard that’s changed in the last few years, and the Veteran’s hospitals are serving increasing numbers of younger vets.
A new study by Yoder and colleagues looks at whether there’s a difference among veterans in response to treatment for PTSD. The treatment is Prolonged Exposure (PE) therapy, an empirically-supported exposure-based therapy for PTSD. The study compares veterans of Vietnam, the Gulf War, and what are known as OEF (i.e., “Operation Enduring Freedom” aka the war in Afghanistan), OIF (i.e., “Operation Iraqi Freedom”), and OND (i.e., “Operation New Dawn” coined to indicate the shift from combat to stabilization in Iraq).
What Did They Look At?
Conducted at the VA Hospital in Charleston, SC, the researchers used archival data to test their hypotheses. What this means is that the study was not originally designed to answer the questions posed. This in itself is not a problem, but it means that the results should be taken with a bit more caution until replicated.
The study looked at veterans who completed PE for PTSD. There were 112 participants total: 61 OEF/OIF/OND; 34 Vietnam; and 17 Gulf War. Veterans were treated by one of three therapists using PE.
Gulf War Veterans May Respond More Slowly to Treatment
Overall, veterans improved with treatment regardless of war background. Interestingly, Gulf War veterans responded less well to PE than Vietnam and OEF/OIF/OND veterans even though all showed comparable scores of PTSD and depressive symptoms prior to treatment. Gulf War veterans were slower to respond to therapy.
Why did Gulf War veterans respond different? The researchers aren’t sure. What they suggest is that:
“It may be due to population differences related to variable stress-diathesis selection processes for chronic fear experiences versus acute types of trauma or to variable self-selection pressures and concurrent treatment seeking behaviors that may vary in some important, though unmeasured, ways among war-zone cohorts.” (p. 8)
This is just a long-winded, gobbledygook way of saying: We don’t know. Maybe Gulf War veterans are different.
The good news is that veterans seem to respond well to PE for PTSD regardless of war. Why Gulf War veterans responded more slowly to treatment may be a fluke. I also wasn’t clear whether the researchers statistically accounted for this or not, but given that there were fewer of Gulf War veterans (n = 17) compared to Vietnam (n = 34), and OEF/OIF/OND (n = 61), it’s possible that the results may be skewed by a few Gulf War veterans who were poor responders to treatment (aka outliers).
For these reasons, I’d wait until the results are replicated with another sample before we can say with any confidence that Gulf War veterans may respond differently to treatment.
One of the hardest things to predict in psychotherapy is how well someone will respond to a particular treatment. A brief report in an upcoming issue of Journal of Consulting and Clinical Psychology by Leiner and colleagues offers some insight into this question. The researchers look at the impact of avoidant coping on PTSD treatment.
What’s Avoidant Coping?
As defined in this article, avoidant coping involves attempts to reduce or block out distress and discomfort. Although not directly referenced in this article, there’s an interesting research literature that suggests avoidance behaviors may maintain PTSD symptoms over time, and that reliance on these strategies is related to greater PTSD symptom severity above and beyond the severity of the original trauma (see Batten, Follette, & Aban, 2001; Polusny & Follette, 1995; Rosenthal, Hall, Palm, Batten, & Follette, 2005). Not wanting to engage painful memories and triggers is very natural, but it may exacerbate and prolong posttraumatic stress symptoms in the long run.
What the Researchers Found
The researchers used data from a previous study comparing Prolonged Exposure (PE) therapy and Eye Movement Desensitization and Reprocessing (EMDR) for adult women rape survivors with PTSD. Both PE and EMDR are exposure-based treatments. (Some EMDR proponents would object to being classified as exposure-based treatments, but that’s another debate entirely.)
The researchers found that greater use of avoidant coping strategies at pretreatment was related to lower PTSD severity after treatment. The researchers then divided up the sample according to greater and lesser scores on a measure of avoidant coping (i.e., Coping Strategies Inventory – Disengagement subscale). They found that women who scored higher in avoidant coping were much more likely to respond to treatment. Conversely, women with lower scores in avoidant coping were less likely to respond to treatment.
