Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
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I have been training providers in Prolonged Exposure therapy (PE) and collecting outcome data for the past seven years. Since I arrived at the Philadelphia VA Medical Center, I have been involved in the training of approximately 45 clinicians in PE and collected outcomes for over 300 cases. And while what follows is certainly not an exhaustive list of factors to consider in providing PE to a Veteran population, it does represent a convergence of my clinical observations and our empirical findings. With that stated, my findings and observations in providing PE to veterans are: 1) therapist experience matters; 2) service-connection is an important issue; and 3) not enough attention is paid to safety behaviors.
Starting with therapist experience, while the majority of PTSD treatment outcome research suggests that provider experience does not affect treatment outcome, our findings suggest that it may. Specifically, we compared the outcomes from “well-experienced” PE therapists (therapists who have completed 10 or more PE cases) with those from “less-experienced” therapists (therapists who completed less than 10 cases) and found that well-experienced therapist had fewer dropouts and better outcomes, i.e., lower post-scores on the PTSD-Checklist (PCL) and the Patient Health Questionnaire (PHQ-9). I see this as encouraging as it may suggest that, with practice, providers get better at delivering PE. Alternatively, it could be that well-experienced therapists become more astute at identifying those individuals who are motivated and likely to benefit from PE.
The finding that well-experienced therapists have fewer dropouts was not surprising to me. Not only have a small handful of studies also found this, but as a PE supervisor I have long believed that drop-out varied according to provider experience and skill. My observations have been that experienced providers tend to be more skilled at cultivating strong therapeutic relationships and delivering PE interventions within the context of this relationship. As a result, they are better able to shepherd patients through PE. I grew up playing tennis, and had many different coaches, and while I was intrinsically motivated, I also recall differences in my motivation (and performance) depending on how much I liked my coaches. With the coaches I liked, I showed up to more practices and tried harder at those practices than I did with coaches I liked less. The parallels with the therapeutic relationship and PE are clear. It is the relationship that brings patients back, session after session, even when they have to recount distressing memories and put themselves in uncomfortable situations.
Alternatively (or in addition to), it could be that experienced providers are more confident in the treatment and this is passed on in non-specific ways to the patient with the end result being greater buy-in for the treatment rationale. When I first started using exposure, I was overly concerned about how difficult it would be for patients, and feared they would not be able to tolerate the distress and therefore would drop-out. Needless to say, they often dropped-out. As I gained experience and confidence in myself and exposure therapy, I became less hesitant and began to share with patients my belief that they would be able to handle the treatment and any distress that may arise therein. I even encouraged them to “lean into” their emotional reactions during treatment. I now have far fewer drop-outs. My confidence allays the anxiety of my patients whereas before my lack of confidence fueled it. Thus, with provider experience comes confidence in the treatment which may be reassuring to patients and result in greater treatment buy-in.
We also found that patients who were receiving disability compensation for PTSD (or other mental disorders) had smaller treatment gains in PE than those who were not receiving disability compensation. This finding is consistent with research with outcomes for various medical procedures. It is also consistent with concerns that VA clinicians have about the current compensation and pension system for PTSD in which monetary compensation is contingent on the continuation of PTSD and other mental health symptoms. Such a system sets up competing and conflicting interests for Veterans and clearly seems to be at odds with recovery-based goals of evidence-based treatments such as PE. In no way do I wish to suggest that Veterans should not be FULLY compensated for their PTSD symptoms. However, to make that compensation contingent upon the continuation of symptoms with the possible result of symptom improvement being loss of income seems to dis-incentivize engagement in an already difficult treatment. If I were trying to lose weight, but was told that for every weight goal I achieved I was more at risk for losing monthly income, my motivation would be adversely impacted. Nevertheless, in our study, Veterans who were service connected still experienced significant reductions in symptoms, but less than those who were not service connected. Specifically, Veterans who were service connected had a mean PCL reduction of 15 points, while Veterans who were not service connected had a mean PCL reduction of 23 points. While this was a significant difference, a reduction of 10 or more points on the PCL is generally considered to be clinically meaningful. As such, Veterans who are service connected are still benefiting from treatment, just less than their non-service connected counterparts.
