Integrating Acceptancebased Behavior Therapy into Exposurebased therapy for PTSD

1
Integrating Acceptance-based Behavior
Therapy into Exposure-based therapyfor PTSD
2
Acknowledgments

• Susan Orsillo, PhD
• Suffolk University
• Lizabeth Roemer, PhD
• University of Massachusetts, Boston

3
The third wave

• Behavior Therapy
• Cognitive Therapy
• Acceptance-based models
• Acceptance 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)

4
An etiological model of PTSD

• Generalized psychological vulnerability
• Generalized biological vulnerability
• Experience of trauma
• Developed by classical conditioning
• Maintained by operant conditioning
• Anxious apprehension
• Avoidance or numbing of emotional response
• Moderated by social support and ability to cope
• (Keane Barlow, 2002 Keane, Marshall Taft,
  2006)

5
Evidence-based psychological treatments for PTSD

• General aims
• Extinction of conditioned fear and anxiety
  responses through repeated, non-reinforced
  exposure to CS
• Development of alternative, competing responses
  to anxiety and fear
• Emphasis on symptom reduction through mastery
  experiences and internal control strategies

6
Evidence-based treatments

• Exposure Therapy
• Anxiety Management Training (AMT)
• Combination treatments
• (Foa, Keane Friedman, 2000 Keane et al, 2006
  Roth Fonagy, 2005)

7
Exposure Therapy

• Patient is guided through a vivid remembering of
  the trauma until extinction occurs
• Goal is to reduce avoidance of anxiety and
  promote control/mastery over trauma-related cues
• (Foa and Rothbaum, 1998)

8
Anxiety Management Training

• Package of behavioral and cognitive strategies to
  reduce and control anxiety
• Progressive muscle relaxation
• Diaphragmatic breathing
• Cognitive restructuring
• Communication skills training
• Time management
• Anger management/assertion training
• (Meichenbaum, 1994)

9
Combination treatments

• Package of CT, exposure and emotion regulation
  skills
• Essential components of CT
• Self-monitoring
• Identification and labeling of thoughts and
  associated emotions
• Cognitive restructuring
• Changing the content of a dysfunctional
  cognition through logical analysis
• Hypothesis testing
• Conducting behavioral experiments to evaluate the
  validity of dysfunctional thoughts

10
Combination treatments

• Cognitive Processing Therapy (CPT)
• Written exposure trials
• cognitive restructuring of trauma related
  erroneous cognitions and schemas, particularly
  regarding safety, trust, power, control,
  self-esteem and intimacy
• STAIRS
• Emotion regulation and distress tolerance skills
• Prolonged exposure
• CSA related PTSD
• (Resick et al. 2002 Cloitre et al., 2002)

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The good news about EBTs for PTSD

• Treatments are efficacious when compared to TAU,
  wait list control and active placebo treatments
• 67 of completers no longer meet criteria for
  PTSD
• 56 of intent-to-treat patients no longer meet
  criteria for PTSD
• Exposure and CBT are generally equally
  efficacious
• (Bradley, 2005)

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Limitations of current treatments

• 44 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 change
• Generalization of findings limited by study
  exclusion rates averaging 30
• Co-morbid Axis I disorder
• Current substance abuse
• Suicidal ideation or behavior

13
More limitations

• Relative lack of effectiveness research
• RCTs generally compare monotherapies and not
  multimodal therapies
• lack of evidence regarding long-term maintenance
  of gains
• Vast majority of community sample patients do not
  receive EBTs
• Due to lack of dissemination
• Due to lack of treatment acceptance by patients

14
And still more

• Lowest effect sizes for patients with
  combat-related PTSD compared to other traumas
• Focus on symptom reduction and not functional
  improvement
• Interpersonal relationships
• Vocational functioning
• General quality of life

15
Limitations specific to CBT

• Relatively 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)

16
Limitations specific to exposure

• Requires memory of a specific trauma event
• May have low acceptability to patients and
  providers
• PTSD patients have more negative attitudes toward
  emotional expression
• Exposure less effective for patients
• High levels of anger at pre-treatment
• High levels of avoidance at pre-treatment
• Perpetrators of harm who experience guilt/shame
  as primary symptoms

17
Potential limitations of standard therapies for
OIF/OEF veterans

• Stigma associated with mental health care
• Reluctance to participate in exposure
• Presence of co-morbid conditions
• Lack of a single traumatic event
• Associated feelings of guilt, loss, anger,
  sadness, grief
• Potential for iatrogenic effects of exposure

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The challenge in treating OIF/OEF veterans

• How 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?