What Does This Mean?
The results make sense conceptually. Exposure-based therapists structure treatment so that clients safely and collaboratively confront memories and triggers they typically avoid. Although it makes sense that people with greater avoidance benefit from a treatment that focuses on confronting the avoided experiences, I find it comforting that there doesn’t appear to be a ceiling effect. That is, the researchers didn’t find that too much avoidance negatively impacted treatment.
The study leaves me with the following questions: What about women with PTSD who are low in avoidant coping? Is there another treatment that works better for them? This remains unanswered.
It also makes me wonder what other variables might be important in predicting response to treatment in PTSD. After all, avoidant coping is only one variable. There may be others that are also important. Nevertheless, this is important work that could have real-world implications for therapists who are trying to figure out who may benefit most from exposure-based treatment for PTSD. Although it’s too early to say definitively, these findings suggest that clients who are relatively more avoidant may be the best candidates for exposure therapy.
As a member of the Anxiety Disorders Association of America (ADAA), I receive their monthly journal Depression and Anxiety. The September issue—I know this post is a little late, it got caught up in editing—features an article on changes that are being considered for diagnosing PTSD in the upcoming DSM-5. It’s not certain that the proposed changes will make it in there, but they provide some interest food for thought.
What Causes PTSD?
PTSD is pretty unique among diagnoses in that the definition requires an external event (criterion A) that other diagnoses—such as depression and other forms of anxiety—do not. There is no posttraumatic stress disorder without a trauma. But what counts as a trauma?
People such as Harvard’s Richard McNally have criticized the current parameters of what can be considered a traumatic antecedent as being too broad. Some of this controversy came out of 9-11, where people were diagnosed with PTSD after seeing news footage of the collapse of World Trade Center, even though they didn’t know anyone who died or were endangered. Anthropologist Allan Young called this “PTSD of the virtual kind” (quoted in McNally, 2009). The point of this is not to diminish the impact of people’s subjective experiences; rather, that a definition that runs the spectrum from rape, torture, and combat violence all the way seeing something distressing on TV may not be clinically useful.
The authors of the proposed DSM-5 revision tighten up the definition and limit criterion A events to those involving threat of harm or death that are either witnessed by the individual or involve a close relative or friend. Additionally, they cut out entirely the second component—that the person experience “fear, helplessness, or horror.” The authors suggest that this second part is not clinically useful.
Expanding Symptom Clusters from Three to Four
Currently, the DSM clusters PTSD symptoms according to three categories: Re-experiencing (e.g., memories, nightmares, flashbacks); avoidant/numbing (e.g., avoiding internal/external reminders, psychic numbing); and hyperarousal (e.g., easily startled, hypervigilant). By contrast, the authors of this article expand the total number of symptoms from 17 to 20, and they categorize them according to four clusters.
The newly added symptoms are “erroneous self- or other-blame regarding the trauma,” “negative mood states,” and “reckless and maladaptive behavior.” I have no problem with the addition of negative mood states, and I think incorporating reckless and maladaptive behavior helps to capture aspects of PTSD that are often exhibited in military veterans.
I’m concerned, however, with the entire notion of “erroneous” beliefs. This is part of the new symptom category, “Alterations in Cognitions and Mood,” which puts more of a cognitive therapy spin on the diagnostic criteria. I find the word “erroneous” troubling, as it places the therapist in the role of deciding what’s realistic and what’s not. This is a problem I have with cognitive therapy, in general, so I’ll admit my bias here. And in fairness to the authors, they have obviously thought deeply about this change and cite their reasoning. Nonetheless, the label strikes me as less descriptive and more evaluative.
