Introduction to prolonged exposure therapy for PTSD
A method of helping the combat veteran community is helping first responders cope with traumatic events by creating a narrative
By Dr. Marla Friedman, Psy.D. PC, Psychologist, Contributor to In Public Safety
Fortunately, most people who experience traumatic experiences can successfully recover without undergoing specialized therapy. However, if a trauma has plagued an EMT or first responder for more than three months, and he or she is having a hard time coping with the harrowing signs and symptoms of post-traumatic stress injury (PTSI), it is time to seek therapy with a mental health professional and consider pursuing a highly focused and intense treatment protocol.
I’ve been working clinically with patients for more than 30 years. I have been trained in, and practiced, each new therapeutic modality including psychoanalytic psychotherapy, gestalt therapy, transactional analysis, cognitive therapy, psycho drama, rational emotive behavioral therapy and more. Some of these therapies are very good, while others I’ve found to be less effective.
When Military One (now called Military One Source) offered a comprehensive training called “Treating Trauma Survivors: Prolonged Exposure Therapy Training for PTSD with a Focus on Our Returning Warriors”, it piqued my interest. At the time, I was using everything I had in my toolbox and was not getting a full reversal of symptoms for patients presenting with trauma.
The training was very hands-on, teaching prolonged exposure (PE) therapy through role-playing and interactive experiences that were closely monitored. Any deviations from the strict protocol were corrected immediately by instructors and redirected to match the method that had been demonstrated. What I learned during this training in 2008 has informed the way I have conducted psychotherapy for trauma ever since.
Navigating trauma-related memories
Prolonged Exposure therapy is currently one of only four evidenced-based treatments that can reverse the signs and symptoms of PTSI. PE is an effective way for patients to emotionally process their traumatic experiences with the guidance of a trained mental health professional. PE therapy teaches patients how to approach and navigate trauma-related memories, feelings and situations that are often avoided in the aftermath of trauma, and sometimes for years afterwards. When individuals are able to talk about the details of their trauma in a safe environment, they can find relief.
PE was developed in response to the high rate of trauma and suicide rates within the combat veteran community. The Veterans Administration was, and continues to be, overwhelmed with soldiers who are suffering from trauma-related symptoms. In response to this situation, Dr. Edna Foa, a leader in the application of therapeutic methods to address traumatic injuries and anxiety disorders, along with her colleagues, developed PE to assist anyone suffering with these conditions.
Who is a candidate for prolonged exposure therapy?
In order for PE to be an effective form of treatment, an individual must be able to recall enough of the trauma to construct a personal narrative. That means they must be able to remember the beginning, middle and end of the event. This narrative does not have to be an objective view of what happened – it is expected they will remember it from their unique perspective, which comes with distortions. Humans are not computers and they remember things based on many factors, both situational and psychological. However, in order for PE to work, a person only needs to reconstruct the incident to the best of his or her knowledge.
First responders who are suffering from other mental health disorders, or who are suicidal or have homicidal thoughts or intentions are not ready for PE. In addition, PE is not recommended for individuals who are suffering from psychosis or if they have a drug or alcohol addiction. These first responders should not engage in PE or other intense therapies until their addiction or other mental health problems have first been addressed.
How do you start prolonged exposure?
Once a first responder qualifies for PE, the therapist begins by explaining what he or she can expect during treatment. From the beginning, it is very important for individuals to understand that they will experience intense and uncomfortable thoughts and feelings during PE therapy. In order for the approach to be effective, responders will need to confront intrusive and painful thoughts and feelings that, in many cases, they have been actively avoiding since their traumatic experience.
Many of these painful memories and emotions will arise outside of their therapist’s office – they will frequently strike during the course of a person’s day or after going to bed. Prior to the commencement of PE, the therapist will teach an individual coping techniques including distraction methods, relaxation, tactical breathing and other compatible treatment processes to help them deal with intense thoughts and feelings while engaged in this treatment.
The process of prolonged exposure therapy
After a first responder is referred to my care, I interview him or her at length in an attempt to understand the person sitting across from me. I ask them questions about their family of origin, educational achievements, social and emotional background, as well as their employment history. I also ask about medical issues, use of alcohol and drugs, head injuries, allergies and medications. I then start the process of documenting the actual problems that are interfering with the person’s normal, daily functioning.
