PE question

[MiniLop]

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For those of you who regularly do prolonged exposure, do you ever get...uh, bored?

Background: I don't specialize in PE, but we sometimes get PTSD cases at my practice so I took a training and have been seeing a case for a few months. It's going fine, it's just that sometimes, after the 70th iteration of the same story, I really struggle to hold my attention. Unlike other forms of therapy, I spend most of the session in a largely passive role, and sometimes I find it hard to stay focused. Anyone else experience this?

 

[WisNeuro]

For those of you who regularly do prolonged exposure, do you ever get...uh, bored?

Background: I don't specialize in PE, but we sometimes get PTSD cases at my practice so I took a training and have been seeing a case for a few months. It's going fine, it's just that sometimes, after the 70th iteration of the same story, I really struggle to hold my attention. Unlike other forms of therapy, I spend most of the session in a largely passive role, and sometimes I find it hard to stay focused. Anyone else experience this?

Yeah, it can definitely feel boring as you progress through the same narrative. That's somewhat of the point, though hopefully the patient also feels this as the narrative becomes more manageable from an emotional standpoint. I tried to double up my focus on changes in the patient as we do the exposures at this point, trying to notice subtle changes in tone, or changes in their non-verbals.

 

[MCParent]

Yeah, it can definitely feel boring as you progress through the same narrative. That's somewhat of the point, though hopefully the patient also feels this as the narrative becomes more manageable from an emotional standpoint. I tried to double up my focus on changes in the patient as we do the exposures at this point, trying to notice subtle changes in tone, or changes in their non-verbals.

Yup. I recall one time recently when I asked a patient to go over it again, and she sighed and made a small eye roll. I stopped her immediately to ask— “ok, two weeks ago did you imagine you’d react to a request to tell this story with a bored sigh??” Good chance to identify / recognize some gains.

 

[R. Matey]

Same as others though I found taking notes on tone and such and then reviewing it with the patient afterwards pretty helpful in sustaining my attention as well as fodder for some good therapuetic process.

 

[MiniLop]

Thanks for the validation, everyone. These are some good thoughts on how to stay focused.

 

[WisNeuro]

Yup. I recall one time recently when I asked a patient to go over it again, and she sighed and made a small eye roll. I stopped her immediately to ask— “ok, two weeks ago did you imagine you’d react to a request to tell this story with a bored sigh??” Good chance to identify / recognize some gains.

Yeah, early on when I talk about the process and procedures, I usually say something to the effect of "we'll go over this narrative so many times that you'll become bored with it" and they almost always respond with skepticism, which I refer back to when they do inevitably become bored. A good therapeutic "I told you so" moment. Which you then use as an example to generalize to other therapy targets.

I've learned several trauma protocols over the years, but I'll still default to PE. By far the best response rates I've had with any treatment, aside from panic control work.

 

[cara susanna]

Absolutely. I've noticed that taking notes, even if it's the 100th time I've heard this story and I remember all of it, helps me stay focused.

Also, if the repetitions are starting to get boring for not only you but the patient, you can also consider that it's time to move onto hotspots/the next hotspot or consider PE completed. Research suggests that there isn't much benefit after 14 sessions.

 

[MiniLop]

Also, if the repetitions are starting to get boring for not only you but the patient, you can also consider that it's time to move onto hotspots/the next hotspot or consider PE completed. Research suggests that there isn't much benefit after 14 sessions.

This brings up another issue that I'm having with this case. My client is in their 70s, single index trauma (relatively recent). We're significantly past 14 sessions at this point. Granted, we're doing 60 rather than 90 minutes sessions, but otherwise I'm following the protocol very closely. We're on our second hotspot. The client isn't habituating all that much. There's been some habituation; they've moved from high distress to moderate distress during both session and homework, but that's about it. Granted, I know from my anxiety/OCD work (which is 90% of my clients) that some people just don't habituate and that's not necessarily the goal of treatment. And the client is doing a lot better symptom-wise, though they still have some length to go. At what point do we decide that PE has had all the benefit it's going to have?

 

[WisNeuro]

This brings up another issue that I'm having with this case. My client is in their 70s, single index trauma (relatively recent). We're significantly past 14 sessions at this point. Granted, we're doing 60 rather than 90 minutes sessions, but otherwise I'm following the protocol very closely. We're on our second hotspot. The client isn't habituating all that much. There's been some habituation; they've moved from high distress to moderate distress during both session and homework, but that's about it. Granted, I know from my anxiety/OCD work (which is 90% of my clients) that some people just don't habituate and that's not necessarily the goal of treatment. And the client is doing a lot better symptom-wise, though they still have some length to go. At what point do we decide that PE has had all the benefit it's going to have?

This is where having some experience with CPT can be really nice. Sometimes this is where focusing on "stuck points" can help move past some blockages. As far as this patient, though, are they seeing improvements in day to day functioning, QoL increases, or regained faculties?