Additionally, the DSM in general tends to draw an imaginary and arbitrary line between thinking and feelings. For example, the new suggestions recast “detachment from others” as “Feeling [italics mine] of detachment or estrangement from others.” The use of the word “feeling” seems imprecise, as it’s impossible to imagine this experience except as filtered through thinking. For example, a dog may feel fear, but I doubt it ever feels estranged from others. This imprecision in the use of language is hardly unique to the PTSD, but pervades the DSM, unfortunately.
What About Complex PTSD?
Coined by psychiatrist Judith Herman, there’s a growing faction of people such as Bessel van der Kolk clamoring for the inclusion of Complex PTSD aka Disorders of Extreme Stress Not Otherwise Specified. They argue that the current definition of PTSD fails to describe victims of severe and prolonged abuse (e.g., some childhood sexual abuse survivors or tortured political refugees). These survivors demonstrate complex clinical pictures which may include features that overlap with borderline personality disorder and dissociative disorders. The authors examined the available research and concluded that there’s not enough evidence to include complex PTSD as a separate disorder. I think this is a reasonable position, and at the very least, provides motivation for advocates to refine their research, which is a little sparse to date.
It’s impossible to predict which of these suggestions will make it into the next edition of the DSM. The authors take pains to state that their suggestions remain speculative and should be subjected to further inquiry. At the very least, this article provides a wonderfully concise summary of current PTSD research, and I highly recommend anyone interested in trauma check it out.
Friedman, M.J., Resick, P.A., Bryant, R.A., & Brewin, C.R. (2011). Considering PTSD for DSM-5. Depression and Anxiety, 28(9), 750-769.
This may be just my limited, subjective impression, but I’ve noticed lately more and more clients who’ve been prescribed antipsychotic medications for reasons other than psychosis—sleep problems, rumination, or suicidal ideation, for example. I’m not anti-med, but given the documented side effects of antipsychotics—weight gain, diabetes, and motor control problems—I think we should be cautious in how these meds are used.
When a recent New York Times article came across my desk that suggested a commonly prescribed antipsychotic, risperidone, may not be very useful in the treatment of PTSD, I was intrigued. Being a dutiful scientist, I tracked down the original article in the Journal of the American Medical Association.
What Did the Study Look At?
In this study, patients were recruited from multiple Veterans Affairs Hospitals across the country. Veterans with PTSD who had not responded to at least two trials of antidepressants were recruited. The 296 participants were randomly assigned to receive either risperidone or a placebo for 6 months. The vast majority of the veterans were Vietnam era and male (96.6%). Nearly three-fourths had also received outpatient mental health services in the preceding month.
The results: There were no difference between antipsychotic medication and placebo
At the end of 6 months, there was no difference between veterans who received risperidone and those who received placebo on PTSD symptoms or anything else that was measured, including depression, anxiety, and quality of life. I will note that contrary to my concern about the potential dangers of antipsychotics, the researchers didn’t find any notable adverse effects of risperidone—at least within the 6-month trial. Given that most of these veterans are Vietnam era and older, it’s very sad that no treatment has been very successful in addressing their PTSD.
Antipsychotics May Not Be an Effective Treatment for PTSD
According to this study, antipsychotics don’t appear to contribute to improvements in PTSD—at least for veterans with whom antidepressants didn’t work. Knowing what doesn’t work can be as important as knowing what does work. It was also heartening to see that, despite listing multiple ties to various pharmaceutical companies, the two main authors of this study let the data speak for itself. Too often, I read about researchers receiving pharmaceutical money massaging data to look more favorably for the meds they’re studying. The authors here seemed very conscientious in how they interpreted the data.
In the same issue of JAMA, Dr. Charles Hoge offers a commentary on treating veterans with PTSD. He supports the use of psychotherapy, antidepressants, and the hypertensive medication prazosin, and warns against the use of antipsychotics and benzodiazepines.
Off label use of antipsychotics seems to be a growing trend. A study that came out last month found that antipsychotic prescriptions for anxiety disorders more than doubled in 10 years—even though there’s no published data suggesting antipsychotics are an effective treatment for anxiety! This trend is worth keeping an eye on.
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