Journal of Traumatic Stress, Vol. 10, No. 3, 1997

Commentary

Client Compliance with Exposure Treatmentsfor Posttraumatic Stress Disorder

Michael X Scott1 and Stephen G. Stradling1,2

Clients with posttraumatic stress disorder (PTSD) do not wish to "relive" theirtrauma, but exposure based treatments try to ensure that they do. While suchtreatments have proven efficacy in controlled outcome studies, how acceptableare they in routine clinical practice? The attempted clinical application of twosuch exposure treatments is briefly reported here. In the first, only 1 of 14clients completed the image habituation procedure for homework in themanner described by its authors. In the second (N = 37), only 57% compliedwith an audiotape exposure treatment, and compliance was related to initialsymptom severity and to severity of comorbid depression. Exposure basedtreatments are not 'treatment of choice' for some clients.

Cognitive avoidance of trauma related material is one of the definingcharacteristics of posttraumatic stress disorder (PTSD; American Psychiat-ric Association [APA], 1987). Exposure based treatments for PTSD directlytarget this avoidance and involve the client in a "re-living" of the traumain order to produce an habituation response. A recent review of eight out-come studies (Otto, Penava, Pollack, & Smoller, 1995) reported encourag-ing results for exposure based treatments. Jaycox and Foa (1996) suggestedthey may be currently regarded as treatment of choice. However, none ofthe studies reviewed by Otto et al. (1995) reported compliance rates withhomework, and only two detailed the numbers of potential clients who were

1Department of Psychology, The University of Manchester, Manchester, M13 9PL, UK.2To whom correspondence should be addressed.

KEY WORDS: PTSD; exposure treatment; compliance; comorbid depression; generalizability.

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excluded or who refused participation. The two studies briefly outlined herereport on the acceptability to clients of two exposure based treatmentswhose efficacy has been empirically validated in the research literature. Forboth studies, therapy was administered by the first author who takes refer-rals from primary health care services and major local employers in theLiverpool, England area.

The first treatment, Image Habituation Training (IHT; Vaughan & Tar-rier, 1992), requires clients to record six brief descriptions of aspects of theirrecurrent intrusive images onto audiotape. Each description is followed by30 seconds of tape silence during which the client is to visualize as intenselyas possible the memory that the description evokes. Thus a taped imagehabituation sequence lasts a little more than three minutes (6 x 30 sec plusthe duration of the brief descriptions). Following in-session training, thehomework assignment is to listen to the tape for one hour, every day.Vaughan and Tarrier (1992) reported that 6 of 10 clients improved consid-erably, 2 moderately, and 2 two showed minimal improvement on a rangeof outcome measures. The only contraindication mentioned was for 2 clientswho abused alcohol and were reported as doing less well.

The second treatment followed that described by Foa, Rothbaum,Riggs and Murdock (1991), who required the 10 female rape victims intheir Prolonged Exposure (PE) condition to imagine the assault as vividlyas possible, describe it aloud in the present tense onto audiotape, and listento the tape for 1 hr daily for homework. No difficulties with compliancewere reported. Results showed the PE treatment produced superior im-provement, compared to other treatments, at 3.5 months follow-up.

Study 1

Image Habituation Training procedures were followed with sevenwomen and seven men all of whom met DSM-III-R criteria for PTSD. Sixhad experienced a car or coach crash, four a physical or sexual assault,two a bomb explosion, one an armed robbery, and one witnessed their part-ner murdered. At initial assessment they all completed two measures ofPTSD symptom severity—the Penn Inventory (PENN; Hammarberg, 1992)and the Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979)—along with the Beck Depression Inventory (BDI; Beck, Ward, Mendelson,Mock, & Erbaugh, 1961).

As well as all meeting the DSM-III-R criteria for PTSD, they all re-corded initial symptom severity scores well above the cut-off score of 35recommended for "caseness" on both the PENN (Hammarberg, 1992) andthe IES (Neal et al., 1994) (PENN: M = 50.86, SD = 8.46; IES: M =

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57.54, SD = 7.54). Mean depression score was high (BDI: M = 28.86, SD= 7.34), and was greater than in the Vaughan and Tarrier (1992) study(Vaughan & Tarrier: BDI: M = 23.22, SD = 8.16), t (22) = 1.77, p < .05,1-tailed.

Preparedness to embark on the IHT procedure as a homework exercisewas assessed at an early session, and compliance with the procedure overa 3-week period was reported to the therapist at subsequent sessions. Atthe early session, 1 of the 14 clients agreed to 15 min a day, 12 would onlyagree to 10 min or less exposure a day, and 1 was unsure what exposurehe could agree to. That is, none anticipated full compliance with the rec-ommended 1 hr daily protocol.

