Episode 31 – An introduction to prolonged exposure therapy with guests Dr. David Paul and Justin Woodcock

MIND BEYOND THE MISSION EPISODE 31 — AN INTRODUCTION TO PROLONGED EXPOSURE THERAPY WITH GUESTS DR. DAVID PAUL AND JUSTIN WOODCOCK

Laryssa Lamrock

Welcome to another episode of Mind Beyond the Mission. I was thinking this morning somewhere around this episode is marking our third year, which is pretty exciting. Not sure I ever would have imagined that. I’m hoping that people that are tuning in are finding it helpful. I think today’s conversation is going to be another compelling one. First, I want to say that my co-host Brian McKenna is still currently away. We’re really looking forward to when Brian is going to be joining us again.

In the meantime, we’re really happy to have another guest co-host. Today, Justin Woodcock is joining us. Justin is a proud First Nations Veteran and social worker from Opaskwayak Cree Nation. His service in the Canadian Forces began in 2009 and spanned nearly a decade, which included service both in the Canadian Army and the Royal Canadian Navy. As Justin’s service in the Canadian Forces came to a close in 2017, he set a new goal for himself.

After losing friends and fellow soldiers to posttraumatic stress disorder, Justin was driven to support and assist fellow Veterans in combating this growing concern through his social work practice. With this goal in mind, Justin enrolled in the University of Manitoba Inner City Social Work program and graduated in 2022. Justin, thank you so much for your service and your continued service. Also, a big thank you for being willing to jump on the podcast with us as our co-host.

Justin Woodcock

Absolutely, it’s an honour. Thank you so much, Laryssa, for inviting me. I really appreciate the work that Atlas does and how they value that lived experience. Really excited to be here to learn. I know exposure therapy is really popular in the Veteran community. I’m excited to learn more about prolonged exposure therapy. Really excited to be here, and thanks for having me.

Laryssa

Yes, that’s great. Thanks, Justin. Justin let part of the cat out of the bag of what we’ll be talking about, but it’ll be in the title of the episode so everybody already knows. If you clicked, you know. Part of the work we do at Atlas is to educate and train service providers to best understand the Veteran and Family culture and help share best practices and cultural competency. The service providers are best prepared to support the community.

I also believe that there’s space to train up Veterans to also be best prepared and informed as they show up to their appointments, I guess to be the best client, best prepared patient they can be. Veterans and Families should have access to solid info so they can take charge of their own recovery and advocate for themselves. I think that’s certainly one of the goals of Mind Beyond the Mission. They deserve to be in the driver’s seat making informed decisions about their health and future.

Today we will be talking about prolonged exposure therapy, which is one of the evidence-based therapies that’s commonly used to treat PTSD, particularly. We’re going to soon find out if it’s used to treat other conditions. I just wanted to put out that “evidence-based” refers to the fact that the treatment is based on research and has shown to be effective for specific issues. I also want to mention that we are not necessarily endorsing prolonged exposure therapy or PE, as we might be referring to it, as the best treatment for every person.

We’re encouraging people to do your homework, and we’re going to get you kick-started in that homework today. That’s why we have invited Dr. David Paul. David Paul is a registered psychologist in private practice in Edmonton, Alberta. He specializes in the treatment and assessment of trauma and stressor-related disorders in both the military and public safety personnel communities for most of his career, which has included positions at the Edmonton Operational Stress Injury Clinic and the Operational Trauma and Stress Support Centre (OTSSC) at CFP Edmonton.

If I could rattle off that acronym right now, I would. Operational Trauma and… something. We’ll figure that out in a minute. He holds a doctoral degree in clinical psychology from McGill University and is certified as a trainer in prolonged exposure therapy by the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, which is why we’re really excited to have you here today. Thanks for joining us.

Dr. David Paul

Oh, thank you very much for having me. I’m thrilled to be here.

Laryssa

OTSSC?

David

Operational Trauma Stress and Support Centre, I think.

