When I was still in graduate school, I had the opportunity to be a practicum student at the Anxiety and Agoraphobia Treatment Center (AATC) just outside of Philadelphia. It was at AATC where I got my first opportunity to learn and practice evidence-based psychotherapy. Specifically, I learned Exposure and Response Prevention (ExRP) from my supervisor, Dr. Jon Grayson. I’d read study after study demonstrating the efficacy of ExRP for Obsessive Compulsive Disorder prior to beginning my practicum and was excited to give it a try. Still, there was a part of me that was a little frightened by the prospect of guiding my clients toward their worst fears, and I was more than a little concerned that I wouldn’t be able to tolerate seeing them in distress. I had visions of my clients “falling apart” when doing in vivo exposures designed to help them face their fears head-on, such “dumpster diving” where the client and I would get into an empty dumpster, or getting angry with me when I instructed them not to wash their hands to avoid their anxiety. Most of all, I was afraid that my clients would think I was some sort of sadist and drop out of treatment prematurely. I spoke with Dr. Grayson about my concerns, and he said, “Yeah. It’s harder to get therapists to do ExRP that it is to get clients to do it.” Luckily, the training and supervision I received (and a decision to have faith in the data) helped me to learn and practice ExRP with my clients. It was simply inspiring to see the courageous efforts of my clients and wonderfully gratifying to share in their treatment success. Since that time, I’ve gone on to learn, practice, and teach EBP for a variety of issues, including both Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT) for PTSD.
Many of the consultees, psychology interns and fellows with whom I have worked have expressed similar concerns to the ones I’d had when I was learning exposure-based therapies. It’s natural to have some trepidation about asking a client to face discomfort because, most of the time, avoiding discomfort seems reasonable (and even healthy, in certain situations). However, avoidance is a main factor in maintaining PTSD symptoms, especially when therapists avoid using EBP with their clients! Decades of research have demonstrated that CPT and PE, both of which require clients to confront reminders of their trauma, are the most effective treatments available for PTSD. Despite the data, many clinicians are reluctant to use EBP with their clients. Clinicians may ask themselves, “Will talking about trauma and facing reminders make my client’s PTSD worse? Will they drop out of treatment? If their symptoms do get worse, will the fail to benefit from treatment even if they stick it out? If I have a client with a history of childhood sexual abuse or who is very avoidant, can they tolerate these treatments?” In the absence of data to guide us, the answers to these questions can seem elusive. It may seem like a “safer bet” to use a therapy that is perceived to be “less risky.”
Drs. Sadie Larson, Sharon Whiltsey Stirman, Brian Smith, and Patricia Resick recently conducted an archival study in an effort to address some of the prevailing concerns about symptom exacerbation. The authors investigated the frequency and implications of symptom exacerbation reported by participants in two randomized clinical trials comparing PE, CPT, and CPT-C (a form of CPT that does not include a written trauma account). In addition, they looked for associations between a history of childhood sexual trauma, co-morbid diagnoses, or being highly avoidant and increased symptom exacerbation. They found that a minority of participants in these trials did experience symptom exacerbations at some point during treatment (28.6% for CPT, 20% for PE, 14.7% for CPT-C), but that there were no significant differences in the rate of reported exacerbations between the three treatments. When exacerbations did occur, the average increase in symptoms was about 11.6 points (10 points is considered “clinically significant,” representing a change of about two standard deviations) on the Posttraumatic Symptoms Scale (PSS). After experiencing an exacerbation, it took approximately one and half weeks for symptoms to return to pre-exacerbation levels for the majority (64%) of participants. In other words, exacerbations tended to be brief “spikes” of increased distress rather than shifts in the trend of treatment response. None of the variables investigated (including history of childhood sexual assault, any demographic variables, co-morbid diagnoses, or being highly avoidant) predicted symptom exacerbation.
Next, the authors examined the impact of symptom exacerbation early in treatment (i.e., prior to the fourth session which is generally the point at which therapeutic confrontation of trauma reminders begins). They found that participants who had exacerbations earlier in treatment tended to report slightly more PTSD symptoms during and after the trial than participants who did not have an exacerbation, but the difference was not clinically significant and did not predict drop-out. Only 14 participants in the same experienced a “high” exacerbation in symptoms, and of those, only four dropped out of treatment. Furthermore, after the conclusion of therapy the vast majority of participants who experienced exacerbations, including most of the participants with “high” exacerbations, tended have clinically significant improvements in symptoms by the end of treatment.
In discussing their findings, the authors conclude that, a minority of participants may experience a small increase in symptoms when receiving PE, CPT, or CPT-C. This is not unexpected, given that a minority of participants in any treatment are likely to report an exacerbation of symptoms which may or may not be related to the treatment that they are receiving. However, it does not appear symptom exacerbation leads to significantly increased risk of drop out or that it will preclude someone from significantly benefitting from EBP. They also note that individuals with histories of childhood sexual abuse and/or co-morbid diagnosis were no more likely to experience an exacerbation of symptoms than participants with less complex clinical presentations. Given that none of the study variables predicted symptom exacerbation, the authors suggested that perhaps therapist experience in delivering EBP may be a useful factor to investigate in future research. In addition, the authors strongly recommend that clinicians who are just beginning to learn EBP for PTSD participate in consultation both to increase competency to deliver these treatments and to reduce the impact of unhelpful and inaccurate beliefs that PE and CPT are harmful.
Taken as a whole, the results of this study provide clinicians with some useful evidence to challenge some of the unhelpful beliefs that may be contributing to reluctance to use PE or CPT with their clients. It is understandable that the idea of confronting emotional pain may give even the most seasoned clinician pause. The precept, “do no harm,” is one of our guiding principles as mental health professionals, and it is not a precept that any of us take lightly. However, it’s important to remember that there is also risk of causing harm by not providing the best available treatment to our clients. It can be difficult to make treatment decisions on our own, and that is why professional consultation, another central aspect of ethical behavior, is so critical.
Studies such as the one discussed in this blog are useful, and we certainly need more of them. We also need to consult with each other, especially when we are uncertain if we can really “trust” the data. Speaking with clinicians who have struggled with the same questions and who have more experience using EBP can be tremendously helpful. I’m thankful that Dr. Grayson was there to talk with me about my concerns because those conversations allowed me to open doors for my clients that I would have avoided otherwise. I’m happy to return the favor, as are the other EBP consultants at CDP. If you would like to discuss the issues raised in this blog or just need some help implementing EBP with your clients, don’t hesitate to take advantage of the many opportunities to participate in free consultation offered by CDP. Thanks for reading!
Andrew Santanello, Psy.D. is a clinical psychologist, CBT Trainer, and CPT consultant at the Center for Deployment Psychology. The article referenced in this blog is:
Larsen, S.E., Stirman, S.W., Smith, B.N., & Resick, P. A. (2016). Symptom exacerbations in trauma-focused treatments: Associations with Treatment Outcome and Non-Completion.Behavior Research and Therapy, 77, 68-77.