Perpetrator Closeness Matters When Considering Effects of Trauma

Perpetrator Closeness Matters When Considering Effects of Trauma

A new study conducted by Portland Psychotherapy’s Melissa Platt, along with colleague Jennifer Freyd, finds that perpetrator closeness matters when considering the effects of trauma. In this study, 124 female survivors of trauma were recruited to participate. Participants completed a set of questionnaires related to trauma, shame, dissociation, and fear. Next, they were randomly assigned to either see a set of images depicting threatening events of an interpersonal nature such as depictions of sexual harassment and interpersonal violence, or a set of images depicting threatening events of a non-interpersonal nature such as depictions of car accidents and natural disasters. After viewing the images, participants again completed self-reports of fear, shame, and dissociation.

Our hypotheses were guided by betrayal trauma theory, which proposes that people who experience traumatic events perpetrated by someone close, trusted, or depended on for survival (high betrayal trauma; HBT), are more likely to dissociate the abuse from awareness compared to survivors of events perpetrated by someone not close, or non-interpersonal events (low betrayal trauma; LBT). Several studies provide support for betrayal trauma theory as it relates to dissociation. In the current study, we aimed to extend the scope of betrayal trauma theory by assessing whether people who have experienced HBT may also be more likely to experience shame, rather than fear, in the context of trauma-relevant cues. The rationale for this has to do with survival. If a person is assaulted by a stranger, it is likely to be adaptive for that person to experience fear and its action tendency to flee and get the heck out of the dangerous situation and away from the source of threat. However, if a person is assaulted by someone who is depended upon for survival, or someone who feels needed for survival such as a life partner, fleeing may seem to be life-jeopardizing, and in the case of abuse by a caregiver, fleeing truly may be life-jeopardizing.

Rather than responding to HBT-relevant cues with fear, we predicted that people would respond with shame (in addition to dissociation). Shame is an emotional experience that is very painful, tends to stop a person in her tracks, and tends to elicit sympathy in others. In addition, shame either shifts the person’s attention inward to thoughts of being flawed or bad, or else causes the mind to go blank. In either case, awareness is shifted away from cues to suggest that the person is being harmed by someone they need and/or love, and therefore protects the relationship with that person, albeit at a cost.

Results of the study showed that, first of all, there was no overall difference in responses between the interpersonal and non-interpersonal threatening images. It was only when we took into account the person’s individual history of HBT and LBT experiences, that differences in responses to the images showed up. In particular, people with a higher number of HBT experiences in their history became more ashamed and dissociative when they saw the interpersonal threatening images, but not the non-interpersonal ones. What’s more, they did not experience an increase in fear in response to either set of images. On the other hand, people with a higher number of LBT experiences in their history became more afraid when they saw the non-interpersonal images. What’s more, they did not experience an increase in shame or dissociation in response to either set of images.

Thus, we found evidence supporting the idea that shame and dissociation may serve a similar function in survivors of HBT, and that HBT and LBT survivors may have quite different experiences in the context of trauma reminders. This would also suggest that treatment needs may differ depending on type of trauma(s) the person has endured. We believe that these findings have particular significance for exposure therapies, such as prolonged exposure, which has a theoretical underpinning based on fear habituation. Before beginning PE with your client, it may be worthwhile to assess whether your client’s primary emotional reaction is indeed fear rather than shame or some other emotional experience and whether he/she tends to dissociate when reminded of the trauma, which may interfere with the ability to learn that memories are not dangerous and thereby the opportunity to heal.

Shorter Imaginal Exposure Sessions as Effective as Longer Exposure for PTSD

Shorter Imaginal Exposure Sessions as Effective as Longer Exposure for PTSD

Prolonged exposure (PE) is an evidence-based cognitive behavioral treatment that uses imaginal and in vivo exposure in the treatment of PTSD. Imaginal exposure involves the client recounting a core traumatic event in great detail repeatedly in session, and then listening to an audio recording of the exposure daily between sessions. In additional to imaginal work, clients engage in in vivo (Latin for “in life”) exposure to trauma-related triggers. Exposure is done until the client habituates to the trauma-related similar, and/or until PTSD symptoms are largely resolved, according to the PE model.

For those unfamiliar with exposure therapy, you can read more about other blog posts I’ve written on exposure.

Standard PE sessions are too long for how most therapists now practice

The research supporting PE is impressive, and I’ve always been impressed with the relative simplicity of its protocol. However, one concern I’ve had about the treatment protocol is that sessions are 90 minutes long, which is nearly impossible to have covered by insurance nowadays. When medical billing codes were revised in 2013, the code for a 90 minute session was cut, and 60 minutes became the longest standard session for which a therapist could bill. This change made PE out-of-step with the practice limitations of many therapists in the US.

To their credit, PE researchers responded to this concern in a recent study (Nacasch et al., 2015). This study is an improvement of a similar study (van Minnen & Foa, 2006) from several years ago.

The study

In the most recent study, 39 veterans were randomly assigned to 10-15 sessions of PE at either 90-minute with 40 minutes of imaginal exposure each session, or 60 minutes with 20 minutes of imaginal exposure each session.

What did they find?

  • Participants in the 60-minute sessions improved just as much as those in 90-minute sessions. There was no difference in outcome between the 2 groups at treatment completion.
  • Although participants in the 90-minutes sessions exhibited greater habituation to trauma-related stimuli, this didn’t impact the overall outcome for either group. I interpreted this as further evidence that, contrast to the emotional processing theory underlying PE,  habituation is a poor marker of improvement in exposure. The authors defend between-session habituation to some degree but admit that it does not seem to be a necessary condition for improvement in PTSD.
  • Very interestingly, even though participants in the 90-minute session condition were receiving twice as much therapy, they did not improve any more rapidly than those in the 60-minute session condition. Both groups completed treatment in the same number of sessions. In this instance, more is not necessarily better.

Summary

This is an extremely important study in that it provides evidence that—for prolonged exposure, at least—not only do people show as much improvement in 60-minute sessions as 90-minute sessions, that 20 minutes of imaginal exposure is no less effective than 40 minutes per session.

Shorter sessions and shorter exposure times can reduce the burden (e.g., time; money) for clients, and it makes it more feasible to offer evidence-based treatments such as PE in settings where 90-minute sessions are not covered.

My hope is that the main researcher and PE core originator, Dr. Edna Foa, does a similar study with her OCD exposure protocol, too, which also relies on 90-120 minute sessions!

If you want to read the full article yourself, the published version is behind a pay wall. However, one of the authors made the “in press” version available here.

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

Using ACT to Guide Exposure-Based Interventions for PTSD

Using ACT to Guide Exposure-Based Interventions for PTSD

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@portlandpsychotherapyclinic.com

Sharing Traumatic Experiences in Group-Based Exposure Therapy for PTSD

Sharing Traumatic Experiences in Group-Based Exposure Therapy for PTSD

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.

Improvements

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.

Experiential Avoidance and Its Relevance to PTSD

Experiential Avoidance and Its Relevance to PTSD

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.

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