Typically, the first few sessions are devoted to collecting information and discussing details about how PE works and what to expect. It is important to use these first few sessions to build a relationship. It takes time to develop trust, especially with first responders. The culture has always dictated that seeking help is a weakness and there remains a stigma about taking responsibility for one’s psychological wellbeing. The fact that a first responder is in my office, tells me they have been suffering for a long time and are ready to do whatever it takes to have a normal life again.
- Discussing the event: After we establish trust and whenever the patient is ready, we begin talking about the traumatic event. Sometimes there is more than one event, and we address each one separately. As the individual is relaying their story, I listen carefully to the content while watching their face and body for any physiological reactions including tears, hand wringing, blood rushing to the face, restlessness or stiff body posture. By noting these signs, I can gauge how much distress the person is in and then compare it to how they present after discussing the exposure.
Sometimes the narrative takes 15 minutes. Sometimes it is just three sentences long. PE works regardless of the quality or quantity of the recollection. I ask the individual to repeat and clarify details of their story. I ask them to focus on the sights, sounds, smells, tastes and tactile occurrences that are built into the trauma. I monitor their reactions and check in with them about how they are feeling. The person repeats the story until it appears we are not missing anything. For many patients, they have been experiencing this over and over, often for years, but this may be the first time they have talked about it in this level of detail.
- Recording and listening to the trauma: At this point, I ask the person to audiotape what is being expressed. They may do this in my office or at home privately. It is their choice. After the material is recorded, their assignment is to listen to the tape for 90 minutes a day, without distractions, every day until our next session.
First responders are understandably uneasy with the prospect of reliving their nightmare over and over. I reassure them that within a week’s time, they will have a totally different perspective on their trauma and they can get in touch with me 24/7 if need be.
When we meet the following week, I ask them how it went and if they listened as prescribed. So far, all my patients have engaged in the task to at least 80 percent completion. I then ask them to repeat the narrative to me now in detail, and again I watch for signs of upset or arousal. If I see something that indicates a physiological reaction, we talk about it.
At the end of our session, I ask them to repeat the assignment the next week, usually to their dismay. I reassure them that they can do this and it will result in a positive outcome – leading to an end of their pain and suffering.
- Recalling the trauma, without the same emotions: At the next session, I ask them to pull up the traumatic memory and determine if they can remember the traumatic experience in full but, without the feelings attached. If they can, then we are finished with that specific trauma. If there are other traumatic incidents, we tackle those one at a time. The patient can then terminate treatment, or – and this is the typical outcome – we continue our work together focusing on issues that have never been dealt with, including family or partner conflicts, child-rearing concerns, general anxiety and other personal issues. Usually, the major life stressors include issues of bullying, conflict, inequity and political issues on the job, which are exacerbated by poor sleep hygiene, unhealthy eating and lack of consistent exercise.
Successful results of PE therapy
In my doctoral program, we were taught to never say that a problem or issue has been cured. However, I can say with confidence that prolonged exposure therapy, done correctly, will result in a reversal of a PTSI diagnosis. In my own practice, I regularly conduct a one-year follow-up with patients who were treated using PE and every single one of them reported that they no longer have signs and symptoms of PTSI.
I am proud to help first responders who are courageous enough to face the horrors that live inside them find relief and reverse PTSI by engaging in prolonged exposure therapy.
About the Author
Marla Friedman is a licensed psychologist in Illinois and Michigan. She develops mental health, trauma cessation and suicide prevention programs for law enforcement and trains psychologists and officers nationally. She is a writer and maintains a full-time therapy practice. She is a member of the Executive Board of Badge of Life and is the chief psychologist for Field Training Associates. She is currently developing a pilot program for the Cook County (IL) State’s Attorney’s Office in conjunction with The Innocent Justice Foundation to assist those who work on child exploitation task forces. She can be reached at IPSauthor@apus.edu. For more articles featuring insight from industry experts, subscribe to In Public Safety’s bi-monthly newsletter.