4/30/18 EXPOSURE THERAPY: SUPERVISION AND TRAINING TECHNIQUES FOR ADDRESSING NEGATIVE BELIEFS ABOUT EXPOSURE AND FOR IMPROVING EFFICACY SCOTT MICHAEL PH.D.; VA PUGET SOUND HEALTHCARE SYSTEM, SEATTLE DIVISION ANDREW SHERRILL PH.D.; EMORY UNIVERSITY SCHOOL OF MEDICINE ALLISON AOSVED PH.D.; VA PUGET SOUND HEALTHCARE SYSTEM, AMERICAN LAKE DIVISION THAD STROM PH.D.; VA MINNEAPOLIS HEALTHCARE SYSTEM Thanks to the following collaborators: Sheila Rauch Ph.D., Emory University School of Medicine Liza Zwiebach Ph.D., Emory University School of Medicine Barbara Rothbaum Ph.D., Emory University School of Medicine 1
4/30/18 LEARNING OBJECTIVES • Describe how to identify trainees’ beliefs and behaviors that are incongruent with exposure therapy. • Recognize and apply training strategies to correct unhelpful beliefs and behaviors of exposure therapy trainees. • Articulate how consultation-of-consultation may reduce the parallel process of the consultant/supervisor colluding with their trainee’s avoidance. • Demonstrate new supervisory skills in addressing ethical and diversity concerns in exposure therapy. OUTLINE • Overview of exposure theory and principles • Effective dissemination of evidence-based therapies • Therapist negative attitudes toward exposure, impact on quality of exposure therapy, or provision of exposure • VA Prolonged Exposure training as exemplar • Best practices for supervision of exposure • Introducing new consultation program at Emory for PE 2
4/30/18 EXPOSURE THERAPY PRINCIPLES • Emotional Processing Theory (Foa & Kozak, 1986) • Fear Structures: learning about how to respond to danger • Anxiety disorders: Over-reactive responding to fear-related stimuli that lacks context • Example: Spider phobic panicking when seeing spiders on TV • Exposure: Experiential learning that contradicts older, less adaptive learning • Situation is not as dangerous as I thought • I can manage this better than I thought EXPOSURE THERAPY: IT WORKS! • Meta-analyses consistently support efficacy of exposure for anxiety d/o (Deacon & Abramowitz, 2004; Olatunji et al., 2010) • Findings are fairly consistent across anxiety disorders, particularly PTSD, OCD, panic, social anxiety, and specific phobia • US Institute of Medicine recommends PE for PTSD in Veterans (2007, 2014) • UK National Institute of Clinical Excellence recommends exposure for anxiety d/o (2011) 3
4/30/18 EFFECTIVE TRAINING IN EXPOSURE • Dissemination literature routinely recommends the following: • Concentrated episode of didactic instruction (often 2-4 days) • Ongoing period of clinical supervision/consultation with a consultation expert • Often translates to 4-6 months of supervised therapy implementation • Listening to therapy sessions by supervisor/consultant often recommended • Basis for Veterans Health Affairs national dissemination of Evidence-Based Psychotherapy (EBP) program: Karlin & Cross (2013) • Has trained over 10,000 VA clinicians in 16 EBPs • Prolonged Exposure for PTSD has trained over 2000 clinicians • VA psychology training has benefitted greatly: Many of the trained clinicians are psychology training program supervisors who go on to train interns and fellows in EBPs like PE GRADUATE TRAINING IN TRAUMA AND EXPOSURE • Graduate training in exposure has strong association with later adoption of therapy • Cook et al. (2017): Only 20% of graduate programs offer a trauma course and practicum experience in treating trauma • Becker et al. (2004): Less than 1/3 psychologists report being trained in imaginal exposure for PTSD • Whiteside et al. (2016): Holding a PhD in psychology & ascribing to CBT orientation associated with higher use of exposure; however ascribing to multiple orientations diminishes this effect 4
4/30/18 IMPLEMENTATION OF EXPOSURE THERAPIES • Effective methods of training exposure therapies • Research is very solid • ….and yet, training in and adoption of exposure therapies is relatively low • Becker et al. (2004): 17% community therapists use imaginal exposure & 11% use in vivo exposure for PTSD • van Minnen et al. (2009): Trauma experts select imaginal exposure less frequently, particularly when depression is comorbid THERAPIST ATTITUDES & EXPOSURE IMPLEMENTATION • Therapists with concerns about exposure tend to exclude patients based upon characteristics (from Deacon, Farrell, and colleagues at U Wyo) • Depression or other comorbidity (e.g., psychosis, bipolar d/o, SUD) • High levels of anxiety • Therapist-perceived emotional fragility of patient • Patient reluctance to do exposure • Overt or covert negative attitudes associated with providing less effective exposure therapy • Overt: Too much exposure can be harmful • Covert: This patient is so distressed, maybe s/he needs deep breathing right now 5
