FAQs for Prolonged Exposure (PE)

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1. Who is appropriate for PE?

2. How do you determine if a client is appropriate for PE? Is there a standardized test I should use?

3. Is PE appropriate for clients who have multiple traumatic events, especially more than one type of traumatic event?

4. Is PE appropriate for PTSD related to trauma that happened long ago such as childhood trauma?

5. Is PE appropriate for clients with comorbid conditions?

6. What about clients with comorbid Substance Use Disorder and PTSD?

7. What about suicidal or self-injurious behavior? Can you use this approach?

8. Can clients with dissociative symptoms be treated with PE?

9. Will repeatedly facing distressing memories, events, and situations worsen my client’s symptoms or cause them to drop out of treatment?

10. Will manualized treatment interfere with the therapeutic alliance?

11.  My clinic is set up for a 50-minute hour. Do I have to do 90 minute sessions?

12.  What if my patient is on a medication like an antidepressant or benzodiazepine. Can I use PE with them?

13.  My patient doesn’t want to record sessions. Is it really necessary?

14.  My patient is worried about having a panic attack during in vivo exposure? What if my patient has had panic attacks in the past when confronting trauma-related cues. Can I still do PE?

15. What should I do if my client is having a hard time identifying their index trauma?

16. What should I do if the client wants to change to another trauma during treatment?

17.  Why can’t my clients use the relaxed breathing technique we teach them during in vivo and imaginal exposure? Won’t they be more willing to try the exposure assignments if they can use it?

18.  I can’t come up with enough in vivo items on my client’s hierarchy. We’re stuck. How can I help them come up with more?

19. Why should I ask my patient for their SUDS throughout imaginal exposure when they recount their trauma memory? I worry about distracting the patient if I ask for these ratings.  The level of distress during imaginal exposure seems clear from the patient’s affect. Is it ok if I skip asking for SUDs?

20.  I am working with a patient who is quite irritable. I know this is part of PTSD, but is there a way of working on this along with the PE protocol?

21. What do you mean by “processing” the trauma memory after my client finishes telling their trauma memory? What do we talk about?

22. How do you define success in PE? When is PE discontinued?

23. What is the HOT SPOT and does everyone have one?

24. My patient reports his trauma occurred during a secret mission, and he is unable to discuss the details with me in treatment. Can I still do PE? Doesn’t HIPAA cover this?

25. What should I do if my PE patient doesn’t do their homework?

26. I’m trained in PE and CPT (or another trauma-focused EBP). How do I know which one to use? Or can I use parts of both?

1. Who is appropriate for PE?
Answer: PE is designed specifically to treat the symptoms of PTSD. It isn’t for people who do not meet all or most of the criteria for PTSD. And because PE involves working with the memory directly, the person must be able to recall the trauma that provoked their PTSD symptoms. It’s all right if the memory is fragmented or confused, but if they have no memory of the trauma or the events surrounding it, PE isn’t the right treatment.

PE therapy is appropriate if the client has:

● Sufficient memory of the traumatic event

● Symptoms of PTSD that interfere with functioning

PE therapy is not appropriate if there are other more urgent symptoms or conditions, for example:

● Imminently suicidal or homicidal

● Experiencing unmanaged psychotic symptoms

● At high risk in an unsafe environment with significant chance for re-traumatization (e.g., the client is living with the perpetrator of sexual violence)

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2. How do you determine if a client is appropriate for PE? Is there a standardized test I should use?
Answer: Before beginning PE or any other treatment, it is important to determine if your patient is likely to benefit from the treatment. This means doing a thorough assessment to evaluate current mental health symptoms and other issues that may be related to the patient’s ability to fully participate in therapy.