19
Spectrum of Post-Deployment Mental Disorders (N
46,571)

• Disorder N
• PTSD 20,638 44
• Drug Abuse 17,768 38
• Depression 14,317 31
• Neurotic Disorders 11,481 25
• Affective Psychosis 7,460 16
• Alcohol Dependence 3,116 7
• Acute Stress Reaction 1,327 3
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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The cautionary tale of Critical Incident Stress
Debriefing (CISD)

• Intervention intended as secondary prevention for
  occupational trauma exposure (Mitchell 19831993)
• Proprietary dramatic claims of effectiveness
• Basic assumptions
• Exposure to traumatic stressor is sufficient to
  cause symptoms that can escalate to a
  pathological condition
• Early and proximal intervention involving
  emotional catharsis (exposure) is prophylactic

21
CISD procedures

• Format
• Group administration
• Delivered by a mental health provider assisted by
  non-professional peers
• Conducted in one 2-3 hour session within 24-72
  hours of traumatic event
• Mandatory attendance customary
• Non-attendees or drop-outs typically retrieved by
  peer facilitator

22
CISD treatment protocol

• Introduction of the debriefing
• Statement of facts regarding the traumatic event
• Disclosure of thoughts regarding the event
• Disclosure of emotional reactions, with focus on
  strong negative affects
• Specification of possible symptoms
• Education regarding consequences of trauma
  exposure
• Planned re-entry to social environment
• (Mitchell Everly, 1993)

23
CISD outcome research

• No clinically significant improvement for
  participants at long-term follow-up
• Slight but statistically significant worsening on
  outcome measures for those accepting debriefing
• Preference for informal sources of support and
  assistance correlated strongly with improved
  outcome
• Those 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)

24
An etiological model of PTSD

• Generalized psychological vulnerability
• Generalized biological vulnerability
• Experience of trauma
• Developed by classical conditioning
• Maintained by operant conditioning
• Anxious apprehension
• Avoidance or numbing of emotional response
• Moderated by social support and ability to cope
• (Keane Barlow, 2002 Keane, Marshall Taft,
  2006)

25
Approaches to providing secondary prevention

• Watch and wait
• Respect the natural course of recovery among the
  resilient
• Support naturally occurring restorative factors
  in patients life
• Provide supportive treatments that do not
  interfere with natural resilience and are not
  iatrogenic
• Wellness
• Provide treatments that enhance naturally
  occurring restorative factors
• Example Behavioral Activation (BA)

26
Secondary prevention approaches

• Rehabilitation
• Support naturally occurring curative factors in
  patients life
• Provide treatments that prevent or inhibit
  pathological mechanisms implicated in the
  development and maintenance of psychological
  distress
• Experiential avoidance
• Co-morbid conditions that serve the function of
  experiential avoidance, especially SUDs and
  rumination

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Acceptance-based Behavior Therapy (ABT)

• Standard therapies
• Based on a conditioning model of PTSD
• Aim is to reduce fear and anxiety through
  extinction
• Coupled with strategies to change trauma-related
  thought content
• An alternative model
• PTSD can be understood as a disorder of
  experiential avoidance (Hayes et al. 1999)
• Aim is to improve quality of life
• Coupled with strategies to change the process of
  cognition rather than the content
• (Orsillo Batten 2005 Batten et al. 2005
  Follette et al. 2004)

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Experiential avoidance

• Attempts 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 disorders
• Anxiety disorders develop when individuals are
  unwilling to experience anxiety (and associated
  thoughts, images, distressing emotions)

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• A variety of external and internal control
  strategies are utilized to alleviate distress via
  escape and avoidance
• Behavioral avoidance of situations and cues (CS)
  that elicit unwanted internal states (CR)
• Cognitive control strategies to avoid unwanted
  states
• Thought suppression
• Worried rumination
• Distraction
• Internal and external control strategies are
  negatively reinforced
• External control strategies generalize
• lead to disengagement with the naturally
  rewarding contingencies in the environment
• Internal control strategies generalize
• Become rigid and inflexible
• Lead to narrowing of attention
• Control strategies maintain distress / cause
  rebound

30
Thought suppression

• Effortful suppression of thoughts
• Initially relieves distress
• Has paradoxical long-term effect with rebound of
  avoided imagery
• Leads to escalating efforts to control and master
  thoughts and imagery
• Thought 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)

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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)

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Acceptance-based Behavior Therapy (ABT)

• Basic assumptions
• Treatment components
• Treatment strategies and techniques

33
ABT assumptions

• Emotions are just emotions thoughts are just
  thoughts memories are just memories
• Emotions are information not good or bad
• Control of internal events is not an option
• Control is the problem, not the solution

34
Similarities to Exposure/CBT

• Both consider avoidance to be a core feature of
  pathology
• Both advocate approach as an integral treatment
  strategy

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Differences from Exposure/CBT

• Approach and avoidance
• Approach behaviors are inherently valuable
• Approach behaviors are pragmatically valuable in
  order to reengage with natural reinforcers and
  expand domains of functioning
• Emphasis on clinically valued change rather than
  symptom reduction