Finally, far too little attention is paid to the role of safety behaviors in most PTSD treatments. Safety behaviors (also known as “false safety behaviors” or “safety-seeking behaviors”) are behaviors performed to reduce situational feelings of anxiety or distress, which have the unintended effect of maintaining, and even exacerbating, anxiety over time. While the term implies an overt behavior, safety behaviors also involve internal mental processes such as scanning and monitoring. When I say that little attention is paid to safety behaviors, I mean that there is no formal assessment for safety behaviors, no session content dedicated to discussing safety behaviors, and little if any guidance for addressing safety behaviors in PE. This is surprising given that research has found that addressing safety behaviors enhances outcomes in exposure therapy. Additionally, research has also found that safety behaviors: 1) preserve anxiety and beliefs about threat and danger; 2) block the development of self-efficacy; 3) can increase situational anxiety; and 4) increase general levels of anxiety over time. Partially in response to this lack of attention, we recently developed a measure of safety behaviors (the Safety Behavior Assessment Form- SBAF) relevant to anxiety disorders and PTSD. While it has only been delivered to a small number of veterans undergoing PE (around 35), preliminary findings suggest that pre-treatment levels of safety behaviors are positively correlated with drop-out. Thus, Veterans with higher pre-treatment safety behaviors may be more likely to drop-out. Examples of PTSD-related safety behaviors assessed by the SBAF include: 1) scope places out before entering; 2) watch others for signs of danger; 3) sit with back to the wall; 4) rush through stores to get desired items and leave as quickly as possible; and 5) check locks on doors and windows. Examples of other types of safety behaviors assessed by the SBAF include: a) social anxiety-related safety behaviors (e.g., pretend I do not see or recognize someone so I don’t have to speak to them, monitor others reactions in conversation, try to hide anxiety); b) generalized anxiety-related safety behaviors (e.g., Research things before I start or before making a decision, seek reassurance about a decision); and c) panic and health-related safety behaviors (e.g., carry a medication in case its needed, request specialized medical exams from providers, pay attention to body for physical symptoms or sensations).
In another small sample, we also administered the safety behavior assessment form and the posttraumatic cognitions inventory (PTCI). Total correlations were strong between the two measures, but the highest subscale correlations were with the “negative beliefs about self” subscale. Thus, safety behaviors may be intimately involved in the failure to develop self-efficacy. Other interesting findings emerged from these correlations. First, not only did PTSD related safety behaviors correlate with the PTCI, but generalized and social anxiety-related safety behaviors correlated with the PTCI as well. This may have treatment implications and suggest that assessment for safety behaviors should be broader then just those aimed at minimizing the possibility of physical threat. Common generalized anxiety safety behaviors are seeking reassurance, calling loved ones to make sure they are okay, procrastinating, or trying to do things perfectly. Common social anxiety related safety behaviors include leaving events early, monitoring conversations, attempting to hide anxiety, etc.
I have found it difficult to explain the importance of addressing safety behaviors to individuals with PTSD. An analogy that has helped in describing the impact of safety behaviors is that of an over-active anti-virus software program that runs continuous and consecutive scans. While it may be detecting viruses early, other important programs lose functionality because too little RAM is remaining. As a result, other important programs freeze or shut down or are limited. Similarly with safety behaviors, they may or may not keep the individual more safe, but other important life areas and functioning are compromised by their presence. I have found it important to spend time educating Veterans about safety behaviors and the way in which they maintain PTSD and anxiety. I stress that dropping safety behaviors will allow Veterans to feel more comfortable in situations and fully engage in important life activities (as opposed to trying to convince them that they are not necessary). Once I have provided education about safety behaviors I then ask Veterans to monitor their safety behaviors without trying to make any changes. From this monitoring, as well as the SBAF, I am able to generate a hierarchy of 10 or so safety behaviors to be addressed in treatment. Together with the Veteran, I choose 1 safety behavior per week to work on dropping or fading. I assure the Veteran that perfection is not the goal, but rather a willingness to keep on trying to drop safety behaviors is what will win the day. During actual exposure exercises, I talk with Veterans ahead of time about what safety behaviors could get in the way of fully engaging in the exposure. I instruct Veterans to recognize without judgment when they are engaging in a safety behavior, drop it, and then return their attention to the exposure task at hand. Again, I stress that perfection is not needed, but a willingness to try is.
In summary, therapist experience seems to matter, and fortunately we seem to get better at PE with practice. Issues related to service connection disability and treatments like PE are important, yet not resolved. Veterans are not only deserving of full and complete compensation, but also of the best treatments unfettered by conflicts of interest. Finally, pay attention to patients’ safety behaviors when treating PTSD and not just those associated with physical safety because of their possible connection to dropping out of PE and maintaining negative beliefs about oneself.
Jason T. Goodson, Ph.D. earned his Ph.D. from Utah State University in 2005 and then completed a two-year postdoctoral fellowship through Dartmouth Medical School in exposure-based treatment for anxiety disorders. He then began working with in the VA system and is currently a staff psychologist on the PTSD Clinical Team at the Philadelphia VA Medical Center (PVAMC) and functions as a supervisory psychologist. Dr. Goodson is also the evidence-based psychotherapy (EBP) coordinator for PVAMC and a national trainer and consultant for prolonged exposure therapy for PTSD. He has published scientific articles in the areas of PTSD, anxiety, and health. Dr. Goodson regularly presents at local and national conferences in these same areas and had been an invited reviewer for several scientific journals. He also has a small private practice specializing in the treatment of anxiety and trauma in Center City Philadelphia.