Ask the... Prolonged Exposure Therapy for PTSD

In My Humble Opinion
1

I’m in the mood to focus on something positive, so I thought I’d share my experience with prolonged exposure therapy here.

The gist: In Fall of 2009 I underwent three months of prolonged exposure therapy to treat my severe PTSD. Prolonged exposure therapy is currently one of the most empirically supported treatments for the disorder. At the clinic where I received the treatment, which is highly structured, they had a whopping 90% symptom reduction rate (which is practically unheard of in a clinical setting.)

I know there are some people out there who are curious about the treatment (as it is very effective but AFAIK very underutilized because the very idea scares people away) so I thought I would start a thread answering questions about what the process is like and how it has affected me personally. I’ve also done several other types of therapy and would be happy to compare and contrast for anyone who is apprehensive.

Ask away.

2

Did it work well for you?

If you don’t mind going into it, can you explain what caused your PTSD? What did the therapist do to expose you to triggers?

3

I heard you mention the PTSD several times & I’m really interested to hear more about it. I just didn’t really know what to ask, so I had been hoping others would ask for me. OK, lemme try:

Was it scary to do?

Was part of the therapy talking about the cause of the PTSD a lot? Did you find that difficult, or was it also relieving?

You did the therapy for only three months, is that the normal amount of time or was it cut short for some reason?

Is it more about changing the response to triggers, or more about learning to deal with the initial cause of the PTSD, or both?

4

Incredibly, shockingly well. I used to be extremely hypervigilant and just immersed in this constant sense of impending doom. I didn’t feel safe anywhere and felt like I could be triggered at any time. The only major symptom remaining is I have nightmares 1-2 times per month. I used to have these a lot more frequently and the sense of dread would stay with me the entire day. Now I feel better as soon as I wake up. I’m not even sure I would qualify for a diagnosis of PTSD at this point.

The PTSD was caused by repeated traumatic experiences in childhood as a result of being raised in an abusive environment.

There are two major types of exposure throughout the therapy. The first is imaginal exposure, where you close your eyes and go through the traumatic event from start to finish, out loud, repeatedly - maybe four times through in a session. Then you take the recorded disc home and listen to it for an hour every day, recording your anxiety levels. At first it’s horrible, and you hyperventilate and cry and hurt, but the more you go through the memory the less you fear it and the less it upsets you. You keep listening, over and over, and reliving the memory, until it’s kind of tedious and boring.

Since my experience was more repeated and ongoing incidents of trauma, what we did was sort of conglomerate them into one narrative, drawing out the major themes. For example, we focused on one of the most traumatic things I remembered - my mother threatening to shoot me with my stepfather’s shotgun - but the events leading up to it, the conflict that ensued, a lot of that was pieced together from incidents over the years. The goal isn’t necessarily to remember every single detail accurately, but to tap into the horror of the experience and confront the anxiety associated with it.

The second part is in vivo exposure, where you identify common triggers and deliberately approach them. This was done at home. First you create a trigger hierarchy, starting small and building up. One of my early exposures was taking a shower without locking the bathroom door, for example. A huge one was keeping my eyes closed at night even when I heard a noise and thought someone had broken into the house. Gradually I became accustomed to the anxiety and eventually these things did not trigger the same anxious response.

5

I think I was less scared than the average person because I knew the science backing it up and I was highly confident that it was going to work. The hardest part for me was being willing to lose control of my emotions in front of a therapist. I had previously refused to cry during sessions, and this required full out weeping and yelling and whatever, as well as talking in very personal detail about the trauma - down to the colors, sights and sounds of every moment. I think deep down I was terrified that if I told the details, the therapist was going to tell me it wasn’t a big deal or something. But taking that step was extremely important. It was a very big deal.

The therapy is almost exclusively focused on specific memories of traumatic events. At first, my symptoms got much worse, which was to be expected. After about 3 weeks of daily exposure, it started getting a lot easier, and then I was amazed to be going through these memories which had once caused so much terror, just laying there calmly - still feeling the hurt, but feeling so much more in control and accepting of what had happened.

The average session is 12 weeks, but because I had a few different issues to address, we expected it to take longer. I ended up stopping earlier than planned due to a demanding graduate school schedule, but my psychologist looked at my self-report scores and told me I was already doing better than most people and it would be okay to stop. She also told me I would continue to feel better over the next few months even though I wasn’t in therapy. I was skeptical of that, but she was right. The more time passes, the better I feel.

It’s about both. During the imaginal exposure, the best way I can explain it is that you walk through that memory with your present self holding your own hand. I was a child then, and some part of my brain got stuck in that reactive child state - hence the PTSD. But now I was experiencing this both as a child and as an adult. I saw the same events from an adult perspective. I stopped needing other people to validate what I had been through, because I realized I’m the only one who really knows, and I can be my own witness.

6

Thanks Olives! I am so glad that it has been working so well for you and that you feel so much better. I especially like the idea of walking through your memories holding child-olives’ hand. I can really imagine that.

So a specific question about the differences: first if you were to step into the shower trying not to lock the door, you would…?
And now, you would…?

