Staff Perspective: A (Northern) Exposure Story - Why the Devil is in the Details During In Vivo Exposure
Two exposure therapists take a hike in the woods in Alaska... It sounds like the beginning of a bad joke, right? Bad joke as it might be, my intention is to use this hiking event to demonstrate how situational factors, purposely manipulated or accidentally occurring, can greatly impact the distress experienced during an in vivo exposure exercise.
The scene is early May in Denali National Park. Two females emerge from their vehicle dressed in puffy coats, leggings, hats, gloves and hiking boots. One carries a backpack containing water, beef jerky, an apple, and hand warmers (so basically total professionals -- as prepared as if we were repeat Everest summiters). Two adventuresome women hell-bent on adding a hike to their collection of Alaska experiences, while away providing training in Prolonged Exposure therapy at military bases in Fairbanks and Anchorage.
For any in-vivo exposure activity, we train providers to use something called a Subjective Units of Distress or SUDS scale. This scale, typically ranging from 0 - 100, can be thought of as an emotional thermometer. It helps us, the provider, understand how distressing or anxiety provoking an exposure activity is for our client. A 0 would be no distress, while 100 is the most distressed/anxious they have ever felt. We use the SUDs scale for many things, but importantly to help rank items on their in vivo hierarchy that contains things/people/activities/places currently avoided due to PTSD (or anxiety/phobia) with the goal of progressively working up the hierarchy, confronting the stimuli and ultimately reducing symptoms.
For Kelly (my colleague) and I, the item “Hike a trail in Denali National Park” was a SUDS of about a 10 as we prepared to leave our hotel room. We were psyched. We were pumped. We did NOT feel anxious or distressed, just excited. Savage Alpine Trail, here we come!
Hike a trail in Denali: 10
But now… now as we leave our car in a completely deserted parking lot (A.K.A. NO ONE else is out here) and pass the wildlife warning sign suddenly things change on our rating of this activity.
Hike a trail in Denali with no one around except dangerous wildlife: 30
This 30 still represents mostly excited anticipation, but now there is a good pinch of nervous. I mean, this IS Alaska, and the ranger DID mention in an off-hand way that the bears have started to come out of hibernation in the past month. And it has become apparent that we ARE, literally, completely alone in this area of an enormous national park. But we can do this! We are exposure therapists. Face your fear, approach, don’t avoid. Full of vibrato, we start our trek!
“Do you think we’ll be ok?” Kelly asks.
“We’ll be fine!” I say. “And now we know… Bear: slowly back away and get big. Wolf: make noise and fight back. Moose: run away fast! Just don’t mess those up and run fast from a bear and chuck stuff at a moose and we’re golden. And, remember, I’ve got hand-warmers...what could go wrong?”
About a half a mile in we start seeing scat. And it is pretty fresh. Kelly even takes pictures. Moose? Wolf? Bear? Unsure, we giggle and press on. This is biological proof a large animal has been here recently.
Hike a trail in Denali with no one around and biological proof (scat) that large/dangerous wildlife have been on trail recently: 40
Our hearts start to pump faster, which we are sure is due to the gain in elevation. Kelly stops us suddenly, pointing to the ground. “What are those tracks? Do you see them? Those are big!” I look down. They are a bit hard to make out, but I see what she is pointing to. A muddy imprint of five round divots, with what looks like claws coming out of each.
Determined, we keep heading up the trail. The tracks are even more defined and they are everywhere. There is no question now. The tracks that we are essentially following are bear tracks. Large ones with massive claw imprints. Kelly remembers that the wildlife warning sign mentioned something about making noise so as to not surprise a bear. So naturally, we start to sing…
Hike a trail in Denali with no one around, with scat and enormous claw prints, proving a bear was recently in area: 50
We are far enough from the trailhead that running back would not be an easy escape. And we are exposure therapists. We don’t “escape,” we confront. So onward we trek. The sky has also started to deposit snow suddenly at a very steady rate. Our trail is growing ever-muddier and slippier.
We hike in silence now. Perhaps our lack of chatter is caused by the steady bear tracks that seem to goad us, luring us forward toward the beast. Perhaps our silence is due to the fact that we are forced to conserve oxygen, as we endure switchbacks on a steep incline. Perhaps the hush is because the once "steady" flakes have now turned to driving snow, whipping our faces. The prospect of a large hungry, bear around every turn FEELS very real. This fear is exacerbated by the reality that the snow has reached “no joke” level.