It is highly recommended that clinicians use the Clinician Administered PTSD Scale for DSM 5 (CAPS-5) or another structured interview when conducting an initial assessment for the presence of PTSD. It is also recommended that clinicians assess clients for diagnoses that commonly co-occur with PTSD including, at a minimum, major depressive disorder and substance use disorder.  Additionally, clinicians should assess other presenting issues that may affect the patient’s ability to participate in PE effectively. These may include suicidal and other self-harm behaviors, aggression and homicidal ideation, homelessness, and being too busy to commit to treatment. Therapists should fully disclose the work expectations of participating in PE and help patients contract to participate. This includes discussing the time commitment involved in PE and whether the client has commitments that may interfere with the sessions and homework.
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3. Is PE appropriate for clients who have multiple traumatic events, especially more than one type of traumatic event? & 4. Is PE appropriate for PTSD related to trauma that happened long ago such as childhood trauma?
Answer:  Patients with PTSD related to multiple or chronic trauma can benefit as much from PE as patients with a single-incident trauma. PE has been used to successfully treat PTSD resulting from many types of trauma, ranging from sexual assault to motor vehicle accidents to deployment trauma, including patients who have experienced more than one type of trauma. This also includes both Veterans with chronic PTSD stemming from combat experiences that occurred decades ago, and adults who experienced multiple incidents of abuse as children.   Research and clinical practice have shown that there is no relationship between the recency, number, or complexity of traumas and the effectiveness of PE for PTSD.
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5. Is PE appropriate for clients with comorbid conditions?  
Answer: PE is also appropriate for clients with comorbid conditions. Some therapists assume that clinical research on PE excludes subjects who have comorbid conditions in addition to PTSD, but this is not the case.  In fact, many studies have demonstrated that the effectiveness of PE is not changed by comorbid conditions such as depression, traumatic brain injury (TBI), high anger, dissociation, suicidal ideation, excessive guilt, or the presence of Axis II symptoms. Indeed, many of these comorbid conditions are actually improved in the course of PE treatment. For example, it is quite common for depression to decrease along with PTSD symptoms when PE is used, even though it was not targeted directly in the treatment. 
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6. What about clients with comorbid Substance Use Disorder and PTSD?
Answer: Patients with both SUD and PTSD diagnoses are most likely to benefit from a treatment that concurrently addresses both problems areas. In the past, it was common to address these problems sequentially, but several recent studies have demonstrated that patients are more likely to remain in treatment, and to experience positive treatment outcomes in both substance use and PTSD symptoms, if the problems are treated at the same time.
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7. What about suicidal or self-injurious behavior? Can you use this approach?
Answer: Non-lethal self-injurious behavior, suicidal ideation, and past suicidal behavior are not uncommon among clients seeking treatment for PTSD. It is important to conduct a thorough and comprehensive risk assessment with every patient, and to develop a safety plan for clients who are at risk of lethal or non-lethal self-injury. Treatment for clients who are imminently at risk of suicide or serious self-injury should focus on reducing risk and increasing safety before addressing other problems areas, including PTSD symptoms.

