The last blog entry on in vivo exposure discussed some strategies to help your client be better prepared to benefit from in vivo exposure. This week I want to talk about “post-in vivo processing”. We don’t usually emphasize processing when we discuss in vivo exposure but it is just as important for in vivo exercises as it is for imaginal exposure. Post-in vivo processing is not merely a check the box activity to make sure the homework was done but instead is an opportunity for a client to reflect on the homework assignment, and extract some understanding or insight from the experience of facing fear and living to tell about it. For some, this may simply mean concluding, “It was easier than I expected it to be!” But for others, it may mean evaluating and dismantling some strongly held beliefs that have kept them “safe” from harm for a long time. Give example?
Many clients will walk into session with in vivo worksheets in hand, ready to discuss their experiences, so I like to ask about homework in the beginning of the session to capitalize on what they just accomplished. Some of my colleagues like to save the processing of homework for the end of session so they can get to the imaginal exposure immediately. Either way can be effective but make sure your client knows what to expect so they don’t feel ignored if you don’t ask about the homework right away. One strategy might be to briefly review the homework at the start of session to provide reinforcement but save the processing and problem solving until the end of session.
Did your client do the assignment?
Begin by finding out whether your client actually did the assignment. If avoidance or a complicated life is preventing him/her from doing the homework, you will spend your processing time trouble shooting those barriers. We could (and maybe we will) write an entire post on troubleshooting barriers, but for now let’s assume that your client did the in vivo assignment and is ready to show you the worksheet. This is your first piece of information to process. What does it tell you?
The most important thing it says is that your client took a step toward getting her life back. She had enough confidence in the treatment, in you, and in herself that she attempted, and perhaps successfully completed the assignment. This is accomplishment number one! She faced her fear!
Lead with the positive
While this accomplishment is certainly rewarding in and of itself, a simple word of praise at this point, from you, will not be wasted.
“You did it!”
“You took the first step. Good for you.”
So perhaps she didn’t stay in the situation as long as you had hoped. Maybe she didn’t do everything exactly as planned, but remember successive approximations from graduate school? This is the process of rewarding small movements or approximations of the target behavior, until the behavior is executed successfully. Shaping behavior in this way takes a few trials so be patient.
It’s not all good, however There may be some problematic aspects to correct for next time, but go ahead and praise what you honestly and sincerely can. Normalize distress and avoidance, and later, after you have extracted all that you can from what went well, constructively discuss the changes that are needed for the next time.
Praise as corrective information
Praise is emotionally rewarding if it is believable, sincerely given and meaningful to the one being praised. But one of the most important things about leading with a bit of praise for effort in this context is that it informs and corrects. For this purpose, it must be descriptive, specific, and timely. One of the biggest problematic beliefs in PTSD is some version of “I am weak for reacting the way I did (having PTSD),” “I should have been able to handle this by myself, ” or “I am incompetent and everyone knows it.” Your specific praise, as well as comments pointing out the evidence against these beliefs is a clear indication that you don’t buy it. On the contrary, you know the treatment is challenging, you appreciate your client’s courage and determination, and you have confidence that she will be able do it. When your praise is targeted in this way, it is not a mindless pat on the head: it actually is corrective information in action.
Broaden your repertoire
PTSD almost always includes many negative, inaccurate thoughts about the self. I hope you take every opportunity to specifically and descriptively comment on, and praise any thought and behavior of your client that disconfirms his deeply held negative beliefs. This means you are going to be praising her a lot, so increase your repertoire of responses. “Great job” is nice to hear a few times, but it starts to sound rote and insincere after awhile. Use humor where it is appropriate.. Tie your praise to the evidence. Look for ways to weave praise into your discussion without fanfare. For example, sometimes a simple statement of fact is a sneaky way to get in some covert praise on the fly.
“You are really working hard.”
“You did it.”
“I can see that you are putting a lot of effort into your homework.”
“You took that one on like nobody’s business.”
“You were like the energizer bunny this week!”
Review the Data
The data begins with the in vivo exposure recording form itself. This form is your client’s experience on paper, and when you go over it together, he can use the recorded data to recall what the experience was like in detail. Most forms use numbers – SUDs - to track the experience, but it is equally valid to use a graphical representation that gives a visual picture, if that is more meaningful for your client. Review the worksheet to get clues about where you might need to focus the discussion. For example, the SUDs data tell you how difficult the assignment was and whether it got easier, or remained distressing throughout the exercise. The number of repetitions tells you about your client’s enthusiasm, commitment to the process, and perhaps something about barriers to doing the treatment, if there are only a few or no repetitions. Perhaps there are notes on the form as well, telling you about your client’s reactions in the moment. Even a sparsely completed form is a clue for follow-up.
