EXPOSURE THERAPY: SUPERVISION AND TRAINING TECHNIQUES FOR - - PDF document

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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
• rder 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

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RECOMMENDATIONS FOR BEST PRACTICES IN SUPERVISION & TRAINING

Didactics

• VA Psychology Training Council website, Model Curriculum didactics contains a PE didactic
• PE web at MUSC website
• Multi-day workshops offered by Center for Deployment Psychology and U-Penn’s Center for the

Treatment and Study of Anxiety) Attitudes toward exposure therapy

• Address concerns, negative attitudes about exposure therapy
• Assess our own as well as our trainees’ beliefs about exposure
• Use Therapist Beliefs About Exposure Scale (TBES; Deacon et al. 2013)

Adherence ratings: Help your trainee know how competence is defined, gives specific behavioral objectives

BEST PRACTICES (CONTINUED)

Supervision

• Listen to recordings of sessions, provide detailed feedback
• Consider use of live supervision: exposure therapy group you can co-lead with trainee(s)
• Make use of role play & modeling in supervision
• Pay attention to exposure micro-skills
• OCD exposure, did you offer reassurance about competence or that it will be OK?
• PE, during imaginal, did you hammer too hard on patient belief trauma was his/her fault. How could you have

used Socratic questioning better?

• Does trainee demonstrate tentativeness around exposure? Or does trainee foster high quality exposure
• f sufficient intensity?

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INCREASING EXPOSURE TRAINING IN TRAINING PROGRAMS

• Impediments other than supervisor attitudes, one of the largest being lack of training

resources for supervisors themselves in exposure therapy

• Supervisors train in what they know
• Finding ways to increase supervisor training in exposure naturally leads to more trained

trainees

• Within

VA – training in PE via the national roll-out

• Outside

VA – the Emory PE Consultant Training Program

PE CONSULTANT TRAINING PROGRAM

Funded by:

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PE CONSULTATION TRAINING (OUTSIDE OF VA)

• Aim: Develop a national network of “Peer-Reviewed PE Consultants”
• Model: 6 months of consultation-of-consultation
• Each consultant-in-training has two trainees, each with two cases
• Consultants-in-training listen to all sessions, record fidelity ratings, and provide feedback
• Weekly “consultant calls” (attendees: PE experts and PE consultants-in-training)
• Weekly “trainee calls” (attendees: PE experts, PE consultants-in-training, and PE trainees)
• Current Network:
• 3 nationally recognized experts, 6 already graduated, 8 graduating in May, 8 starting in June, and now

recruiting for a December cohort (hint-hint!)

• Preliminary pre-post data suggests significant improvement in PE trainee knowledge and skill when

receiving ongoing consultation from a consultant-in-training.

TRAINING MODEL

• First step: select highly skilled PE clinicians
• Requirements:
• Licensed
• Previously received formal PE supervision/consultation
• Strong PE competency (evidenced by two recordings)
• Strong implementation plans for each trainee
• Protect up to nine hours per week
• If no prior formal supervision/consultation:
• 12-month program: 6 months as a trainee, then 6 months as a consultant-in-training

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TRAINING MODEL

• Second step: consultation-of-consultation by experts in a group setting
• Lots of learning content: 288+ sessions reviewed
• Math: 6+ consultants-in-training, each with 2 trainees, each with 2 cases, each with 12 sessions
• Over six months, almost every “PE learning lesson” emerges
• Not simply “updates” but shared learning lessons
• Instruction: trainee present a specific issue, his/her consultation-in-training takes first stab, then other consultants-in-training

take another stab, then experts provide any needed guidance

• New theme every week:
• Examples: creating in-vivo hierarchy, presenting rationale, providing verbal prompts to enhance engagement with trauma

memory, processing patient’s thoughts of guilt and perceived perpetration, etc.

• Instilling culture of adoption
• Culture of positive perspectives of exposure and the expectation that treatment will work
• Prevention of “colluding with avoidance” between consultant-in-training, trainee, and patient

SHAPING BELIEFS IN CONSULTATION GROUPS

1. At outset, entire group is made aware of common yet problematic beliefs (“myths”). 2. Problematic beliefs are normalized and targeted as pitfalls to PE fidelity. 3. Trainees are encouraged to test beliefs with actual cases much like PE clinicians ask patients to test beliefs (e.g., “Patient can’t handle exposure without using relaxation technique”). 4. Ultimately, trainee beliefs are shaped by clinical experiences, not conformity or obedience.

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ANECDOTES FROM OUR GRADUATES

• Four consultation strategies
• 1. Borrowing confidence
• 2. Normalizing and undermining clinician avoidance
• 3. Utilizing parallel processes
• 4. Reframing ethical concerns

ANECDOTES FROM OUR GRADUATES

• Borrowing confidence
• “The group shared so much evidence against exposure myths that it created an exposure-positive

culture that gave my trainee confidence in the protocol despite never using it before.”

• “The trainee was not confident that PE would work.