Hike a trail in Denali with no one around, with scat and enormous claw prints proving a bear was recently in area, in driving snow: 60
I feel the urge to push forward faster...but the altitude has us at bay. We can only go so fast through this leg of the climb and still be able to breath. Just stopping and quitting this (Northern) exposure exercise isn't an option. We have reached the rocky ledge at the top. Snow is up to our knees and visibility has dropped to zero. The trail is now completely gone under the snow. We have two choices. We can turn around and head down the way we came. Or we can stay the (planned) course and hope the loop that takes us down the other side somehow appears soon.
Hike a trail in Denali with no one around, with scat and enormous claw prints proving a bear was recently in area, in a blinding snowstorm with no clear trail: 75
We pause at the top. The wind has already blown snow over the footprints we made but minutes ago. I turn to Kelly and we nod to each other. We fought our way up, pushed past our fear of the bear, slogged through lashing snow. It was OK to go down the way we had come. There was no shame in a backwards retreat. We weren’t escaping or avoiding! This exposure exercise was WAY MORE intense than we had predicted it would be. We misjudged. And THAT was ok. It happens to ALL of us.
Sometimes, even with our best efforts to help our clients identity objectively safe in vivo exposures things go wrong. Sometimes what someone thought would be a 30 is actually a 70 because of (random or not) environmental conditions that weren’t factored in. The take-home is to DO something with that experience and data. Find the parts you can reinforce as great work despite a harder exercise with your client. Demonstrate how you can work as a team to break down an item into more reasonable steps by purposely manipulating aspects of the exposure. Remind them that they STILL did more than last week/month/year and are on the right path (or hiking trail). The in-vivo list is a work in progress, always editable, open to change. The important thing is to keep going and not lose track of the rationale behind why approaching instead of avoiding helps gain back the territory taken by PTSD.
So, if or when you struggle with this aspect of exposure work with your clients, remember, two exposure therapists hiked into the woods in Alaska and came out stronger, happier, and better for the experience... bears, moose, wolves, snow, and all.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Jenna Ermold, Ph.D., is a clinical psychologist working as the Assistant Director of Training and Education with the Center for Deployment Psychology at Uniformed Services University of the Health Sciences in Bethesda, MD.
Two exposure therapists take a hike in the woods in Alaska... It sounds like the beginning of a bad joke, right? Bad joke as it might be, my intention is to use this hiking event to demonstrate how situational factors, purposely manipulated or accidentally occurring, can greatly impact the distress experienced during an in vivo exposure exercise.
The scene is early May in Denali National Park. Two females emerge from their vehicle dressed in puffy coats, leggings, hats, gloves and hiking boots. One carries a backpack containing water, beef jerky, an apple, and hand warmers (so basically total professionals -- as prepared as if we were repeat Everest summiters). Two adventuresome women hell-bent on adding a hike to their collection of Alaska experiences, while away providing training in Prolonged Exposure therapy at military bases in Fairbanks and Anchorage.
For any in-vivo exposure activity, we train providers to use something called a Subjective Units of Distress or SUDS scale. This scale, typically ranging from 0 - 100, can be thought of as an emotional thermometer. It helps us, the provider, understand how distressing or anxiety provoking an exposure activity is for our client. A 0 would be no distress, while 100 is the most distressed/anxious they have ever felt. We use the SUDs scale for many things, but importantly to help rank items on their in vivo hierarchy that contains things/people/activities/places currently avoided due to PTSD (or anxiety/phobia) with the goal of progressively working up the hierarchy, confronting the stimuli and ultimately reducing symptoms.
For Kelly (my colleague) and I, the item “Hike a trail in Denali National Park” was a SUDS of about a 10 as we prepared to leave our hotel room. We were psyched. We were pumped. We did NOT feel anxious or distressed, just excited. Savage Alpine Trail, here we come!
Hike a trail in Denali: 10
But now… now as we leave our car in a completely deserted parking lot (A.K.A. NO ONE else is out here) and pass the wildlife warning sign suddenly things change on our rating of this activity.
Hike a trail in Denali with no one around except dangerous wildlife: 30
This 30 still represents mostly excited anticipation, but now there is a good pinch of nervous. I mean, this IS Alaska, and the ranger DID mention in an off-hand way that the bears have started to come out of hibernation in the past month. And it has become apparent that we ARE, literally, completely alone in this area of an enormous national park. But we can do this! We are exposure therapists. Face your fear, approach, don’t avoid. Full of vibrato, we start our trek!