Laryssa

Way better than what I was trying to fumble. Yes, we’re really glad to have you. Let’s get kicked off, prolonged exposure therapy. I think this is one of the first episodes — I know we did do an episode on neurofeedback, which if people are interested for them to go back and have a listen to that again, to be educated in their own recovery or in someone they may be supporting. Prolonged exposure therapy, let’s break it down to the basics. I think it’s often misunderstood. I wondered if you can just walk us through what it is and how it might specifically help Veterans with PTSD and potentially other conditions.

David

Yes, that’s a great place to start, I think. One way to think about prolonged exposure therapy is it is a tailored version of a more general therapeutic approach, that being exposure therapy. PE is really a treatment that was created and refined specifically to treat PTSD. It is a PTSD treatment and only a PTSD treatment, as it is manualized, really. Another way to think about it is it’s just a customized version of some broader exposure type interventions that are used much more broadly for a whole range of anxiety disorders, from phobias of things like dogs or heights or public speaking, to panic disorder, to OCD, et cetera. It’s like a particular packaging and customization of things that have been around a lot longer, specifically targeted towards the treatment of PTSD.

Laryssa

I’m curious, what makes it targeted to PTSD? What specifically about it is best for that?

David

It has to do with the way the treatment was developed. PE has its roots in studies that began in the late 1980s. The way the treatment has evolved is really through this process of trying some things out with people who are diagnosed with PTSD and then looking at the results, then either adding or subtracting components of the treatment, depending on whether they added any value to the outcomes or not. The reason it exists the way it exists, just to provide a bit of an overview of what PE looks like, it has three, or depending on how you look at it, four main components.

Two of those are specific types of exposure therapy. One of those is called imaginal exposure, which is really exposure to the memory of the trauma itself. Then the other main exposure piece of PE is what we call in vivo exposure, which is just a ornate term for real-life exposure. Typically, that’s exposure to all of the situations or objects, or things out in the world, that are going to evoke memories of the trauma. Both of those types of exposure are used in various forms for other types of anxieties. That particular combination is a combination that the research shows is particularly effective for treating the symptoms of PTSD.

More specifically, what the data suggests is that exposure treatments that involve both imaginal exposure and in vivo exposure, that’s the most effective combination. That’s a conclusion that really was arrived at over years in multiple studies. You can think of PE as really just the combination of those two things, along with some more cognitive interventions that are about exploring the beliefs. That, we know, is the combination that’s most effective for people who have been diagnosed with PTSD. That’s essentially how we arrived at that version of exposure therapy, which we call PE.

Justin

I was just wondering if you could explain the difference between imaginal exposure and the vivo exposure in a little bit more detail, just so I can get a better understanding of what that actually looks like.

David

Maybe it helps to give a sense of what the theory underlying PE looks like, and that’ll explain what those are and why they’re included. The basic idea with prolonged exposure and the theory on which it’s based, which is something called emotional processing theory, is that to boil it down. One of the things we know empirically about traumatic events is that all of the symptoms that we think of when we think of PTSD, nightmares, flashbacks, intrusive memories, feeling panicky when you’re around things that remind you of a traumatic event, right after a trauma happens to somebody, most of those symptoms are present for people.

Depending on the type of trauma somebody experiences, almost everybody who’s been through that trauma may have quite high levels of those symptoms. For many people, those symptoms naturally subside over time. There’s this phenomenon after trauma called natural recovery. What’s normative after a trauma is that most people have symptoms, but then many people will naturally recover from those symptoms over time. PTSD is something that we typically will think of as an interruption to that process of natural recovery.

The various evidence-based treatments for PTSD, they will differ a little bit in how they think about the thing that blocks that natural recovery. PE really hinges on this idea that the thing that blocks the recovery is avoidance. There’s two particular types of avoidance. They’re closely related. One of them is an effort to avoid the memory of the trauma itself. Not to think about it, push it away, stay super busy all the time so there’s no room for it to come into mind. Substance use is a common way of trying to avoid the memory as well.