However, suicidal thinking or even a history of past suicidal behavior is not a reason to delay the start of PE. In fact, suicidal thinking tends to decline significantly during the course of PE (Bryan et al., 2016; Gradus et al., 2013), and exacerbations in suicidal thinking present before initiating treatment appear to be much less likely for Service members receiving PE as compared to other treatment (Bryan et al., 2016).
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8. Can clients with dissociative symptoms be treated with PE?   
Answer: Clinicians who are treating PTSD patients with dissociative symptoms, which are often seen in individuals with complex trauma histories, should not be discouraged from using PE.  During the course of PE, dissociative symptoms tend to decrease along with other PTSD symptoms. In fact, patients with severe dissociation may actually benefit more from PE due to the structure and opportunity it provides to consolidate trauma memories (Resick, Suvak, Johnides, Mitchell, & Iverson, 2012).  In some cases, when a patient’s dissociative symptoms are interfering with their ability to learn or benefit from the imaginal exposure, the clinician may need to modify the standard techniques to titrate the client’s emotions.  While working with dissociative patients may seem overwhelming, strategies for modifying imaginal exposure can be as simple as asking them to recount their trauma narrative in the past instead of present tense and opening instead of closing their eyes.  These types of modifications are discussed in Chapter 8 of the PE manual (Foa et al., 2007) and please feel free to consult with us.
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9. Will repeatedly facing distressing memories, events, and situations worsen my client’s symptoms or cause them to drop out of treatment?
Answer: Some clinicians are concerned about using a trauma-focused therapy like PE because they worry it will exacerbate their patients’ symptoms or “retraumatize” them.  However, research has shown that while minor symptom exacerbation is normal in the course of PE (Larsen, Stirman, Smith, & Resick, 2016; Foa et al., 2002;), it is experienced by a relative minority of patients, around 10%. Exacerbations tended to be brief “spikes” of increased distress rather than shifts in the trend of treatment response.  The slight worsening did not result in negative outcomes, higher dropout, or increased risk for the clients receiving treatment. By the end of treatment, both groups improved. In fact, when dropout rates are compared across studies, clients are no more likely to drop out of exposure-based treatment than from other evidence-based treatments for PTSD (Hembree et al., 2008)
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10. Will manualized treatment interfere with the therapeutic alliance?
Answer: Like other modern manualized therapies, PE is not intended to replace clinical skill or judgment. Rather, PE is an additional framework that presupposes and depends on the “common factors” characteristics essential to all good therapy - active listening, validation, empathy, genuineness, warmth, and unconditional positive regard. In addition, the treatment is structured to foster alliance-building early in the protocol to improve treatment adherence and outcome.   

Far from being a “cookie cutter” approach, PE requires the development of an individualized protocol for each patient addressing symptoms in the specific situations and circumstances that are most affected.
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11.  My clinic is set up for a 50-minute hour. Do I have to do 90 minute sessions?              
Answer: The original PE protocol required 90 minutes for each session, and we recommend 90-minute sessions if possible, especially if you are new to the treatment. This allows plenty of time to cover all the content and leave time for questions and wrap-up. However, subsequent research has demonstrated that PE can be successfully implemented in shorter sessions. This requires splitting some of the psychoeducational content over more sessions and shortening the length of imaginal exposure in the later sessions. For example, Van Minnen et al., (2009) found no significant difference in improvement in PTSD symptoms when they shortened the amount of imaginal exposure to 30 minutes in order to reduce the overall session length to 60 minutes.   In a more recent study, Veterans showed significant reductions in PTSD symptoms whether they participated in 60-minute sessions that included a 20-minute dose of imaginal exposure or 90-minute sessions with a 40-minute dose of imaginal exposure (Nacasch et al., 2015).  These modifications suggest that PE can be done in shorter sessions, but you will need to manage your time very carefully to meet all of the session goals.   
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12.  What if my patient is on a medication like an antidepressant or benzodiazepine. Can I use PE with them?
Answer: The rule of thumb for patients on antidepressants like SSRIs (e.g., sertraline, paroxetine, fluoxetine) or SNRIs (e.g., venlafaxine) is that they should be stabilized on them for about three months prior to starting PE, but there is no reason they can’t do the treatment while they are taking these medications. At the same time, we have found that after patients have successfully completed a course of PE and their PTSD symptoms (and in many cases depression symptoms) have remitted or subsided, they no longer need to rely on the antidepressant as they did prior to the therapy.

With respect to benzodiazepines like lorazepam or diazepam, the research is clear that they are ineffective for addressing PTSD and, in fact, are harmful (VA/DoD Clinical Practice Guideline, 2017). If you are working with a patient who has been prescribed a benzodiazepine, find out why they are using it, which may require consulting with their prescribing practitioner. If it’s being used to treat PTSD symptoms, provide psychoeducation to both the patient and prescribing provider about how it is strongly recommended against and can have adverse effects. However, if the benzodiazepine is being prescribed PRN for anxiety or to assist with sleep, clarify that it should not be used during exposure assignments because it will limit the patient’s ability to benefit from the experience (i.e., they won’t learn they can tolerate the distress without the aid of the medication).  Specifically, recommend they not take the benzodiazepine before, during, or right after their in vivo exercises, imaginal sessions, and listening to the recordings of their imaginal sessions.
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13.  My patient doesn’t want to record sessions. Is it really necessary?  
Answer: Sessions are recorded to provide the client with additional opportunities to review psychoeducational material covered in the session, as well as additional opportunities for exposure to the traumatic memory outside the session. Though research has not compared PE with and without recording directly, some studies have addressed the role of “homework” as it relates to treatment outcome. This may give us a clue about the importance of “dosage” as it relates to exposure. Cooper et al., (2017) found that patients who completed more of their homework were more likely to have positive outcomes at the end of treatment. Homework in PE includes listening to recordings of the session as well as an in vivo exposure component and breathing exercise.

