Integrating Acceptance-based Behavior Therapy into Exposure-based therapy for PTSD.
Integrating Acceptance-based Behavior Therapy into Exposure-based therapyfor PTSDAcknowledgmentsSusan Orsillo, PhDSuffolk UniversityLizabeth Roemer, PhDUniversity of Massachusetts, BostonThe third wave Behavior TherapyCognitive TherapyAcceptance-based modelsAcceptance and Commitment Therapy (ACT)Mindfulness-based Cognitive Therapy (MBCT)Acceptance-based Behavior Therapy for GAD Dialectical Behavior Therapy (DBT)Integrative Behavioral Couple Therapy (IBCT)Behavioral Activation (BA)Functional Analytic Psychotherapy (FAP)Mindfulness-based Relapse Prevention (MBRP)An etiological model of PTSDGeneralized psychological vulnerabilityGeneralized biological vulnerabilityExperience of traumaDeveloped by classical conditioningMaintained by operant conditioningAnxious apprehensionAvoidance or numbing of emotional responseModerated by social support and ability to cope(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)Evidence-based psychological treatments for PTSDGeneral aimsExtinction of conditioned fear and anxiety responses through repeated, non-reinforced exposure to CSDevelopment of alternative, competing responses to anxiety and fearEmphasis on symptom reduction through mastery experiences and internal control strategiesEvidence-based treatmentsExposure TherapyAnxiety Management Training (AMT)Combination treatments(Foa, Keane & Friedman, 2000; Keane et al, 2006; Roth & Fonagy, 2005)Exposure TherapyPatient is guided through a vivid remembering of the trauma until extinction occursGoal is to reduce avoidance of anxiety and promote control/mastery over trauma-related cues(Foa and Rothbaum, 1998)Anxiety Management TrainingPackage of behavioral and cognitive strategies to reduce and control anxietyProgressive muscle relaxationDiaphragmatic breathingCognitive restructuringCommunication skills trainingTime managementAnger management/assertion training(Meichenbaum, 1994)Combination treatmentsPackage of CT, exposure and emotion regulation skillsEssential components of CTSelf-monitoringIdentification and labeling of thoughts and associated emotionsCognitive restructuringChanging the content of a dysfunctional cognition through logical analysisHypothesis testingConducting behavioral experiments to evaluate the validity of dysfunctional thoughtsCombination treatmentsCognitive Processing Therapy (CPT)Written exposure trialscognitive restructuring of trauma related erroneous cognitions and schemas, particularly regarding safety, trust, power, control, self-esteem and intimacySTAIRSEmotion regulation and distress tolerance skillsProlonged exposureCSA related PTSD(Resick et al. 2002; Cloitre et al., 2002)The good news about EBTs for PTSDTreatments are efficacious when compared to TAU, wait list control and active placebo treatments67% of completers no longer meet criteria for PTSD56% of intent-to-treat patients no longer meet criteria for PTSD Exposure and CBT are generally equally efficacious(Bradley, 2005)Limitations of current treatments44% of intent-to-treat patients continue to meet criteria for PTSD (Bradley, 2005)Using DSM criteria as treatment outcome may not be relevant to clinically significant changeGeneralization of findings limited by study exclusion rates averaging 30%Co-morbid Axis I disorderCurrent substance abuseSuicidal ideation or behaviorMore limitationsRelative lack of effectiveness researchRCTs generally compare monotherapies and not multimodal therapieslack of evidence regarding long-term maintenance of gainsVast majority of community sample patients do not receive EBTsDue to lack of disseminationDue to lack of treatment acceptance by patientsAnd still moreLowest effect sizes for patients with combat-related PTSD compared to other traumasFocus on symptom reduction and not functional improvementInterpersonal relationshipsVocational functioningGeneral quality of lifeLimitations specific to CBTRelatively difficult to train therapists to adherence (Kohlenberg, 2004; Dimidjian et al, 2006)Emphasis on control and mastery strategies can have paradoxical effect in anxiety disorders (Roemer & Borkovec, 1994)Limitations specific to exposureRequires memory of a specific trauma eventMay have low acceptability to patients and providersPTSD patients have more negative attitudes toward emotional expressionExposure