Then, in addition to that, there’s often quite a number of efforts to avoid anything that might bring up memories of the trauma. People might avoid the things that will make them remember the trauma itself, or they might avoid other things that are not necessarily related to the trauma, but they don’t feel safe in the same way that they used to. Crowded places full of people that you don’t know, for example, or that’s a very common thing that people will try to avoid after a trauma.

Imaginal exposure is really meant to overcome that first type of avoidance. Imaginal exposure really means helping people to approach the memory of the worst trauma that they’ve experienced, the one that is hardest for them to think about and talk about, and the one that tends to drive most of those re-experiencing symptoms like intrusive memories or nightmares, et cetera. Imaginal exposure is really just exposure in your imagination to that event.

That event that continues to haunt you. In vivo exposure, on the other hand, is more about going out into the world and confronting some of those situations that you’re avoiding either because they will make you think about the trauma when you don’t want to, or that people tend to avoid because they just don’t feel like that’s a safe thing to do in the way they might have before.

Some examples of in vivo exposure might mean looking into photographs of people you lost in a trauma, or places you were on tour, or watching films that bring up the memory is a common one as well. Similarly, as I mentioned, maybe going out and being in crowded public places where you have this sense that this is not safe. I don’t know who these people are, and I’m not sure what’s going to happen. One is very much in your imagination, the other is more about tangible things, places or activities.

Laryssa

I’m processing so much right now. First, I wanted to say thank you very much for — I think it’s an important point to make that when someone qualifies, I suppose, for diagnosis of posttraumatic stress disorders, one of the key indicators is that it’s existing over a period of time. There’s probably a fixed period of time within the diagnostic manual, but for some people, what I heard you say was they might experience trauma, but after a couple of weeks or a month, those symptoms and nightmares, constantly thinking about it, will gradually subside.

Your system is processing it. It’s important to note that posttraumatic stress disorder is when those symptoms remain over a longer period of time and don’t subside. I don’t know that we’ve ever fully talked about that here. I think that’s important for people to know. Then, talking about what you’re describing, so if we can get into that. What it might look like is, as you were suggesting, a Veteran working together with the clinician to maybe talk about the event, and it might be repeatedly talking about the event. My experience with a lot of Veterans is they work really hard to push that away. As you were saying that they want to avoid that.

People don’t seek discomfort. They don’t seek that. They want to avoid that. For a long time, a Veteran might’ve been working really hard to push those things away, to subside them, to avoid them. What this treatment is asking is for them to confront those. Probably it’s not done in one session. It’s going to take a little bit of time. That might sound really scary to a Veteran. That might sound really overwhelming, very intense. Are there any misconceptions around that? What would you say to Veterans who might be learning about prolonged exposure for the first time, and are like, “No way, I’m not doing that”?

David

That is an extremely important point and question. I think you’re absolutely right that that’s a stumbling block for many, many people for precisely the reason you say, Laryssa. The priority for many people struggling with PTSD is to do whatever they can not to think about these events. Anything that threatens to bring these memories to the forefront often sounds like the worst possible option. I’ve certainly had many, many clients who, when I’m reviewing their options for evidence-based treatment, they hear about PE and the words out of their mouth next are “Whatever that other option is, I’m going to do that.”

It’s understandable, because one of the things we know about PTSD is that these events, which are often among the most terrifying or the most horrifying things people have experienced, they’re distinct from just memories. The line between present and past is fuzzy in a way that it isn’t for other things that have happened in the past. One of the hallmarks of PTSD is that thinking about something that is over elicits the same response emotionally and physiologically as going through that thing.

It evokes the same fight or flight reaction that somebody had when their life may actually have been in danger. Asking people to be willing to feel that way is a very hard sell for reasons that I think are understandable for most people. I think the responsibility of clinicians is to really be clear about exactly how we’re going to do that, but more importantly, exactly why it might be helpful and important to do. Prolonged exposure has a lot of — especially in the early sessions of the treatment, there’s a lot of time spent trying to explain that rationale to people.