Eliminating session recordings essentially decreases the “dose” of exposure. As a result, the patient experiences fewer opportunities to process the trauma. Rather than eliminating recording, we recommend discussing the patient’s objections to determine if they have privacy or technology concerns that can be addressed without sacrificing treatment dose. Having an open discussion about their concerns and about the importance of session recordings prior to starting PE can go a long way in building trust and understanding, especially because this aspect of the treatment may seem unusual or threatening.
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14.  My patient is worried about having a panic attack during in vivo exposure? What if my patient has had panic attacks in the past when confronting trauma-related cues. Can I still do PE?
Answer: PE is still recommended for patients who worry about or have panic attacks. As you know, panic attacks, or severe bouts of anxiety that are accompanied by uncomfortable physiological responses such as hyperventilation, dizziness, shaking, and sweating, are not uncommon in clients who suffer from anxiety and may occur in those with PTSD when they are confronted with trauma cues.  A panic response may be one of the most uncomfortable anxiety reactions a patient experiences, resulting in extreme physical discomfort as well as unwanted attention from others, embarrassment, and an increased desire to avoid trauma cues. And while there are fewer patients who suffer from frequent panic reactions, they need to experience only one or two true episodes of panic to produce significant anticipatory anxiety and pervasive avoidance to prevent another.

In PE treatment, panic reactions are viewed as a non-dangerous anxiety symptom that will dissipate with repeated, prolonged exposure, much like other, less extreme anxiety reactions. In practice, it is often possible to gradually move through the anxiety hierarchy such that the patient is never sufficiently overwhelmed to precipitate a panic attack.  For example, by starting your patient at mid-level in vivo assignments (i.e., tasks that are in the 40 to 50 SUDS range), they can learn that they are able to face the situation and ride it out even if their anxiety goes up and they feel uncomfortable. By the time the get to higher-level in vivo assignments (i.e., tasks that are in the 80 to 100 SUDS range), they don’t have the anticipated panic attacks.  In these cases, we will often process their anticipatory anxiety as an overestimation of catastrophe, or an underestimation of their ability to cope or manage.

However, prevention of panic is not and should not be the goal of treatment. A patient may occasionally have a panic reaction during exposure. It is important to discuss this possibility and reaffirm the non-dangerousness, as well as the transience of panic. Panic reactions should not change the in vivo exposure instructions to remain in the situation until anxiety peaks and starts decrease.

In some cases, the panic attacks will merit a separate diagnosis of panic disorder (see DSM-5 for symptoms of panic disorder).  Attempts have been made over the last several years to combine treatment for PTSD and panic disorder to help patients with both disorders.  For example, Multiple Channel Exposure Therapy (MCET), adds interoceptive exposure to a PTSD treatment protocol based on CPT (Falsetti, Resnick, & Davis, 2005). Early trials indicate good PTSD symptom reduction, as well as good improvement on symptoms, though validation of this protocol is still underway.