You could hear it in his wishy-washy rationale delivery to the patient. He told me it was hard to be confident if he’s never done it before. I asked him to not wait for confidence but to act as if he were confident – to borrow it from the consultation team. He was able to do that, which allowed him to deliver the treatment with fidelity, which then gave him genuine confidence for his next patient.”

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ANECDOTES FROM OUR GRADUATES

• Normalizing and undermining trainee avoidance
• “I told my trainee that I still genuinely regret my first PE case. During exposures, I felt dirty and thought

I was re-traumatizing her, so I would end each exposure prior to any habituation. I was just reinforcing avoidance… and her symptoms did not remit. I told my trainee that the dirty feeling still shows up

• ccasionally but I know now that trying to avoid my own discomfort is going to harm the patient. This

example made it easier for the trainee to notice her emotions without acting on them.”

• “I had my patient re-watch a session in which he was worried he pushed his patient too far. I told him I

also had difficulty seeing the patient in emotional pain but I did not observe the patient over-engaging. When watching the video, my trainee saw that (1) the patient could indeed handle it and (2) the memory triggered his own discomfort in the session, which biased his assessment of the patient’s response. The trainee actually noticed the patient’s engagement was optimal. He reframed the session as an achievement because he did not collude with avoidance.”

ANECDOTES FROM OUR GRADUATES

• Utilizing parallel processes:
• “We don’t ask patients to just agree with us – we set up a context in which they experientially learn

they can handle distress and that distress will eventually diminish. I took the same approach with my

• trainee. I had her reiterate the rationale to me many times – I didn’t ask her to believe it but to

understand it. Then, I asked her to deliver the treatment by-the-book and then let her experience inform her beliefs. “

• “Much like we want the patient to perceive success in the first exposure to create buy-in, we spent

several weeks role-playing imaginal exposure to improve the chances of success in the first imaginal

• exposure. A lack of preparation could have resulted in poor execution that would confirm negative
• beliefs. We avoided that by over-preparing.”
• “Just like with patients who struggle with engagement, one of the worst outcomes is having trainees

think they are doing PE with no success when, in fact, they are not actually doing PE as described in the

• manual. To prevent the development of negative beliefs, it was important to clearly articulate when

they deviated from the manual.”

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ANECDOTES FROM OUR GRADUATES

• Reframing ethical concerns
• “My trainee expressed that exposure is harmful and therefore unethical. Rather than me justify

why exposure therapy is ethical, I asked the trainee to build an argument for why it is ethical to use unsupported treatments. This assignment resulted in considerable reflection and the resolution that not doing exposure therapy would be harmful.”

• “I asked my patient why she would choose chemotherapy if diagnosed with cancer. I then asked

why wouldn’t her reasoning apply to mental health. It was provocative but helped the trainee understand exposure therapy from the perspective a treatment-seeker.”

NEXT STEPS ON CONSULTANT TRAINING

• Manualization of PE consultation
• Improves opportunity to systematically study consultation strategies
• Helps consultants maintain skills and knowledge after training program
• Measure consultants-in-training beliefs toward exposure
• Helpful for program to target problematic beliefs that may need revision
• Examine if it is related to success and future utilization among their trainees
• Follow-up interviews with trainees
• To understand trainees’ perspective on what consultation strategies were most helpful
• To understand barriers to implementation despite mastery of protocol
• To understand unhelpful beliefs that are resistant to change

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GROUP PARTICIPATION AND DISCUSSION

DISCUSSION QUESTIONS

• For programs already teaching exposure therapy
• What challenges do you encounter in the internship and/or postdoctoral training of exposure therapy techniques?
• What are examples of effective training practices in exposure therapy do you know of?
• For programs considering teaching exposure therapy
• If you were going to develop an implementation plan within your program to teach/supervise interns and/or postdocs in

exposure therapy techniques what would it entail?

• What barriers would you foresee to implementing your ideal exposure therapy teaching/supervision plan?
• What are possible solutions to the barriers to implementing your ideal exposure therapy teaching/supervision plan?
• What ethical concerns, if any, do you see related to providing training/supervision in exposure therapy?
• What ethical concerns, if any, do you anticipate related to NOT providing training/supervision in exposure therapy?
• What diversity consideration would be addressed (and/or unaddressed) by implementing training/supervision in exposure

therapy?

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VIGNETTE BASED QUESTIONS

• “Short on resources” – a small program with only a few resources wants to implement this type of

exposure therapy training/supervision experience in their program, how could they do this?

• “In-vivos as a minority”– your trainee is seeing person of color and/or a trans person who is doing in-

vivos and has legitimate concerns re: safety, how would you address diversity factors in training/ supervision?

• “I’m hurting my patient” – your a trainee, without a behavioral background, believes imaginal exposure is

harming their patient, how would you address this in supervision?

• “Mixed messages” – describe another supervisor in your program believe exposure is harmful and tells

your trainee (perhaps the same trainee as above) that they are hurting patients by doing exposure during a team consultation/staffing that you do not attend regularly, how do you respond to this?

THE END!

Questions?