There’s different ways to look at it that might make more or less sense to people. One of the things that it’s important for clinicians to try to get across is that avoidance is not a bad word. Sometimes when clinicians are new to this and they’re gung-ho about the treatment, they go a little too far in almost like turning the idea that avoiding memories or avoiding things that are hard is a weakness or something that you — it doesn’t make any sense. When the reality is people avoid because it helps them.

It works. It only ever works incompletely, I think. What we’re trying to get across when we talk about PE is that there’s a trade-off here between feeling better in the short term and feeling better in the long term. Though avoidance helps people escape high levels of distress when it’s right in their face, it only ever works temporarily. The cost of it is that it keeps the underlying beliefs that drive those symptoms alive.

What we’re asking people to do in PE is consider reversing that trade-off and asking them to be willing to tolerate higher levels of distress in the short term, but with the goal of lower distress in the long term. There is a PR problem with this treatment. Even the name, frankly, prolonged exposure, if you’re asking folks to consider doing hard things, I’m not sure that is the treatment name that the developers, with the benefit of hindsight, would choose if they had it to do over. I think that this is a primary problem that we need to be really intentional about.

Justin

David, I’m wondering if you have any tips or do you have any messaging about how do you explain to a Veteran that discomfort is a part of the healing process? How do you explain that to a Veteran, and do you have any tips for folks trying to explain that?

David

I think there’s various analogs of that in the health world. A lot of treatments are like, you have to hurt to heal. Physiotherapy is like this. That’s not a pleasant thing to go through sometimes. It often involves a lot of hard work and some pain on people’s parts. Chemotherapy, frankly, is a brutal treatment for anybody who’s been through it but it, too, is in service of healing. I think many Veterans, just by virtue of their work, they’ve had some experience with physiotherapy. Hopefully, chemotherapy is a less personal experience for most folks, but most people can attach to that principle.

Then I think there’s other maybe more commonplace like metaphors around exercise, training. If you lift weights, that hurts, but it’s about building strength. Sometimes metaphors like that are helpful. One of the points as well that we often make, and this I think goes along with that idea that avoiding, though it’s helpful, it’s only ever short-term. I think a lot of fears around prolonged exposure and maybe exposure generally, both among Veterans but also among like providers, frankly, has to do with this idea that it’s — I hear this term “re-traumatizing” frequently.

This idea that you’re somehow harming people if you ask them to confront these things and endure this distress. The fact of the matter is the distress is like, we’re not giving people these experiences when we do this treatment, they’re already there. Those memories are already there, and the distress is already at some level there. People are already carrying this. All we’re really doing in some ways is trying to help people take control of that and decide when and how and where they’re going to invite that distress in.

The idea here is that folks are already suffering, but this is more about giving them control over this process in a way that ultimately is going to reduce that suffering. I think one way where you can frame that maybe has some resonance for Veterans is that with PTSD, you have a choice of rules, I think. Although I don’t love this terminology, the rules that you have to choose from are you’re either going to be the aggressor with the symptoms or you’re going to be the victim of them. What we’re asking people to do here is be the aggressor.

I think that people, especially anyone from the combat arms, might understand the logic of that. They may not want to take on the role of aggressor, and that’s understandable. The reality with this is if we’re not able to engage directly with these symptoms, the symptoms are going to drive the bus. I think the idea here is people who have PTSD through their service probably have quite extensive histories of doing hard things of showing courage and of tolerating distress.

Really, what we’re trying to do with this treatment is sell them on the idea of just extending that to this domain. What I mean by that is one of the things that keeps these symptoms alive is almost like a lack of confidence that I can tolerate these emotions. One of the things we want people to get out of this treatment is some direct evidence that that’s not true. That whatever these emotions are, they’re things that are not going to harm me, even if they’re deeply distressing, that I’m capable of tolerating them when they’re there, and that if I can tolerate them long enough, they’re eventually going to subside.