4/30/18 EXAMPLES OF THERAPIST ATTITUDES IMPACTING EXPOSURE • Therapist belief that intense exposure could be damaging • Therapist belief that it is important to give patients stress-ameliorating coping skills so they can manage the emotions that come up in exposure • Therapist belief that it is important to go slow in exposure and not push patients too hard to try all their exposure hierarchy items, particularly the hardest ones POTENTIAL OUTCOMES OF THERAPIST CONCERNS ABOUT EXPOSURE • Patients encouraged to use anxiety amelioration techniques which function as safety behaviors • Less ambitious hierarchies are created • Individual exposure exercises are less intense, yield less gain • Elevated anxiety wo/ as much improvement leads to higher drop out • Patient are not offered PE when research indicates that would benefit 6
4/30/18 COMMON FACTORS AND EXPOSURE • Integration of common and specific factors are critical to maximize effectiveness (Boswell et al. 2014). • Contextual model: Therapy most effective when both the relationship and the expectations for therapy converge (Wompold, 2015) • Specific ingredients and expectation: Good exposure therapy relies heavily on being able to develop consensus between therapist and patient on why exposure therapy works • Drop out is often related to a lack of convergence between expectations of therapist and patient on the rationale for exposure therapy • Relationship is critical to the more sensitive work of exposure at times of heightened distress ADDRESSING ETHICAL CONCERNS ABOUT EXPOSURE • Clinician concerns that exposure may not be ethical can be a critical attitude leading to less implementation of exposure or offering sub-optimal exposure (Whiteside et al. 2016) • Do no harm • Exposure may lead to damaging levels of distress • And yet, not offering some of the strongest evidence-based psychotherapies for a disorder may be the less ethical choice 7
4/30/18 DIVERSITY CONSIDERATIONS AND EXPOSURE • Using the PE literature as exemplar • Foa et al. (2005) • Overall sample 43.6% were African-American women, 7.3% other than Caucasian; One site inner city Philadelphia 51.4% African-American • 48% overall sample had income less that $15,000 • Schnurr et al. (2007): Veteran and active duty • 33.3% African-American; 5.7% Latina; 5% “other” • PE has been successfully implemented in various populations: Japanese, Israeli, Argentinian, Refugees in U.S. • Manual translated into 12 languages WHAT ABOUT SUPERVISOR ATTITUDES? • Very little research to date on whether supervisor attitudes toward exposure affect trainee style of implementing exposure • And yet, certainly reasonable to assume those attitudes do 8
4/30/18 BUILDING EXPOSURE SELF-EFFICACY • Harned & colleagues (2013): Therapist exposure self-efficacy predicts use of exposure by therapist • So how do we build self-efficacy? • Farrell et al. (2016): Enhanced didactic training; module directly addressing attitude change • Review common concerns re: safety & tolerability • Use testimonial videos of patients who succeeded • Have trainees go through sample exposure (e.g., try hyperventilating for interoceptive exp.) • Reid et al (2018): Progressive Cascading Model • Trainee begins as therapy aid, assists primary therapist with exposures • Promoted to role of co-therapist, independent therapist, and then treatment team leader • Intensive group and individual feedback via treatment team meetings VA PROLONGED EXPOSURE TRAINING 9
4/30/18 VA EVIDENCE-BASED PSYCHOTHERAPY (EBP) PROGRAM • VA commissioned Institute of Medicine to provide PTSD treatment recommendations • Committee set high bar – Evidence-based practice • Only sited trauma exposure therapies as meeting this criteria: CPT and PE • VA chose to begin training in these 2 PTSD treatment modalities, then rolled out further trainings • Over 2000 clinicians trained in PE to date Reference : Institute of Medicine (IOM): 2008. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press. PE TRAINING MODALITY • Intensive didactic training, generally 4 days • Approx 6 months of consultation which includes listening to recordings of sessions • Seeing approx. 2 cases through to completion, more if consultant deems it is necessary in order for trainee to reach competence threshold • 2243 VA Clinicians trained • How has psychology training in VA benefited? • 46 PE clinicians have been trained as consultants and vast majority are psychologists • Many of those psychologists are supervisors, training interns/fellows using similar modalities 10
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