Prolonged Exposure in the Media

[cara susanna]

I'm wondering if anyone else has seen this article and/or any of the other ones previously written by the author. He is NOT a fan of PE, to say the least.

http://www.slate.com/articles/healt...sd_the_va_s_treatment_has_dangerous_side.html

It makes me sad that he is spreading this message about PE, as it may discourage others from pursuing it.

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[smalltownpsych]

I'm wondering if anyone else has seen this article and/or any of the other ones previously written by the author. He is NOT a fan of PE, to say the least.

http://www.slate.com/articles/healt...sd_the_va_s_treatment_has_dangerous_side.html

It makes me sad that he is spreading this message about PE, as it may discourage others from pursuing it.

Great article. My takeaway from it is that the author is raising some valid concerns with any type of treatment becoming the only option. It also raises questions about how we implement those treatments. His description of PE is that it was administered to him using flooding as opposed to gradual exposure. Fortunately I can still select the treatment based on what the patient and I feel will be most beneficial and the research evidence that I have access to is our guide. The author is lucky he didn't end up with an EMDR devotee.

 

[cara susanna]

In his article in the NYT (if I recall correctly) he describes his experience with PE in more detail, including the fact that his therapist was a psychology intern or prac student.

Edit: Found the link - http://opinionator.blogs.nytimes.com/2015/01/17/after-ptsd-more-trauma/

 

[deleted343839]

Attacking the therapy rather than the therapist is more click-worthy, though, right?

I think PE is a great treatment option but no, it's not for everyone. For me, the Slate article raises questions about how reasonable it is to try and implement this kind of treatment on a massive, system-wide scale when we have such a quality control problem in psychology to begin with.

 

[Chalupacabra]

Attacking the therapy rather than the therapist is more click-worthy, though, right?

Well, this is a Slate article....

 

[WisNeuro]

Doesn't sound like a good characterization of PE as it is actually taught. Remember to take anything in the VA with a grain of salt. From working in this institution for several years, you see how pervasive the secondary gain is, and how in the media, everything is a political football. It's much different at the ground floor where the actual clinical work lies. Look into the data on PE on populations where it doesn't pay (literally) to appear sick. You don't see these "adverse effects."

 

[Fan_of_Meehl]

I recently got 'officially' trained in the 12-session Cognitive Processing Therapy protocol for PTSD and am finding it to be a very effective (and, once people can get over the natural tendency to avoid cognitions/beliefs related to their traumatic experiences and the impact on their lives) and tolerable treatment options for veterans with the condition. I haven't received the 'official' training for the Prolonged Exposure protocol (but am very familiar with and experienced with exposure-based treatments for other anxiety disorders). The article's characterization of the literature on the efficacy of PE doesn't seem to jive with my reading of the broader literature on PE (they seem juuuuuuuuust a tad slanted in their characterization/coverage), but I wouldn't be surprised to find more aversion to PE vs. CPT in the average veteran.

Although PTSD certainly has a large 'anxiety' component to it (as well as avoidance), it has long been acknowledged that it is 'more than' simply another anxiety disorder. It is not surprising that a pure exposure-based protocol would not be a perfect solution for all veterans with the condition and I imagine that most responsible clinicians are providing informed consent prior to implementing the protocol. Saying that prolonged exposure is based on shoddy science is just pure rhetoric. The principles of operant and classical conditioning along with the extinction of fear response after repeated exposure is just about one of the most studied/supported and robust paradigms within the history of psychological science. The fact that the 'tool' of exposure doesn't work perfectly to eradicate PTSD painlessly in all people who take that approach is likely just a byproduct of the complexity of the disorder rather than the fact that a behavioral model of PTSD is somehow 'shoddy science.'

 

[Rivi]

"Therapy, like any other kind of human relationship, only works when both parties are being heard and respected. During prolonged exposure therapy at the VA, I felt distinctly unheard and my needs ignored, largely because they diverged from the therapeutic protocols in place at the time. From my standpoint, I just wish that my VA therapist had done his due diligence and warned me at the outset that prolonged exposure might make my symptoms worse and let me know about my other treatment options."