Other efforts have included combining PE with CBT-based panic disorder treatment, which places psychoeducation about PTSD, common reactions to trauma, and PTSD treatment in the beginning of the therapy followed by a more detailed psychoeducational segment on panic disorder. Subsequently, interoceptive exposure is introduced, after which the PE protocol is resumed, with the addition of interoceptive exposures as needed to continue to address any panic symptoms that continued after the initial sessions of interoceptive exposure. If you have a patient who meets criteria for both PTSD and panic disorder, we recommend that you consult with us about these modified treatment approaches.
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15. What should I do if my client is having a hard time identifying their index trauma? & 16. What should I do if the client wants to change to another trauma during treatment?
Answer:  Selecting the worst traumatic event as the focus of treatment is recommended because this is the event most associated with trauma-related avoidance and trauma-related cognitive distortions. When a client has suffered multiple incidents of trauma that are difficult to distinguish due to the passage of time and/or the similarity of content among the events (e.g., chronic childhood abuse, repeated domestic violence, or multiple combat traumas), it can be difficult for them to select a discrete event. Yet when clients focus on and process their most distressing traumatic memory first, there often is a ripple effect so they don’t need to target other traumatic events, which can expedite the course of treatment.

It may help to remember that the “index” event or target trauma is selected as a matter of efficiency rather than for some ultimate meaning. If possible, the event chosen should be salient in memory and representative of the client’s experiences so that it can be narrated in imaginal exposure. It should be associated with the client’s distress and avoidance so that it can serve as a vehicle for processing. If there is an easily identifiable “worst” event, it usually meets these recommendations, but other events may serve as well.

If during or after imaginal exposure on the “index” event the client becomes aware that another trauma is associated with their distress, they may process the new event as well, but they  should wait until the originally selected  trauma has been fully processed. They should not jump from one trauma to another. While rare, on some occasions, a client may need to move to a second or third trauma after doing a good round of imaginal exposure on the first trauma to gain the most benefit from treatment.

Some clients, especially those who have served in the military, may also struggle with beliefs about what it means to choose one trauma over another; for example, they worry that doing so minimizes or invalidates those events not chosen or even dishonors the military members who were part of those events. In this instance, the client may remember the events distinctly but refuse to choose. This is an opportunity to discuss the client’s beliefs and clarify the purpose of choosing one event with which to begin, while recognizing that other events may be equally egregious, unjust, or deserving of attention.
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17.  Why can’t my clients use the relaxed breathing technique we teach them during in vivo and imaginal exposure? Won’t they be more willing to try the exposure assignments if they can use it? 
Answer: While relaxed breathing can reduce distress in the moment, it is important for the client to experience the natural course of arousal as it peaks and habituates. If the patient does relaxed breathing during in vivo or imaginal exposure, they may misattribute decreased distress to the breathing rather than to habituation and begin to use the breathing as a safety behavior. It is preferable the client learn they can tolerate distress without using special techniques or performing certain behaviors, and that distress will decrease on its own with time and exposure.

In addition to the relaxed breathing technique, look out for other safety behaviors clients may use during exposure, such as carrying a weapon, relying on their smartphone, engaging in rituals or superstitious behavior, constantly scanning, or only going out if they are with a family member. Although seemingly benign and helpful, these kinds of safety behaviors are actually avoidance strategies that reduce a client’s distress in the short run but help maintain their PTSD symptoms in the long run.
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18.  I can’t come up with enough in vivo items on my client’s hierarchy. We’re stuck. How can I help them come up with more?
Answer: There are several strategies you can use when you and your client are struggling to identify in vivo items.  Review your client’s current symptoms. If they have PTSD, by definition they are avoiding trauma-related cues of some kind, but they may be unaware because their avoidance behaviors have become a habit.  Ask about how their life and their activities have changed since the trauma. What things did they previously enjoy that they no longer do? What would family members or friends say they avoid or have stopped doing since the trauma? If there are only a few avoided situations, look for ways to make those situations easier or harder by changing some characteristics of the activity. For example, if they avoid going to the grocery store, ask if it would easier to go with their partner or at a time when it is less crowded.  Additionally, help your client pinpoint the core fear associated with identified items, then look for other contexts or activities where they may encounter the feared stimulus. You can also suggest commonly-avoided situations or activities reported by other trauma survivors to see if they resonate with your client -- for example crowds, open spaces, or social events. If your client can identify with them, ask for examples from their life. Finally, remember that your client’s in vivo hierarchy is a work in progress. Encourage them to take the list home and add items that come to mind as they move through their daily activities.
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19. Why should I ask my patient for their SUDS throughout imaginal exposure when they recount their trauma memory? I worry about distracting the patient if I ask for these ratings.  The level of distress during imaginal exposure seems clear from the patient’s affect. Is it ok if I skip asking for SUDs?
Answer: Collecting the SUDs helps you track changes in distress over time, and helps you identify hotspots when it is time to focus on specific parts of the memory. It may be the case that your subjective evaluation will correspond with the patient's SUDs rating and therefore seem superfluous, however, it is important to have convergent data. It may happen that the subjective appearance of the patient is different from the SUDs rating given. At those times, the SUDs rating is most useful, for it can indicate the patient is less or more engaged than perceived, or it can highlight some important piece of information that might be untold but contributory, thus giving you clues about what to prompt or ask in the next iteration.

