The Ugly Truth about Prolonged Exposure: A Case Study in Medical Ethics

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Episode 007: Assuming you don't believe that that past 100 years of psychotherapists were actually trying to cause harm to patients, you'll soon better understand how mental health interventions are a double-edged sword. History demonstrates that the Law of Unintended Consequences applies here.

Before we get into the weeds in prolonged exposure, let's first start off by discussing unintended consequences of a psychotherapy for PTSD that I actually do like and agree with - Cognitive Processing Therapy. Now, I'm putting references here so that you can follow the research trail for yourself if you need proof to show to your circle of influence.

In CPT, there are a couple of writing assignments at the beginning: The Impact Statement followed by the Trauma Account. As opposed to Prolonged Exposure Therapy, Cognitive Processing Therapy does this brief, one-session account of the details of what actually happened during the trauma. The intent is to use the information explicitly during later stuck point work. The knowledge in that situation was worth it, we thought, to expose the patient to the anxiety, nightmares, flashbacks and sometimes depression and relapse with substances of abuse - all related to having to tell their story. For them, they are re-living it. Because they are.

No Trauma Account Needed in PTSD Therapy

  1. Resick 2015. Cognitive Processing Therapy (CPT) without a trauma account written by the PTSD patients versus group present-centered therapy.

Many years later, we finally start asking the question - do we really need to do the trauma account? Here? Now? What if we do everything else in CPT, but leave that part out? Guess what they found. That's right, the reliving of every excruciating detail of the trauma wasn't necessary to relieve the suffering and improve quality of life! The lesson isn't that I instinctively didn't like the trauma account meetings I attended in training where veterans went through every detail. My resistance wasn't personal for me, for my ECS was not yet totally out of balance. I could handle and cared passionately for the work I was doing.

I was ok. No, the problem was I saw the torment through their eyes and their bodies were reliving it. We were doing this to them. And we still are - today. Just because a paper comes out that says we don't have to doesn't mean people stop the harm overnight. Of course, I firmly believe in an individualized treatment plan and this here is not medical advice per se. Trauma Accounts should be done on a case-by-case basis where the patient has every bit of informed consent as what I'm presenting in the entirety of this podcast, not having simply signed an informed consent piece of paper.

There are many options for PTSD symptom relief

Those that need body-based approaches are largely ignored by mainstream psychiatry. However, a few techniques have made it into the halls of military facilities for post-war reset programs. Acupuncture, Reiki energy healing, mindfulness meditation are good, but they are only the tip of the iceberg when it comes to different types of techniques that will work. If you ask me, I think the clinical scientists today are waiting a bit too long for randomized trials with the underlying science has already been worked out to show how similarly body-based techniques really work the same way.

For example, massage, acupuncture, putting your hand on a sore spot, using a heating pad, and a doing a hot water soak all do the exact same thing to a bruised elbow - they increase capillary blood flow, tune up the nervous system responses, and literally help move electromagnetic field waves stuck in various parts of the torso and extremities. Massage is no different than weight lifting for the Endocannabinoid Receptor System and Brain-Derived Neurotrophic Factor - both of which depend on healthy nutrition, sleep, and quality of life balance. That's called rest, folks!

The Ugly Truth about Prolonged Exposure

In episode 3, I discussed the generalization of the fear-based response to threat. Well, Prolonged Exposure can be quite traumatic itself. The median number of follow up appointments once PE was explained was one. This means more than half of patients refuse to participate. Those statistics were left out of the effectiveness data when this approach was used for every type of PTSD. Many of the patients that do PE have a significantly worse quality of life for weeks afterwards.

The strategy of Prolonged Exposure is to get you more physically and emotionally calm when recalling memories or being triggered of your past in real life. The tactic is to have your write out the specific details of your worst trauma in excruciating detail. Then, read it out loud repeatedly during your psychotherapy” session. The hope is that by exposing yourself to the painful memories in a safe environment that the calmer feeling will persist. Suffice is to say that I’ve seen countless PE patients do worse, but have also had some say it helped them.

Caregiver Resource for PTSD

Therefore, I feel it’s best used in specific phobia-type circumstances after full disclosure on a case-by-case basis. I have trouble coming up with a good example of when to use it, but that’s just my professional opinion and the approach to my practice. I simply disagree with it being systematically rolled out for the masses to accept as a top 20 therapy for PTSD. That’s right in the courses at PTSD Academy, I teach how to use more than 20 approaches better than PE. I wrote more about Prolonged Exposure in my book The Warrior Class: Caregiver’s Guide to Posttraumatic Stress Disorder (Available at http://www.lulu.com/shop/daniel-williams/the-warrior-class-caregivers-guide-to-posttraumatic-stress-disorder/paperback/product-22999335.html).

Unfortunately, I think the real problem with PE isn’t PE itself. It’s a problem of some counselors that don’t foster and teach about felt safety to patients. That’s why the courses at PTSD Academy first teach felt safety. The only way to change this culture is from within with true leadership and the fairest conceptual frameworks we can find that actually work. When we work together to study the right outcomes, we can better understand the cultural problems behind PTSD and begin to prevent it. In order to do that, I need to also introduce you to other critical tasks of adult maturation.

Four major areas of adult maturity:

  1. Helping others.
  2. Receiving care from others.
  3. Negotiating one’s needs.
  4. Feeling comfortable with autonomous decisions.

This is a bit shorter episode, but reason I created The PTSD Blueprint in the first place is to get my ideas out to you to try and help. The only way you can put my messages into proper perspective is to know the type of psychiatrist and person that I am. Hence, my dislike of PE was important to include up front.

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