Laryssa

I love what you’re saying there. It’s almost empowering saying to them, you’ve done hard things before, you’ve got this. I’m going to walk alongside with you and guide you through it. That’s almost empowering. I will disclose my spouse’s experience with prolonged exposure therapy. I’ve been there as the supporter. As you were chatting before about needing to do hard things for the long-term benefit, I’m thinking of like the bumper sticker or the poster, going back to the gym analogy. What is it? Short-term pain for long-term gain.

Going into the Family support piece of it and sticking with that analogy, what I noticed with my spouse and unfortunately it was my own observations, and that nobody gave me the heads-up on this. What I noticed was a couple of days before his session, he’d start to be a little bit irritable, maybe not sleeping, a little bit more of an edge. Then he would attend the session and come home and would be more symptomatic because he was exposed to that trauma. Probably didn’t sleep that night and maybe for the next day or two.

There was this blip in the radar, so to speak. The analogy that I’m going to use for the gym is that you go to the gym and go, “I don’t want to go today, I need to get going.” Motivate yourself to get there, do all the reps, whatever, and then come home and your muscles are sore for the next couple of days. Just wanted to draw that analogy and put that out there. That was our experience. I just wanted to see if that might be a lot of other Veterans’ experience, because I think we want to be honest with them on what to expect.

I think if you know what to expect, you and your Family can then plan around that and how to best support that piece of it. As I say often in our conversations, there’s a question buried in there somewhere. I think one of the things that I’d like to know is what’s the role of the Family members in supporting a Veteran through prolonged exposure therapy, and maybe not just Family, but close friends or other people around the Veteran?

David

Thank you for that question, Laryssa, because I think it’s hard to actually emphasize this part of it enough. As you know well and as I think we’re starting to pay more appropriate attention to, it is extremely rare that PTSD ever affects one person. It affects the entire system in which that person exists. We know that if we do a bad job in preparing systems and families for what this treatment is likely to look like in the short term, we’re probably decreasing the odds that the veteran is going to be able to finish it in a productive way.

Thank you also for highlighting this idea that if we’re asking people to trade long-term for short-term gain, what that means is we’re asking them to approach things that are distressing to them in the short term, and their symptoms are going may, I should say. This does not happen all the time, but it’s often the case that the symptoms in the short-term increase, especially at certain parts of PE. In particular, when people are starting imaginal exposure, that is the point in the treatment where the dropout rates tend to peak.

If individuals don’t know this is coming and their symptoms suddenly increase, they may think, “This doctor is crazy. This is a terrible idea. I should stop doing this.” If a spouse or a Family member witnesses that, they’re very likely to have the same thought. We need to prepare individuals for this possibility. More and more, I think we’re cluing into the fact that we need to prepare Families for it as well. In an ideal world, what we should be doing in the early sessions of PE is inviting, I think, significant others in to also be a part of this conversation about what the rationale for this treatment is and what the likely effects of it are going to be.

Just so that people don’t have an experience where they think we’re going backwards, this is making the problem worse, and we need to stop. Because really, the way we would want people to interpret a temporary increase in the symptoms is that that is a sign that you are successfully reducing your avoidance and you’re doing the thing that is going to get you better, and we just need to stick this out until we get to the other side. If everybody’s clear on that message, I think it really increases the odds of a good outcome.

Then I think the other part of that is the symptoms of PTSD almost always, to some extent, rope in Family members. People get implicated in avoidance strategies. If you’re in Costco with your partner and they’re starting to get panicky, most compassionate people would at least consider saying, “Hey, like I got this, why don’t you go out to the car and calm down, and I’ll finish off the shopping here?” Just the same way avoidance functions with the individual like that makes things better in the short term.