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Differences

• Attention
• CBT emphasizes directing attention toward stimuli
  associated with disorder (or distract from)
• ABT emphasizes directing attention broadly toward
  flow of experience

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Differences

• Cognition radically different understanding of
  the role of cognition in development and
  treatment of disorders
• Cognitions are causal vs. cognitions are
  responses
• Importance of content vs. importance of function
• Goal to change content vs. goal to change
  relationship to ones own thoughts and feelings

38
Differences

• Control within the CBT framework
• Lack of perceived control and unpredictability
  strongly associated with distress (Mineka et al.
  2006)
• Control/predictability can be increased by
• Attending to thoughts and associated emotions
• Changing thoughts from irrational to rational
• Through process of logical analysis and
  behavioral experimentation

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Differences

• Control within the ABT framework
• Efforts to exert internal control maintain
  distress
• Thoughts and emotions are transitory experiences
  of the mind and body
• Treatment provides experiential learning of
  acceptance rather than control
• Distress naturally wanes as a consequence of not
  being escalated by control strategies (e.g.,
  MBCT)

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ABT treatment components

• Overarching goals
• Target experiential avoidance and expand
  experiential acceptance
• Target associated behavioral restrictions and
  expand engagement with valued life goals and
  activities
• 1. Psychoeducation
• 2. Assessment
• 3. Experiential acceptance
• 4. Valued action

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1. Psychoeducation

• Role 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)

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2. Assessment

• General assessment
• Symptom review and diagnostic assessment
• Self-report measures
• PTSD
• Anxiety
• depression
• Self-report functional measures
• Life satisfaction
• Valued life domains
• (Roemer Orsillo, 2004 Orsillo Batten, 2005)

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2. Assessment

• Avoidance and suppression
• Self-report measures of experiential avoidance
  and thought suppression (Hayes et al. 2006
  Eifert Forsyth, 2005)
• Acceptance and Action Questionnaire (AAQ)
• White Bear Suppression Inventory
• Thought Control Questionnaire
• Values assessment
• Self-report measures to identify idiographic
  treatment outcomes (Hayes et al. 1999, Eifert
  Forsyth, 2005)
• Generate values
• Rate values to establish priorities
• Identify intermediate steps, actions and barriers

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3. Experiential acceptance

• Mindfulness
• Targets identification of thoughts/feelings as
  reality
• Willingness
• Encourages approach behaviors
• Distress tolerance skills
• Targets avoidance due to inability to tolerate
  emotion
• Emotion regulation skills
• Targets avoidance due to inability to modulate
  emotion

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Key concepts in Mindfulness

• Decentering
• Experiencing thoughts and feelings as mental
  events and not reality
• Early problem recognition
• Intentional awareness allows turning toward
  difficulties
• Anti-ruminative
• Experience is of current awareness, not elaborate
  thinking about implications, meaning, etc.
• Generic skill
• Daily practice competes with development of
  avoidance, escape and control strategies
• (Segal et al, 2002)

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Steps in Mindfulness training

• Practice attention to a single sense
• Practice attention to the flow of experience
• Practice attention to thoughts, feelings, images
  as part of the flow of experience
• Practice attention to the flow of experience
  during activities

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Mechanisms of Mindfulness

• Exposure to previously avoided classes or
  categories of emotional experience, leading to
  decreased distress via extinction
• Self-monitoring associated with improved
  appraisal of actual contingencies, leading to
  increased flexibility in responding
• State of relaxation (response prevention)
• Change in attitude toward internal experiences
  leads to decreased volatility
• (Baer, 2003 Teasdale et al. 2002 Segal et al.
  2002)

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4. Valued action

• Assessment questions
• What 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?

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4. Valued action

• Intervention techniques
• Writing exercises to clarify values
• Self-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 setting
• Identify concrete steps intermediate to valued
  activities
• Commit to plan
• Identify potential barriers
• Review previous goals
• (Roemer Orsillo, 2004 Eifert Forsyth, 2005
  Orsillo Batten, 2005)

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Integrating Exposure Therapy

• Exposure sessions for specific events as well as
  classes of emotion
• Goal is acceptance rather than extinction
• Therapist must be practiced in approaching
  emotional experience, and mindful of not
  colluding with patient in experiential avoidance
• Therapist must be capable of achieving the
  metacognitive state of engaged observation

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Summary

• Acceptance-based therapies are useful extensions
  of exposure-based in secondary prevention of PTSD
  and co-morbid disorders
• Empirical support in treatment of anxiety,
  depression, SUDs, couples, BPD
• Acceptable to patients
• Accommodates exposure for emotions other than
  fear anxiety, or in absence of Criterion A
• Teaches 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 problems
• Goal is broad functional improvement