Only 1 of 14 clients managed to complete the image habituation pro-cedure for homework in the manner described by its authors (1 hr, daily).No others managed a full 1 hr exposure on any days; four others manageddaily exposures but of lesser duration (3 to 30 min).

Study 2

A Prolonged Exposure treatment was administered to 12 women and25 men, all of whom met DSM-III-R diagnostic criteria for PTSD. Clientswere asked to make a comprehensive recording of their trauma, in the firstperson, present tense, and, for homework, to listen to the tape daily foras long as it took them to habituate (a procedure detailed in Scott & Strad-ling, 1992) rather than for the standard one hour a day procedure describedby Foa et al. (1991). Even with compliance liberally interpreted as usingthe technique at least 3 times/week for 3 weeks, only 21 of the 37 (57%)complied.

Noncompliers and compilers differed on initial severity of both PTSDsymptomatology (PENN: Non-Compliers: M = 53.69, SD = 10.17; Com-pliers: M = 44.24, SD = 9.15), t (35) = 2.98, p < .01, and depression(BDI: Non-Compliers: M = 31.00, SD = 11.09; Compilers: M = 21.19, SD= 10.19), t (35) = 2.79, p < .01. In addition, mean depression score wassignificantly greater than in the Foa et al. (1991) study (Foa et al. PE con-dition: BDI: M = 19.60, SD = 9.41) for the non-compliers, t (24) = 2.70,p < .05, but not for the compilers, t (29) = 0.42, p > .05.

Symptom scores at the end of the 3-week homework period were avail-able for 23 of the 37 participants. Thirteen of 15 compilers and one ofeight non-compliers had reduced their Penn Inventory score by more than1 SD of the distribution of scores for these 23, showing an association be-tween compliance and improvement, x2 (1, N = 23) = 12.05, p < .05.

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Discussion

Controlled outcome studies properly address threats to internal validityin a number of ways, typically including strict subject exclusion for treat-ment non-compliance and for high levels of co-morbidity. This may, how-ever, limit the generalizability of findings from research settings to dailyclinical practice. Clients seen in clinical practice seem likely to benefit fromexposure treatments if they find them acceptable, but many do not. Datafrom both studies here suggest those with more severe symptoms and thosewith higher levels of co-morbid depression may be the clients least likelyto tolerate exposure treatments. New ways of conducting cognitive restruc-turing (Scott, 1997) may prove more acceptable to such clients.

References

American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders,(3rd ed., rev.). Washington, DC: Author.

Beck, A. T, Ward, C. H., Mendelson, M, Mock, J., & Erbaugh, J. (1961). An inventory formeasuring depression. Archives of General Psychiatry, 4, 561-571.

Foa, E. B., Rothbaum, B. O., Riggs, D., & Murdock. T. (1991). Treatment of PTSD in rapevictims: A comparison between cognitive-behavioral procedures and counselling. Journalof Consulting and Clinical Psychology, 59, 715-723.

Hammarberg, M. (1992). PENN Inventory for posttraumatic stress disorder: Psychometricproperties. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 4,67-76.

Horowitz, M. J., Wilner, N., & Alvarez, W. (1979). Impact of Event Scale: A measure ofsubjective stress. Psychosomatic Medicine, 41, 209-218.

Jaycox, L. H., & Foa, E. B. (1996). Obstacles in implementing exposure therapy for PTSD:Case discussions and practical solutions. Clinical Psychology and Psychotherapy, 3,176-184.

Neal, L. A., Busuttil, W, Rollins, J. Herepath, R., Strike, P, & Turnbull, G. (1994). Convergentvalidity of measures of posttraumatic stress disorder in a mixed military and civilianpopulation. Journal of Traumatic Stress, 7, 447-455.

Otto, M. W, Penava, S. J., Pollack, R. A., & Smoller, J. W. (1995). Cognitive-behavioral andpharmacologic perspectives on the treatment of posttraumatic stress disorder. In M. H.Pollack, M. W. Otto, & J. F. Rosenbaum (Eds.), Challenges in psychiatric treatment:Pharmacologic and psychosocial strategies. New York: Guilford.

Scott, M. J., & Stradling, S. G. (1992). Counselling for posttraumatic stress disorder. London:Sage Publications.

Scott, M. J. (1997). Counselling for trauma and posttraumatic stress disorder. In S. Palmer& G. McMahon (Eds.), Handbook of counselling. London: Routledge.

Vaughan, K., & Tarrier, N. (1992). The use of image habituation training with posttraumaticstress disorders. British Journal of Psychiatry, 161, 658-664.

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