To be as unobtrusive as possible, prepare the patient for the brief but regular interruptions, and instruct them to answer quickly and continue with the narrative. It can feel odd if you are not accustomed to interrupting in this way, but if you prepare the patient in advance and prompt them to stay engaged, we discover that most patients do not find it to be distracting or disengaging, even if it is a little awkward for the therapist.  Finally, consider explaining how the SUDs ratings gathered during the imaginal exposure - like the SUDs ratings they record for their in vivo assignments - are important data to track their progress during treatment along with their self-report scores.
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20.  I am working with a patient who is quite irritable. I know this is part of PTSD, but is there a way of working on this along with the PE protocol?
Answer: Irritability is part of the arousal cluster of PTSD and should dissipate as other PTSD symptoms do during the course of PE, though this cluster of symptoms often dissipates last after the others have decreased. While you don’t need to target irritability in particular, it can help to highlight and work through cognitions associated with irritability during the processing of exposure exercises. In some instances, irritability and anger may mask underlying emotions that are more difficult or vulnerable for the patient to identify or express, such as sadness, fear, or guilt. It is important to be on the lookout for this potential, then work with the patient to address these other emotions and the thoughts associated with them that may be keeping them stuck. Also, keep in mind that Service members and Veterans tend to be more willing to express their anger than other emotions, given the premium placed on it and aggression in their military training.
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21. What do you mean by “processing” the trauma memory after my client finishes telling their trauma memory? What do we talk about? 
Answer: Processing in PE is functionally similar to cognitive restructuring, though it is generally much less structured than formal cognitive therapy. The main goal is to help the client gain a more balanced perspective about, and an improved sense of mastery over, their trauma memory so it has less power or pull over them. This means helping them to develop more realistic or accurate beliefs and new insights regarding themselves, the world, and others, which often occurs during the reflection period that immediately follows imaginal exposure.

When the client has repeated the memory for the allotted amount of time, you will prompt them to stop so that you have time to process the memory and assign homework before the client leaves the session. Though you can be more structured if you like without negatively affecting treatment outcome,  the protocol certainly does not call for this.  Instead, the discussion that follows is typically more informal and should provide support for the client’s courage and effort, validate their reactions during the trauma and in the present, and help them identify and evaluate cognitions that maintain symptoms, and develop more adaptive views to move forward. 