less effective for patients:High levels of anger at pre-treatmentHigh levels of avoidance at pre-treatmentPerpetrators of harm who experience guilt/shame as primary symptomsPotential limitations of standard therapies for OIF/OEF veteransStigma associated with mental health careReluctance to participate in exposurePresence of co-morbid conditionsLack of a single traumatic eventAssociated feelings of guilt, loss, anger, sadness, griefPotential for iatrogenic effects of exposureThe challenge in treating OIF/OEF veteransHow do we provide secondary prevention?Proper treatment may help prevent the development or progression of symptoms, or the underlying mechanisms leading to pathology (Zatzick et al. 2004)what are these mechanisms?What is the natural course of resilience, remission and recovery? (Bonanno 2004)How can we use current treatments in secondary prevention?How can we adapt or elaborate on these treatments for use with recently returned veterans?Spectrum of Post-Deployment Mental Disorders (N = 46,571)Disorder N %PTSD20,63844%Drug Abuse17,76838%Depression14,317 31%Neurotic Disorders11,48125%Affective Psychosis 7,46016%Alcohol Dependence 3,116 7%Acute Stress Reaction 1,327 3%VHA Office of Public Health and Environmental Hazards, February 14, 2006The cautionary tale of Critical Incident Stress Debriefing (CISD)Intervention intended as secondary prevention for occupational trauma exposure (Mitchell 1983;1993)Proprietary; dramatic claims of effectiveness Basic assumptions Exposure to traumatic stressor is sufficient to cause symptoms that can escalate to a pathological conditionEarly and proximal intervention involving emotional catharsis (exposure) is prophylacticCISD proceduresFormatGroup administrationDelivered by a mental health provider assisted by non-professional peersConducted in one 2-3 hour session within 24-72 hours of traumatic eventMandatory attendance customaryNon-attendees or drop-outs typically retrieved by peer facilitatorCISD treatment protocolIntroduction of the debriefingStatement of facts regarding the traumatic eventDisclosure of thoughts regarding the eventDisclosure of emotional reactions, with focus on strong negative affectsSpecification of possible symptomsEducation regarding consequences of trauma exposurePlanned re-entry to social environment(Mitchell & Everly, 1993)CISD outcome researchNo clinically significant improvement for participants at long-term follow-upSlight but statistically significant worsening on outcome measures for those accepting debriefingPreference for informal sources of support and assistance correlated strongly with improved outcomeThose with highest levels of both avoidance and intrusive recollection deteriorated most after debriefing; recovery better among those not receiving treatment (Mayou et al. 2000)CISD is inert at best and iatrogenic at worst (Lohr et al. 2003)An etiological model of PTSDGeneralized psychological vulnerabilityGeneralized biological vulnerabilityExperience of traumaDeveloped by classical conditioningMaintained by operant conditioningAnxious apprehensionAvoidance or numbing of emotional responseModerated by social support and ability to cope(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)Approaches to providing secondary preventionWatch and waitRespect the natural course of recovery among the resilientSupport naturally occurring restorative factors in patients lifeProvide supportive treatments that do not interfere with natural resilience and are not iatrogenicWellnessProvide treatments that enhance naturally occurring restorative factors Example: Behavioral Activation (BA)Secondary prevention approachesRehabilitationSupport naturally occurring curative factors in patients life +Provide treatments that prevent or inhibit pathological mechanisms implicated in the development and maintenance of psychological distressExperiential avoidanceCo-morbid conditions that serve the function of experiential avoidance, especially SUDs and ruminationAcceptance-based Behavior Therapy (ABT)Standard therapiesBased on a conditioning model of PTSDAim is to reduce fear and anxiety through extinctionCoupled with strategies to change trauma-related thought contentAn alternative modelPTSD can be understood as a disorder of experiential avoidance (Hayes et al. 1999)Aim is to improve quality of lifeCoupled with strategies to change the