So you have constructed an in vivo hierarchy in collaboration with your client. You have identified a variety of exercises across a wide range of SUDs ratings that appear to target the client’s core fears. You have proactively discussed the use of safety behaviors and asked your client to refrain from using them during the in vivo exercises. You’ve specifically instructed them not to use the breathing retraining exercise they’ve been learning when they do in vivo homework.
Next, according to the PE manual (Foa, Hembree & Rothbaum, 2007), you will work with your client to choose a couple of moderately challenging items (SUDs = 40-50) and assign them for daily homework between sessions. You will instruct your client to rate his/her distress before, during and after the exercise, and remind him/her to stay in the situation for 45 minutes or until their SUDs decreases by half.
Beyond these instructions what else can you do to maximize the likelihood your client will benefit from in vivo exposure?
Here are a few ideas to help focus the work and put your clients on track to complete the exercises successfully.
1. Let your clients know that a reduction in distress may not be experienced during the first exposure exercise.
Though we often emphasize habituation as an important goal of exposure, there is much evidence to suggest that habituation is not the whole story. In fact, habituation during a single trial of an exercise may not be nearly as important as habituation across many trials.
2. Emphasize tolerance of distress rather than reduction of distress.
Again, feeling immediate relief is not the goal of in vivo exposure. If it were, avoidance would be the better choice. Rather the goal is to block avoidance so something new can be learned. The more a clients can tolerate distress (as long as the distress is not coming from actual danger or injury) the more opportunity they will have to stay in the situation and learn something new.
3. Ask clients what they fear will happen during the in vivo exposure and how likely they would rate that outcome?
You may be surprised by the answer, especially if you haven’t assessed these beliefs before. What you see as a fear of mortal injury may really be a fear of feeling vulnerable or guilty, fear of falling apart, or of reacting inappropriately. Sometimes avoidance is so strong and immediate that clients don’t even know the answer to this question. Some simply avoid the distress they feel when confronted with their feared stimuli, but have no strong beliefs about what will happen if they remain present. Clarifying feared outcomes can help unearth and define those underlying beliefs that maintain symptoms.
Even if you covered their feared outcomes when you generated the hierarchy items, be sure to specifically mention and confirm them again before the exercise. This primes clients to look for (or more importantly, notice the absence of) those feared outcomes.
4. Encourage the clients to call for consultation if something comes up to prevent them from doing the homework as assigned.
If you have planned well this shouldn’t be necessary, but sometimes even the best laid plans are fouled up by weather, family crises or broken down cars. I tend to address this by telling my clients that I don’t want them to waste one minute of treatment time because of unexpected foul-ups. If something comes up to prevent their completing an assignment, they are to call me so we can improvise an alternate plan. It is really about accountability. Even if there is no problem and the exercise goes without a hitch, this conversation makes it clear that the stuff we ask our clients to do between session is critical to their success in treatment.
Both for support and for accountability, you may even arrange a planned phone call or e-mail to check in on the homework. This serves the same function but may be more useful if a client is particularly avoidant or disorganized. If you are unable to make calls, setting reminders by automatic e-mail, text message or smart phone might be another option to keep your clients on track and increase accountability.
5. Finally, resist the urge to reassure your clients that nothing bad will happen, or that the in vivo exercises are perfectly safe.
Most importantly this is not true. While we try to construct relatively safe exercises with predictable outcomes, accidents and unexpected outcomes occur. This is actually one of the important lessons our clients need to learn as they work their way through treatment. Bad things may happen, even if you were careful and diligent in your planning of the exercise, and safety is never guaranteed, no matter what the situation.
In addition, your reassurances can become a safety signal that dials down the threat level of the exercise and puts all your hard work constructing a meaningful hierarchy to waste. Instead, if you need to say something encouraging, focus on the work the client is doing to reduce PTSD symptoms and get his or her life back.
In vivo exposure is a powerful tool, and it makes a lot of sense to clients when they understand the rationale. Often, clients are so convinced by the initial rationale that they are motivated to begin making changes in their avoidance habits even before they get to the formal exposures. However, even the best tools can be sharpened and directed in ways that improve their usefulness and accuracy. Spending some time setting up in vivo exposure so that your client is primed to tolerate distress and pay attention to his or her feared outcomes can help focus learning and deepen the processing portion of the exercise in your review of the homework.
What are some ways you prepare your client for in vivo exposure?
Do you have any words of wisdom for your colleagues to help them get the most out of this powerful therapeutic tool?
In the next irregularly scheduled entry on in vivo exposure, I will talk about processing in vivo exposure exercises. Until then...