And previously if you were to read a thread here about a mother threatening her child, you would…?
And now, you would…?

What would you say the biggest difference is? Is there anything you could previously not do, that now you can?

(These situations might actually not apply, if so pls adjust them! I’m just trying to get it really concrete.)

Thanks again for sharing this with us, it’s really brave of you! Obviously if there is anything you don’t want to answer then don’t!

7

Before, I could not shower without locking the bathroom door. I was also prone to peeking around the curtain to make sure nobody was there. Now I shower with the door open. I have occasional twinges of anxiety but I don’t peek.

I would become very anxious, interpret everything that was said personally, and probably post a lot of TMI. Then I’d spend the rest of the night obsessing over my past, and go to bed early in the morning, freaked out and exhausted. In the morning I would regret what I posted and feel ashamed.

Now, I view these threads more or less as objectively as I would any other topic. If I sense myself becoming emotionally upset and wanting to post a bunch of personal stuff, I can now step back and just spend a few minutes sitting with the painful memories. Maybe I’ll cry for two or three minutes, and then I’ll move on with my day. The key is I’m not afraid of the memories, and I recognize sadness and other emotions as healthy and normal, without letting myself get emotionally swamped.

The biggest difference is that I don’t expect something horrible to happen at every moment of every day. There were a lot of symptoms I did not recognize as PTSD - for example, I had unusually high levels of anxiety while driving, I was afraid of darkened movie theaters, and every time I saw someone with their hands in their pockets, I expected them to pull a gun. I couldn’t sleep at night because every noise would convince me that someone was breaking in to stab me to death. I was especially sensitive to unfamiliar noises.

I recall one night my cat knocked a candle off a bathroom shelf. I bolted from bed, immediately locked the door and turned on the lights, and stood shaking in terror with a metal pipe gripped in my hands… My husband woke up when I turned on the lights, immediately deducted that we were safe and went back to bed. I probably stood there for 10 minutes without moving a muscle. It took me another 20 minutes to calm down enough to open the door. I was awake for hours afterward. I will never forgot how terrified I was that moment. It was like the final straw for me, because I said, ‘‘I can’t live like this any more,’’ and sought help.

I thought, since my trauma is not accident, theater or break-in related, these things were not PTSD, but my therapist helped me to understand that, particularly in cases of repeat trauma, this pervasive sense of danger is very common in people with PTSD.

As for things I couldn’t do before but now can do, I can sleep and I can have sex. Those are the big ones. I can also handle a lot more scary situations in movies/media better than I could before, so I have more variety in my entertainment now.

Two days ago I was sitting at my computer with my back to the door, and a gust of wind blew the door shut with a big WHAM! In the past I would have been a wreck. But I didn’t feel any anxiety at all. I just propped open the door and got on with life.

8

You mentioned that your symptoms got worse for a few weeks before you began to feel better.

My question is this - was that limited to the time specifically in therapy (either at the therapist or doing “homework” for therapy) or did it bleed over into the rest of your daily life?

If the second option holds, how did you manage your thoughts/emotions to stay functional and societally-acceptable during that time?

(really do * want to deal with my own issues, really don’t* have upwards of a week where I can be even more of an emotional basketcase than I currently am)

Many thanks for the answer, and what a brave and thoughtful thread this is!

9

How do you find a qualified practioner? How do you evaluate whether they are experienced and competent?

10

Actually it resulted in a pretty big disruption in my life. It’s a long story, but I had just started graduate school and my first year internship was with parents with severe psychiatric disorders who had neglected or abused their children. I started the therapy right around the same time I started to have difficulties with the internship - and of course we were studying things like child abuse in classes at the same time. It was emotional turmoil 24/7.

It got bad enough that I went to my supervisor and field instructor for advice, and we all decided I would be transferring to a different internship. My field instructor wanted me to quit the therapy because it was so intensive and I was so busy, but I told her I had to do it and now was the time. And actually that’s when I made the decision not to be a clinical therapist. I went in a macro direction and focused on organizational development and administration.

It might have been the intersection of those two intensive stressors that led to me sort of falling apart psychologically, I don’t know. But it was a very tough time. In the least, it significantly disrupted my life for 2-3 weeks. Arguably, it changed the entire course of my career.

So I would say, expect it to hit you pretty hard, plan ahead, maybe approach it the way you would schedule a major medical procedure.

11

I was fortunate enough to get my treatment at Penn’s Center for the Treatment and Study of Anxiety in Philadelphia. The center is directed by Dr. Edna Foa, who is a worldwide expert on the treatment of post traumatic stress, OCD and other anxiety disorders. Basically I was lucky enough to be treated at probably the best place in the world to be if you have PTSD.

I would say look for a clinic that specializes in research and who is familiar with Foa’s work. They should be able to explain exactly why prolonged exposure works and provide several citations supporting the treatment. They should be able to describe the training they have had. I’m guessing you could contact the Center for references in other parts of the country. This is also a common treatment for war veterans, so contacting the local VA could also result in good resources.

I was actually treated by an intern in order to save money. A lot of people think of interns as less competent, but research shows that as long as they are under supervision, they administer treatment with equal effectiveness to licensed psychologists.