In the end, it’s getting in the way of helping the Veteran learn that they don’t need to do that. That if they just stay put, they can handle what they’re feeling, they’re not going to get hurt, and eventually, they’re going to feel better. Families almost always wind up getting stuck in helping clients avoid. It can be a delicate conversation around how to identify that and how to change that. Doing it, I think it’s really important to helping Veterans recover, but also helping Families be a part of that process.

Laryssa

Justin, I know you have a question. I just had an epiphany. David, as I said, my spouse went through prolonged exposure therapy and as you were talking about the Veteran becoming triggered in Costco, I had a physiological response to that as you were talking about it. I was like, “The Family is going through prolonged exposure therapy as well. What you’re asking is for them to stick with that and move through it.” The Family in Costco in that moment, they have to contend with that anxiety, discomfort, everything else. The Family, essentially on a sidebar thing, is also going through prolonged exposure therapy. Justin, sorry, I know you had a question.

Justin

Yes, David, I just wanted to touch on a point you made there. I’m wondering how do you measure success in prolonged exposure therapy, and what are some key indicators that the Veteran may be improving?

David

I think that there’s no single indicator. Some of them are clinical indicators. Are the symptoms coming down? Are scores on clinical measures changing? I think more importantly, what we’re also looking for is changes that we would observe in the client. Are they able to talk through this memory with less distress, in more detail, without the same urge to avoid it? Are they getting back to doing the things that have importance to them in their lives?

Are they able to go out and sit with the other parents at their kid’s hockey game instead of staying in the car or sitting up in the rafters? Is their Family giving them feedback about change? Are things getting easier for Family members as well? Other more raw, functional things, like is the person getting back to work or seeing friends more, et cetera? It’s really, I think, an amalgam of different channels of information that hopefully, if they’re all pointing in the right direction, we’re seeing symptoms come down, but we’re also seeing people get back to living their lives.

Because the way I think lots of clinicians tend to think about PTSD is it’s like something that comes along and just knocks the train off the tracks. PE is really just about helping people get the car back on the tracks. There’s this whole other conversation, I think, that opens about where is this train going? What is life going to look like? One of the indicators that therapy has done or is doing its job is that people are starting to think more about that. They’re starting to maybe consider possibilities for the future in a way that had not really been possible or productive for them in the past.

Justin

Thank you. Yes, that’s important to know. When we’re starting to see those indicators of improved outcomes, how long is the — I know everyone’s different, but what is the average length of therapy time for prolonged exposure? Is there any figure for that to what a Veteran can expect on when they’ll start seeing results?

David

Yes. The broad range of sessions, and we’re talking about 90-minute sessions, so that we should keep in mind, PE can be delivered either as a 60 or a 90-minute treatment. Thinking at least about 90-minute sessions, typically it’s anywhere between eight and 15 or so sessions. I would say probably on average for most experienced PE therapists, we’re talking somewhere in the 10 to 12 range. If that’s weekly, then we’re looking at two and a half to three months of treatment.

There’s an increasing emphasis on doing more intensive formats. Mass prolonged exposure, for example, this is something that was created mostly to deal with problems of accessibility and dropout. In particular, in the US Armed Forces, where some of the early research on this was conducted, mass PE is essentially 10 sessions of PE delivered in two weeks. Monday to Friday, every day. Then there’s intensive outpatient programs as well that are similar in structure to that.

One of the things we know about those formats is that there’s a lower dropout rate, because that’s one of the problems in delivering evidence-based treatments to especially military populations, is that the dropout rate tends to be higher than for civilians. In prolonged exposure, depending on which study you’re looking at, the dropout rate may not be substantially different than other good PTSD treatments like CPT or EMDR.

In some studies, it is a bit higher. We know that delivering things in those compressed formats tends to reduce that. That’s potentially an important option for the future. The short answer to your question, although I’m well beyond that now, is somewhere between 10 and 12 sessions. The amount of time that takes really depends on how often we’re delivering this.