process of cognition rather than the content(Orsillo & Batten 2005; Batten et al. 2005; Follette et al. 2004)Experiential avoidanceAttempts to change the form or frequency of internal events (thoughts, feelings, memories, sensations) (Hayes et al. 1996)EA contributes to the development and maintenance of various forms of psychopathology, particularly anxiety disordersAnxiety disorders develop when individuals are unwilling to experience anxiety (and associated thoughts, images, distressing emotions)A variety of external and internal control strategies are utilized to alleviate distress via escape and avoidanceBehavioral avoidance of situations and cues (CS) that elicit unwanted internal states (CR)Cognitive control strategies to avoid unwanted statesThought suppressionWorried rumination Distraction Internal and external control strategies are negatively reinforcedExternal control strategies generalizelead to disengagement with the naturally rewarding contingencies in the environment Internal control strategies generalizeBecome rigid and inflexibleLead to narrowing of attentionControl strategies maintain distress / cause rebound Thought suppressionEffortful suppression of thoughtsInitially relieves distressHas paradoxical long-term effect with rebound of avoided imageryLeads to escalating efforts to control and master thoughts and imageryThought suppression associated with negative tx outcome (CSA, rape, MVA, Gulf War, urban violence)Behavioral therapies have been adapted to specifically target experiential avoidance as a core feature of pathology(Borkovec et al. 2004)Acceptance-based Behavior Therapies (ABT)Acceptance and Commitment Therapy (ACT) (Hayes et al. 1999, 2004; Eifert & Forsyth, 2005)Mindfulness-based Cognitive Therapy (MBCT) (Segal et al. 2002)Acceptance-based Behavior Therapy for GAD (Roemer& Orsillo, 2004, 2005)Dialectical Behavior Therapy (DBT) (Linehan, 1993)Integrative Behavioral Couple Therapy (IBCT) (Jacobson & Christensen, 1996)Behavioral Activation (BA) (Jacobson et al. 1996; Dimidjian et al. 2006)Functional Analytic Psychotherapy (FAP) (Kohlenberg & Tsai, 1991; Kohlenberg et al. 2004) Mindfulness-based Relapse Prevention (MBRP) (Marlatt et al. 2005)Acceptance-based Behavior Therapy (ABT)Basic assumptionsTreatment componentsTreatment strategies and techniquesABT assumptionsEmotions are just emotions; thoughts are just thoughts; memories are just memoriesEmotions are information; not good or badControl of internal events is not an optionControl is the problem, not the solutionSimilarities to Exposure/CBTBoth consider avoidance to be a core feature of pathologyBoth advocate approach as an integral treatment strategyDifferences from Exposure/CBTApproach and avoidanceApproach behaviors are inherently valuable Approach behaviors are pragmatically valuable in order to reengage with natural reinforcers and expand domains of functioningEmphasis on clinically valued change rather than symptom reduction DifferencesAttentionCBT emphasizes directing attention toward stimuli associated with disorder (or distract from)ABT emphasizes directing attention broadly toward flow of experienceDifferencesCognition radically different understanding of the role of cognition in development and treatment of disordersCognitions are causal vs. cognitions are responsesImportance of content vs. importance of functionGoal to change content vs. goal to change relationship to ones own thoughts and feelingsDifferencesControl within the CBT frameworkLack of perceived control and unpredictability strongly associated with distress (Mineka et al. 2006)Control/predictability can be increased byAttending to thoughts and associated emotionsChanging thoughts from irrational to rationalThrough process of logical analysis and behavioral experimentationDifferencesControl within the ABT frameworkEfforts to exert internal control maintain distressThoughts and emotions are transitory experiences of the mind and bodyTreatment provides experiential learning of acceptance rather than controlDistress naturally wanes as a consequence of not being escalated by control strategies (e.g., MBCT)ABT treatment componentsOverarching goalsTarget experiential avoidance and expand experiential acceptanceTarget associated behavioral restrictions and expand engagement with valued life goals and activities1. Psychoeducation2. Assessment3. Experiential