Processing in early sessions is likely to be more heavily weighted toward support and validation than identification of the client’s beliefs related to the trauma.  It relies more heavily on open-ended questions to draw out the client’s views and emotions so that they are available for examination, rather than directly challenging the client’s beliefs. As treatment progresses and the client’s views are more fully elaborated, the discussion should shift to focus more on unhelpful thoughts and beliefs. In later sessions, the therapist may offer alternative views or other insights to help the client evaluate and revise cognitions that hamper functioning. 
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22. How do you define success in PE? When is PE discontinued?
Answer: There are several sources of data to consider with regard to successful treatment outcome, and ideally, they should converge toward the end of treatment.  The client should report significantly fewer symptoms on self-reports like the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5).  As habituation occurs, in vivo assignments should become easier to manage and provoke less distress.  If some distress remains, the client should find that they are able to manage their emotions and behavior in a functional and adaptive manner during those experiences, unhampered by intense or debilitating emotions. During imaginal exposure, the client should be able to recount their trauma narrative without intense or debilitating fear or anxiety, though they may continue to experience sadness, anger, and other appropriate primary emotional responses to this negative event. Consistent with this experience, SUDs ratings collected during imaginal exposure should be low or moderate.  Some clients even describe feeling bored by their narrative rather than distressed near the end of treatment, but not always.

Cognitively, the client should be able to distinguish the memory from the trauma itself, and recognize that the memory, though unpleasant, is not dangerous.  Usually clients are able to articulate that they “are done with it”, i.e., the trauma memory no longer has power over them. Maladaptive beliefs about the self (e.g., I’m incompetent; I can’t cope; I’m weak) are replaced with compassion for self; and maladaptive beliefs about the world (e.g., Nobody can be trusted; The world is unsafe; Everything is dangerous) are revised with more realistic or balanced views to permit greater functionality in everyday life. Finally, functioning in areas typically hampered by PTSD symptoms -- such as interpersonal relationships, work, and overall quality of life -- should be improving.
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23. What is the HOT SPOT and does everyone have one?             
Answer: Hot spots are segments of the imaginal exposure narrative that are most disturbing to the patient after other parts have ceased to provoke significant distress. They are often the portion(s) of the trauma memory that are directly relevant to the cognitions that maintain symptoms and which are, therefore, addressed intensively later in treatment. In PE, you should be looking for hot spots sometime between sessions 5 and 7, typically. By focusing on the identified hot spots one at a time rather than retelling the full trauma narrative over and over again, the client can more efficiently work through those parts of the memory that still carry intense emotions.

It is possible that a client may not have a hot spot, but this is likely an exception rather than a common occurrence.  If your client is struggling to identify hot spots, you can help by pointing out what parts of the memory still have high SUDs ratings associated with them or where you’ve noticed they have trouble getting through a section (e.g., they skim through or jump over that portion or aren’t able to provide sensory details). It can also help by sharing a metaphor to explain what a hot spot is. Examples are found in chapter 6 of the PE manual or in our PE Metaphor Bank.
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24. My patient reports his trauma occurred during a secret mission, and he is unable to discuss the details with me in treatment. Can I still do PE? Doesn’t HIPAA cover this?
Answer: It is true that if your client participated in a mission requiring security clearance, then he won't be able to discuss details of it with you, even though your records are protected by HIPAA. It would actually be a violation of the law for him to do so. It is also possible that your client, like most people with PTSD, would prefer to avoid discussing their trauma because it is distressing to do so. Your client may use the secrecy of the mission as an avoidance strategy to prevent facing it at all.

What happens in a traumatic event can often have little to do with the strategic or tactical detail of a particular place, date, time, or mission. So, find out if the details of the particular mission, the mission goals, the names of individuals, the dates and places are important to the trauma itself.  Is it possible for your client to discuss the trauma without including those details, but also without sacrificing the organization and articulation of the memory that needs to occur in imaginal exposure?

Your client may, in fact, be able to engage in the imaginal exposure by describing the trauma itself rather than the specific details of the mission -- for example, a firefight, an extraction, combat death, etc. Many missions, secret or not, are similar, so you are not likely to identify those details during imaginal exposure. Don’t jump to the conclusion prematurely that a client with this type of trauma won’t be appropriate for PE without considering these questions. 