The above quote is the main point of the article IMO, and one that our field needs to listen to.

 

[Fan_of_Meehl]

"Therapy, like any other kind of human relationship, only works when both parties are being heard and respected. During prolonged exposure therapy at the VA, I felt distinctly unheard and my needs ignored, largely because they diverged from the therapeutic protocols in place at the time. From my standpoint, I just wish that my VA therapist had done his due diligence and warned me at the outset that prolonged exposure might make my symptoms worse and let me know about my other treatment options."

The above quote is the main point of the article IMO, and one that our field needs to listen to.

Agreed...and I think that one of the biggest issues I see at my own VA is mental health clinicians having a very concrete and narrow understanding of 'evidence-based' therapy. The majority of them literally consider the term 'evidence-based therapy' simply synonymous with the VA list of alphabet-soup specific protocols (PE, CPT, CBT-I, MI, etc. etc.) such that any therapeutic approach (even if it is 'evidence based', e.g., structured behavioral activation for depression, in that it enjoys sound support for its efficacy from the broad empirical literature, is based on good clinical science, etc., they do not consider it 'evidence-based' therapy because it is not on the VA list of approved 'evidence based' therapies). They are not familiar with the very rich debate going on in the field with some authors (Barlow among others) arguing that it is time to move toward identifying and testing empirically-supported principles of behavior change (e.g., behavioral activation, cognitive restructuring, exposure, goal-setting, motivational interventions, etc.) that are trans-diagnostic and, many, trans-theoretical in nature. When some of the products of applied clinical science (i.e., specific 'evidence-based' protocols that have established efficacy) become confused with the merits of the scientific process itself, people go around worshiping specific protocols rather than honoring/valuing the scientific process.

I was always taught (and have found) that, no matter how good the (presumed) 'active ingredients' of your protocol may be (or your skill in implementing them), you ain't got diddly-squat of a chance to help your client if you don't have a solid therapeutic working relationship.

 

[ela]

Related, recent RCT comparing Interpersonal Psychotherapy to PE. In American Journal of Psychiatry:

http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2014.14070908

few highlights from discussion:

- As IPT emerged no more than minimally inferior to prolonged exposure on the primary outcome measure, had a statistically nonsignificant but clinically meaningful higher response rate, and had a lower dropout rate among patients with comorbid major depression, the treatments appeared roughly equipotent. These findings contradict the widespread clinical belief in PTSD therapeutics that patients require cognitive-behavioral therapy or exposure to trauma reminders.

- IPT may have preferential advantages over prolonged exposure for patients with comorbid PTSD and major depression.

- IPT may work through alternative, attachment mechanisms involving emotional understanding, social support, and learning to cope with current life (18, 24, 47) rather than confronting past traumas. Yet, in order to remit from PTSD, patients must eventually face their fears. As previously reported (18), patients who improved in IPT seemed to gain confidence in daily social interactions, gathered social support, and then spontaneously—without therapist encouragement—exposed themselves to trauma reminders.

 

[WisNeuro]

Interesting article, I'll be interested to see some independent analyses on this in the future. They seem to unabashedly make some aggrandizing claims about things that were not measured in this particular study.

 

[ela]

Interesting article, I'll be interested to see some independent analyses on this in the future. They seem to unabashedly make some aggrandizing claims about things that were not measured in this particular study.

Care to expand? Im curious what claims/measures you're referring to.

 

[WisNeuro]

Mostly about the social interactions and self-exposures. It seems that measured those, but didn't really report the group differences. They don't present any of the data from their self-created exposure scale, unless I missed it. Not saying there is nothing there, just that the verbiage and lack of some stats make me skeptical. Don't worry, I make the same claim about Foa, she's a fairly proliferative aggrandizer of PE. Luckily there are many independent studies and RCT's to allow fairly extensive meta-analyses of that one, with much longer follow-up data.