“Do you think we’ll be ok?” Kelly asks.
“We’ll be fine!” I say. “And now we know… Bear: slowly back away and get big. Wolf: make noise and fight back. Moose: run away fast! Just don’t mess those up and run fast from a bear and chuck stuff at a moose and we’re golden. And, remember, I’ve got hand-warmers...what could go wrong?”
About a half a mile in we start seeing scat. And it is pretty fresh. Kelly even takes pictures. Moose? Wolf? Bear? Unsure, we giggle and press on. This is biological proof a large animal has been here recently.
Hike a trail in Denali with no one around and biological proof (scat) that large/dangerous wildlife have been on trail recently: 40
Our hearts start to pump faster, which we are sure is due to the gain in elevation. Kelly stops us suddenly, pointing to the ground. “What are those tracks? Do you see them? Those are big!” I look down. They are a bit hard to make out, but I see what she is pointing to. A muddy imprint of five round divots, with what looks like claws coming out of each.
Determined, we keep heading up the trail. The tracks are even more defined and they are everywhere. There is no question now. The tracks that we are essentially following are bear tracks. Large ones with massive claw imprints. Kelly remembers that the wildlife warning sign mentioned something about making noise so as to not surprise a bear. So naturally, we start to sing…
Hike a trail in Denali with no one around, with scat and enormous claw prints, proving a bear was recently in area: 50
We are far enough from the trailhead that running back would not be an easy escape. And we are exposure therapists. We don’t “escape,” we confront. So onward we trek. The sky has also started to deposit snow suddenly at a very steady rate. Our trail is growing ever-muddier and slippier.
We hike in silence now. Perhaps our lack of chatter is caused by the steady bear tracks that seem to goad us, luring us forward toward the beast. Perhaps our silence is due to the fact that we are forced to conserve oxygen, as we endure switchbacks on a steep incline. Perhaps the hush is because the once "steady" flakes have now turned to driving snow, whipping our faces. The prospect of a large hungry, bear around every turn FEELS very real. This fear is exacerbated by the reality that the snow has reached “no joke” level.
Hike a trail in Denali with no one around, with scat and enormous claw prints proving a bear was recently in area, in driving snow: 60
I feel the urge to push forward faster...but the altitude has us at bay. We can only go so fast through this leg of the climb and still be able to breath. Just stopping and quitting this (Northern) exposure exercise isn't an option. We have reached the rocky ledge at the top. Snow is up to our knees and visibility has dropped to zero. The trail is now completely gone under the snow. We have two choices. We can turn around and head down the way we came. Or we can stay the (planned) course and hope the loop that takes us down the other side somehow appears soon.
Hike a trail in Denali with no one around, with scat and enormous claw prints proving a bear was recently in area, in a blinding snowstorm with no clear trail: 75
We pause at the top. The wind has already blown snow over the footprints we made but minutes ago. I turn to Kelly and we nod to each other. We fought our way up, pushed past our fear of the bear, slogged through lashing snow. It was OK to go down the way we had come. There was no shame in a backwards retreat. We weren’t escaping or avoiding! This exposure exercise was WAY MORE intense than we had predicted it would be. We misjudged. And THAT was ok. It happens to ALL of us.
Sometimes, even with our best efforts to help our clients identity objectively safe in vivo exposures things go wrong. Sometimes what someone thought would be a 30 is actually a 70 because of (random or not) environmental conditions that weren’t factored in. The take-home is to DO something with that experience and data. Find the parts you can reinforce as great work despite a harder exercise with your client. Demonstrate how you can work as a team to break down an item into more reasonable steps by purposely manipulating aspects of the exposure. Remind them that they STILL did more than last week/month/year and are on the right path (or hiking trail). The in-vivo list is a work in progress, always editable, open to change. The important thing is to keep going and not lose track of the rationale behind why approaching instead of avoiding helps gain back the territory taken by PTSD.
So, if or when you struggle with this aspect of exposure work with your clients, remember, two exposure therapists hiked into the woods in Alaska and came out stronger, happier, and better for the experience... bears, moose, wolves, snow, and all.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Jenna Ermold, Ph.D., is a clinical psychologist working as the Assistant Director of Training and Education with the Center for Deployment Psychology at Uniformed Services University of the Health Sciences in Bethesda, MD.