Justin

You raised an interesting point there. I’m wondering, are there any unique considerations when you’re treating military Veterans versus RCMP Veterans? Is there unique challenges or barriers, or anything that you can share with us?

David

I think the treatment broadly is very adaptable to both those populations. A lot of it was later developmental work, at least it was conducted in Veteran and military populations. In terms of unique considerations, I think the historical one that comes to mind first is just accessing these populations and finding time to do this. This may be less the case now than it has been in Canada in the past, and possibly less the case now in Canada than in the US, but where there’s high operational tempos and you can’t get people in one place for three months at a time, it can be hard.

That’s, in some ways, the part of the problem that mass delivery formats was created to address. I think similarly with RCMP, if folks are working, it can be difficult to find the time to attend sessions and to do the homework. Because a big part of what makes PE effective is clients are doing repeated exposures every day in between sessions. If you don’t have time to do that, it will really stretch out the amount of time required to complete the treatment. That’s one hurdle. I think that in some ways, depending on the type of environment an RCMP member is working in, exposures may in some ways be easier and in some ways be harder. What I mean by easier is potentially more accessible to you.

If RCMP members are living in the community in which they’re policing and potentially in the community in which they were traumatized, the symptoms are going to be triggered more often because they’re constantly around the reminders. They might be driving past the place where the trauma happened to and from work every day, whereas somebody whose trauma occurred overseas in a theater of war, that might be less the case. That’s neither, I think, a good nor an evil.

What it means is, if you’re around trauma reminders every day, you’re probably going to have a higher level of distress, but it also opens up more opportunities to do effective exposures. That can be a challenge, but I think it also can be an opportunity. It often will lead to people have had to live their lives around those reminders, and so they’ve often got quite elaborate avoidance strategies developed that you’re going to have to provide a good rationale for undoing in some ways, which can be a challenge.

Laryssa

I think there’s so much to unpack here. I’m glad we got this conversation started. I hope it provided some information for Veterans and their curiosity so that they’ll continue to ask questions. I hope they will go to their providers or clinicians and ask some informed questions so they can make the best decision that’s right for them and their Family. I wondered, as we’re closing out, are you able to share an example of a Veteran that you might have worked with that went through prolonged exposure therapy, and if there were any transformational results, or an example you might be able to share?

David

The one I have in mind, I think this is maybe a good one to share in slightly anonymized form, because it illustrates an important point that I think is also a misconception. This is maybe more a misconception held by providers than by Veterans, but there’s sometimes a belief out in the world, the treatment world, that PE is only a treatment for fear-based traumas, and it doesn’t address traumas like moral injury or traumas that are also morally injurious events.

Moral injury, as folks are probably aware, involves other emotions than fear. Traumas in which you may not have been directly in harm’s way yourself, but you might have witnessed or been a part of actions that really broke an important moral rule. Those types of traumas often involve — there may be fear, but they may also implicate emotions like guilt or shame or anger or grief. One of the things that sometimes surprises providers is that PE, much like CPT, without very much modification, is suitable for those types of traumatic events as well.

One Veteran that I worked with had an event like that. It was both a trauma in the classic fear sense, but also a morally injurious event in which he was involved in an event in which some civilian children were killed. His actions played a direct role in that. Because this was so distressing for him to think about, he didn’t or at least he didn’t think about the memory, or he wasn’t able to really fully attend to the context in which this terrible event happened.

He would start to think about the memory and then shut it down because it was very, very upsetting to him. He also avoided a lot of things in his personal life that would evoke this memory, including children in his own Family, which, as you can imagine, made it very, very hard to function in the way that he and his family would have liked. For him, prolonged exposure meant going back to that memory and repeatedly talking about it in great detail. The goal there was not to torture him, but it was to help him appreciate all of the things that happened that day that limited his options in that moment.