However, If the mission details are key, or if lingering concerns about possible security violations distract from treatment, choose another method of treatment. CPT and EMDR do not require clients to share their trauma in as much detail, so these may be good options. Also consider discussing with your client the idea of seeking treatment within his or her organization. Special Operations organizations have psychologists with training in evidence-based PTSD treatments and a security clearance high enough to discuss any details needed for effective treatment.
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25. What should I do if my PE patient doesn’t do their homework?
Answer: Non-compliance of practice assignments is an important concern, since successful homework completion is linked to successful treatment outcome. Therefore, when non-compliance arises, it should be addressed directly and immediately as a threat to successful outcome.  However, because noncompliance is highly related to avoidance, especially in PTSD, homework noncompliance should be anticipated as a normal part of treatment, and as an opportunity to learn more about the client, as well as to refine the treatment plan to better help the client. Homework review should never be experienced by the client as a time of judgment or blame, but rather dealt with collaboratively and with understanding. Accomplishing the session agenda should not be postponed. Address homework issues at the beginning of the session, with additional focus given at the end as needed. 

Compliance barriers can be highly idiosyncratic but can often be grouped into a few problem-solving targets: a) logistical barriers -- for example, a military client who is given an unexpected duty assignment that prevents him from doing homework; b) incomplete or inaccurate understanding of the rationale for treatment or instructions; and c) symptomatic avoidance. Keep in mind that targets may overlap. As you discuss the barriers to homework, you may need to address all three targets.

When logistical barriers are at the root of non-compliance, problem-solving can help eliminate or work around life circumstances that stand in the way of completion. Unexpected life events, family crises, financial/employment issues, technology or transportation failures, and lack of material resources are just some of the barriers that may interrupt homework. These issues may derail treatment completely if they are significant; however, most often they present complications which may be overcome with forethought and planning. Problem-solve with the client to develop solutions that facilitate homework while respecting that sometimes life gets in the way.

When the issue is incomplete or inaccurate understanding, it is useful to repeat the rationale and instructions.  Make sure you supplement your explanation with analogies and metaphors that resonate with the client.  Draw examples from your own experiences and those of the client to illustrate the principles of the rationale. Confirm that the client fully appreciates the explanation by asking him or her to explain it to you in their own words.

When logistical barriers and understanding have been eliminated, PTSD-related avoidance is the likely culprit.  Even if the main reason for non-compliance is lack of understanding or logistical barriers, avoidance may play a role.  Explore the anxiety level anticipated by the PE assignment and make sure it isn’t too high. Sometimes a client will rate an in vivo item only to discover it is much more difficult than anticipated.  It may be necessary to start with a lower-rated assignment. Also check to see if an in vivo assignment involves more than one trigger. For example, an assignment to go to a crowded shopping area may also involve triggers due to the time of day or night, the area of town, the means of transportation used to get there, or other unanticipated cues. It may be necessary to separate the triggers into multiple assignments if this is the case. 
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26. I’m trained in PE and CPT (or another trauma-focused EBP). How do I know which one to use? Or can I use parts of both?
Answer: Both CPT and PE are equally effective in reducing the symptoms of PTSD, and despite several head-to-head comparisons, neither has emerged as preferable for one or another subset of clients, conditions, or circumstances. If a client has access to both treatments, they should be given a clear and descriptive summary of both to help them decide which seems preferable. If you are trained in both CPT and PE but feel significantly more comfortable or confident in one, you can convey your preference for it in your overview while still giving your client a choice.  Remember that a client’s motivation to engage in treatment is influenced by how credible they find the therapist; it’s likely you will convey more credibility when you’re describing the EBP you prefer.  

With regard to mixed approaches, while both treatments are based on theoretically sound principles and have some areas of overlap, outcome research has focused most often on the standard CPT and PE protocols as standalone treatments with only a few notable exceptions. Foa and colleagues compared standard PE to PE combined with cognitive restructuring in one instance (Foa et al., 2005) and with stress inoculation training (SIT) in another instance (Foa et al., 1999). In both studies, though these extra therapy elements did not appear to negatively affect outcome, adding them to the standard protocols did not produce better results. And there actually was a trend toward higher dropout in the combined approaches, suggesting that the additional burden might have been too much for some clients.

We recommend choosing one EBP or the other to save both you and your client time and confusion. Sometimes more is not better!
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