Let the client do the talking
While you are reviewing this rich data, resist the urge to open your mouth and start talking, unless you are going to offer praise, or clarify something you don’t understand. Instead gather the data from your client before you start offering your wisdom. Get her impressions of the experience before offering your own. You can use open-ended questions like these:
“How was this experience for you?”
“Did you learn anything new?
“Were your fears confirmed?”
“What are your thoughts?”
“What do you make of the numbers?”
“Was it as bad as you thought?”
“What kept you going? Why were you able to hang in there?”
Normalize PTSD related distress and avoidance
Chances are, even if the assignment went well, your client had some PTSD related distress or avoidance along the way. This is expected, predicted and should be treated as such. Let her know that this is par for the course. Be empathic and compassionate, but accept, and help your client accept, that distress and avoidance are part of PTSD, and confronting them is a planned part of the treatment. Emphasize the opportunity to test out problematic beliefs about distress, its alleged omnipotence, and your client’s ability to have a satisfying life even if distress is sometimes present.
E.g., “Even though it was distressing to be in such a large crowd, you were pleased to be able to attend the graduation ceremony for your daughter. “
Look for habituation, emphasize tolerance
We are always delighted when we see those SUDs numbers going down during the in vivo exercise and across repetitions of the same exercise, right? Look for it, and if you see it, ask about it. Find out how your client views the decrease. Did it get easier, or did she disengage? Did she use distraction or other safety behaviors, or did she habituate?
If the habituation seems credible, celebrate it, but don’t make it your only measure of success because not all the in vivo assignments will follow this pattern. Though some patients successfully habituate to everything on their hierarchy, others do not, and they get better anyway. Sometimes distress tolerance is as important as habituation. And it is a useful skill to highlight and develop because in the end, there will be more distress in life. Learning to tolerate and move through distressing experiences will give your client another way to take care of herself.
Finally, you get to talk
By now, your client may have worked through her experience with your support, of course, and there is nothing left to say except “great job.” But chances are you have noticed some things your client didn’t, so now is the time to ask more pointed, but still open-ended questions. Help your client deconstruct problematic beliefs by asking for more information about her views versus the new information learned in the in vivo. Look for thoughts and beliefs that maintain symptoms and focus the discussion toward these by asking about experiences during the in vivo and at other times that are contradictory.
E.g., “You say that you don’t have control of your temper, but you were able to be civil even though the clerk was rude to you and you felt very angry about it. What do you make of that?”
Now is the time process the safety behaviors or avoidance that may have interfered with learning. What triggered the avoidance? How did the safety behavior function in the exercise? Did it allow your patient to stay when he otherwise would have escaped? Did it prevent him from experiencing distress? Did it help or prevent him from testing his problematic beliefs? Is he willing to drop the safety behavior for the next assignment? Is he willing to stay longer and test the problematic beliefs that maintain avoidance?
Resist the urge to sum it all up in a nice little package. Your client may need to do the exercise a few more times before she can come up with more helpful ways of viewing the situation. Let her have that experience. It will teach her so much more than your possibly brilliant but premature summary could do because it will include the nuances of her own life and her own reactions that you cannot possibly know. So be patient. There are times when you will lead your client more directly, but this is always a second line strategy. Let the more powerful strategy of personal experience have a chance to work first.
Do it again
Once you have sufficiently mined the experience for all that it is worth, it is time to collaborate with you client as you plan the next in vivo exercise. Is there more to learn from this item or has it been sufficiently processed? If it is still difficult, or if there are problematic beliefs or safety behaviors still at play, it is important to continue working on it. Does it need tweaking to get at other aspects of the core fear? Are there new questions that need to be tested? Will the corrective information gleaned from this experience easily generalize to other, similar activities, or do you need to change the context to encourage more generalization?You will be aiming to move up the hierarchy as you progress from session to session, but don’t get married to the original hierarchy. New situations may come up as your client gets more active and engaged with his life. Add those new situations as they arise.
While this may seem like a lot to do in homework review, it doesn’t usually take more than a few minutes, and as you model this approach each session, your client might begin processing on her own, making your job even easier. In the end, as with all your interventions, you are not only working through the traumatic experience, you are teaching your client a set of skills, and an approach to life that will serve him well in the future.
Am I the only one who has a hard time keeping my “pearls of wisdom” to myself so the client has a chance to find their own wisdom?
Am I the only one to discover that my fabulous would-be interpretation of the client’s experience was totally off the mark (whew, glad I kept my mouth shut that time!), when he found his own wisdom a few sessions later?
What have you learned helping people process their experiences in therapy?