He, prior to PE, would be telling himself things like, “I killed those kids,” or “I should have done this. I should have turned this way,” or “I should have stopped.” By virtue of the fact that he wasn’t allowing himself to think about this, he was neglecting details like he was under fire at the time, and he couldn’t see what was happening, and he didn’t have room to maneuver in a way that would have allowed him to avoid those kids. That was one of the big outcomes of the imaginal exposure is he was able to more fully attend to those details and put that awful event into the context in which it happened.

The goal was never for him to forget that or to feel good about something so terrible, but it was about fully appreciating what the limits were on his actions, and also more fully appreciating the other folks who contributed to that thing happening, which included the people who were trying to kill him. Then the in vivo exposure was really about having him approach all of those things that he was avoiding. That meant children and his Family.

He had this belief that somehow, in ways that he couldn’t define, if he was around kids, something bad would happen to them, just by virtue of his presence. Exposures there were about teaching him that was not true, and teaching him also that though this was very upsetting for him initially, again, he could stick it out and he could get to a place where that level of distrust was much less. That’s an example of, or one example I guess, of him getting back to functioning in his family life.

Laryssa

David, I know that might’ve been challenging for you to anonymize that, but that was so powerful. I appreciate you so much sharing that. I was getting shivers and goosebumps because I think a lot of Veterans will hear or see themselves in that story. I think a lot of Family members might see their loved one in that story from what they know of their experiences. I think, not to make light of it, but you talked about marketing before. I think when a Veteran can see themselves in it and maybe see hope through what you just shared in that example, that is the power, and what might help someone determine that prolonged exposure might be a route for them. I really do appreciate you sharing that. Justin, was there any questions that you were really hoping to ask that you didn’t get a chance to?

Justin

Just briefly, I’m just wondering, David, if you have any suggestions for organizations like mine that support First Nation Veterans, how we can better support access to this type of therapy?

David

Yes. I think one of the big obstacles is trying to find providers with appropriate training and experience. There’s a sizable number of good PE trainers, I think, who are helping people develop proficiency in this treatment. I think one tip is how do we connect Veterans to people who have good training and experience in PE? Right now, probably one of the best resources for that is the website maintained by the Center for the Treatment and Study of Anxiety at Penn.

That’s a link maybe we can provide, but they have a listing of some of the therapists and consultants that they have certified, and they’re the treatment developers. They’re the gold standard, but there are, I think, other folks as well who are doing good training in this space. That’s one challenge. I think another challenge, like one of the research streams currently underway in the States, has to do with whether Veterans who are going through in vivo exposure as part of PE benefit from having a peer who has also completed that treatment to help them navigate that.

I don’t know that we have the results on that yet, but having peers available who have an understanding of this treatment and understand the model and know some of the same things that we’ve been talking about are important for the individual or the family member to know in terms of like, what’s the idea here? What do we do when the distress levels go up? How do we help people get through that? Having peers who are educated and then able to, I don’t want to say reassure in a way, but help the client — the Veteran — stick it out, that can be helpful as well. I think a big part of this is like education. I can think about resources that we can add or make available that would be helpful there. I don’t know if that answers your question, Justin.

Justin

No, that does. That’s very helpful. Thank you, David.

David

You’re welcome.

Laryssa

Thank you so much for this conversation. I know I learned a lot, even though I took it upon myself to learn a little bit about prolonged exposure therapy when my spouse was going through it. I think I just will share with folks that, you mentioned, David, about the Family members providing feedback. I have seen a lot of improvements in my spouse. He’s able to participate in things or be in places where he wasn’t before. I can see his level of distress is much lower. That’s my little plug for prolonged exposure therapy, that it worked in our situation.

Again, thank you, David, for joining us, and Justin for being a spectacular co-host. Thank you, everyone, for joining another episode of Mind Beyond the Mission. I asked you folks before, I’m going to ask it again to subscribe, rate the show so that you’re drawing other people in the community. If you’re finding the podcast of benefit, share it, like it, so that others in the community can come around to it. Hopefully, it’ll help them as well. Thank you both. We’ll see you soon again.