 

[MiniLop]

This is where having some experience with CPT can be really nice. Sometimes this is where focusing on "stuck points" can help move past some blockages. As far as this patient, though, are they seeing improvements in day to day functioning, QoL increases, or regained faculties?

They're seeing improvements in all three areas; it's just that some symptoms (particularly intrusive thoughts) are still relatively persistent.

 

[Therapist4Chnge]

I guess if they are still experiencing improvements in day to day functioning, QoL, etc....I'd give it a bit more time. I would probably circle back around to their goals, which may need to be revised if they have plateaued.

 

[WisNeuro]

They're seeing improvements in all three areas; it's just that some symptoms (particularly intrusive thoughts) are still relatively persistent.

This is pretty common in my experience. I would validate those intrusive thoughts, but highlight the improvements in the other areas.

 

[MCParent]

They're seeing improvements in all three areas; it's just that some symptoms (particularly intrusive thoughts) are still relatively persistent.

Intrusive thoughts w/o activation or such? I’d just normalize that yup that’s a bad memory.

I use an analogy of a gremlin living in the attic: without PE you imagine it’s some horrible monster. After PE you let it out of the attic and it’s still an ugly little troll but it’s just annoying when it gets underfoot, not the source of horrible imagined doom.

God I love doing PE.

 

[MiniLop]

This is pretty common in my experience. I would validate those intrusive thoughts, but highlight the improvements in the other areas.

Oh sorry, yes there's still significant arousal accompanying the intrusive thoughts.

That said, it's also becoming clear that there's a streak of perfectionism in the client, which may contribute to them viewing remaining symptoms as unacceptable.

 

[cara susanna]

This brings up another issue that I'm having with this case. My client is in their 70s, single index trauma (relatively recent). We're significantly past 14 sessions at this point. Granted, we're doing 60 rather than 90 minutes sessions, but otherwise I'm following the protocol very closely. We're on our second hotspot. The client isn't habituating all that much. There's been some habituation; they've moved from high distress to moderate distress during both session and homework, but that's about it. Granted, I know from my anxiety/OCD work (which is 90% of my clients) that some people just don't habituate and that's not necessarily the goal of treatment. And the client is doing a lot better symptom-wise, though they still have some length to go. At what point do we decide that PE has had all the benefit it's going to have?

I would definitely have a conversation with the patient about whether it makes sense to continue. PE is teaching someone skills, so they should continue to feel better as they keep using them even after therapy has ended. Also, you are right about habituation: PE works because of inhibitive learning, not habituation. So it's not about the numbers going down, but about the patient continuing to challenge avoidance and tolerate discomfort.

I was taught an analogy that I really like. Basically, it's like you have a garden and the weeds are avoidance. We've been weeding and pulling out some of the big ones, but there are still probably weeds left. You have to keep weeding your garden (not only going after those weeds we didn't get to, but also looking for new weeds popping up).

 

[WisNeuro]

I would definitely have a conversation with the patient about whether it makes sense to continue. PE is teaching someone skills, so they should continue to feel better as they keep using them even after therapy has ended. Also, you are right about habituation: PE works because of inhibitive learning, not habituation. So it's not about the numbers going down, but about the patient continuing to challenge avoidance and tolerate discomfort.

I was taught an analogy that I really like. Basically, it's like you have a garden and the weeds are avoidance. We've been weeding and pulling out some of the big ones, but there are still probably weeds left. You have to keep weeding your garden (not only going after those weeds we didn't get to, but also looking for new weeds popping up).

Thanks, I may steal this one for the toolbox.

 

[Therapist4Chnge]

I like the weed example and also Dr. Parent's gremlin idea.

I'm old school and just use Dr. Foa's movie theatre example of turning down the volume of a scary movie.

 

[MCParent]

I was taught an analogy that I really like. Basically, it's like you have a garden and the weeds are avoidance. We've been weeding and pulling out some of the big ones, but there are still probably weeds left. You have to keep weeding your garden (not only going after those weeds we didn't get to, but also looking for new weeds popping up).

I tried to say this about two patients ago to someone but ended in a tortured metaphor about substrate mycelium. Your weed analogy is better, consider that stolen 🙂

 

[AcronymAllergy]

I'm partially convinced that much like "common factors," having good analogies is a crucial component of effective psychotherapy (and neuropsych feedback). I don't do much therapy now, but will likely be shamelessly stealing all of these if I do more in the future. Thanks all.

 

[MiniLop]

Thanks for the feedback, everyone. I brought up your points with my supervisor today and we agreed to shift treatment focus away from PE and more towards acceptance and addressing some of the other underlying issues.

 

[R. Matey]

I'm partially convinced that much like "common factors," having good analogies is a crucial component of effective psychotherapy (and neuropsych feedback). I don't do much therapy now, but will likely be shamelessly stealing all of these if I do more in the future. Thanks all.

Right, it's a both/and, not an either/or. Ironically, it seems the common factors zealots are the only ones who don't seem to realize that.