acceptance4. Valued action1. PsychoeducationRole of emotions as information (Linehan 1993)Limits and costs of control strategies (Roemer & Orsilllo 2004)Importance of approach and emotional engagement in therapy sessions (Jaycox et al. 1998)2. AssessmentGeneral assessmentSymptom review and diagnostic assessmentSelf-report measuresPTSDAnxietydepressionSelf-report functional measuresLife satisfactionValued life domains(Roemer & Orsillo, 2004; Orsillo & Batten, 2005)2. AssessmentAvoidance and suppressionSelf-report measures of experiential avoidance and thought suppression (Hayes et al. 2006; Eifert & Forsyth, 2005)Acceptance and Action Questionnaire (AAQ)White Bear Suppression InventoryThought Control QuestionnaireValues assessmentSelf-report measures to identify idiographic treatment outcomes (Hayes et al. 1999, Eifert & Forsyth, 2005)Generate valuesRate values to establish prioritiesIdentify intermediate steps, actions and barriers3. Experiential acceptanceMindfulnessTargets identification of thoughts/feelings as realityWillingnessEncourages approach behaviorsDistress tolerance skillsTargets avoidance due to inability to tolerate emotionEmotion regulation skillsTargets avoidance due to inability to modulate emotionKey concepts in MindfulnessDecenteringExperiencing thoughts and feelings as mental events and not realityEarly problem recognitionIntentional awareness allows turning toward difficultiesAnti-ruminativeExperience is of current awareness, not elaborate thinking about implications, meaning, etc.Generic skillDaily practice competes with development of avoidance, escape and control strategies (Segal et al, 2002)Steps in Mindfulness trainingPractice attention to a single sensePractice attention to the flow of experiencePractice attention to thoughts, feelings, images as part of the flow of experiencePractice attention to the flow of experience during activitiesMechanisms of MindfulnessExposure to previously avoided classes or categories of emotional experience, leading to decreased distress via extinctionSelf-monitoring associated with improved appraisal of actual contingencies, leading to increased flexibility in respondingState of relaxation (response prevention)Change in attitude toward internal experiences leads to decreased volatility(Baer, 2003; Teasdale et al. 2002; Segal et al. 2002) 4. Valued actionAssessment questionsWhat is important to the patient?To what extent are they living life in accordance with their values?How do their symptoms interfere with the pursuit of their values?4. Valued actionIntervention techniquesWriting exercises to clarify valuesSelf-monitoring to assess degree to which life is spent in valued activities (and/or degree to which patient is emotionally engaged in valued activities)Goal settingIdentify concrete steps intermediate to valued activitiesCommit to planIdentify potential barriersReview previous goals(Roemer & Orsillo, 2004; Eifert & Forsyth, 2005; Orsillo & Batten, 2005)Integrating Exposure TherapyExposure sessions for specific events as well as classes of emotionGoal is acceptance rather than extinctionTherapist must be practiced in approaching emotional experience, and mindful of not colluding with patient in experiential avoidanceTherapist must be capable of achieving the metacognitive state of engaged observationSummaryAcceptance-based therapies are useful extensions of exposure-based in secondary prevention of PTSD and co-morbid disordersEmpirical support in treatment of anxiety, depression, SUDs, couples, BPDAcceptable to patientsAccommodates exposure for emotions other than fear & anxiety, or in absence of Criterion ATeaches cognitive and behavioral skills that may prevent development of avoidant and controlling strategies associated with the exacerbation of anxiety, depressive relapse, substance use, conflict, and intimacy problemsGoal is broad functional improvementRates of VHA enrolled veterans who have PTSD have been consistently rising since 2003. The overall percentage of patients with PTSD seeking VA care more than doubled between February 13 and December 9, 2004 (Kang & Hyams, 2005).Reserve component troops were as likely to develop PTSD as were Active Duty personnel (in VA utilization data).Total number of OIF/OEF vets Dx with PTSD represents about 5% of VAs total PTSD workload (as of 2005 NEPEC report for FY04)