Behavior Therapy Prolonged Exposure for PTSD

 In the Rauch & Foa (2006) article, the authors discuss exposure therapy, its theoretical base in emotional processing theory, and its application to PTSD. Here, the authors describe emotional processing theory as describing a fear as a stimulus response, meaning elements designed as a program to escape danger, and an action like avoidance. When something similar to the stimulus is activated, it spreads throughout the network as a whole. Overall, I think this model is smart, because it seems to have some EFT flavors in it where there is direct processing and intentionally zoning-in on emotions, what the client feels like, how to not avoid emotions, and what it means to process emotions. On top of that, the theory and practice seems to add in a clear cognitive path that explains why these fears decrease over time. In exposure therapy, these links are quite evident, but this theory makes it clear how this would work in other anxiety type disorders as well (ex: avoidance of the stimuli creates no space for disconfirming evidence, negative reinforcement loops). This theory also integrates core beliefs such as 'the world is dangerous, I am incompetent' which can serve as a good jumping off point for therapists to grab disconfirming evidence. In many theories, I often have the question 'and then what', and I am not sure if it is the bias that I know this theory better, but it seems very comprehensive. It also seems to integrate the bio-psycho-social model well and allow the therapist flexibility even if it is not a typical client. This article also talks about under-activation and overactivation. For a client experiencing under-activation, I think methods used in EFT could be used to broaden someone's sense of their inner emotions, especially if they are using safety behaviors to try to avoid inner feelings. I understand why overactivation would be hard to study (IRBs), but I also wonder what the limit of overactivation is. According to this theory, overactivation almost seems incompatible, for as long as there is disconfirming evidence, the fear should start to extinguish. I am not sure if I buy the whole 'they just can't pay attention' to it argument. I also wonder about re- traumatization, but I think this is why theory and practice are important as well as psychoeducation at the beginning of therapy. Concerning safety behaviors, I wonder how this would work with someone who experiences depersonalization? Although it would hinge on the therapist-client relationship, I can see someone being able to say all the right things, and actually lower their SUDS, but do it in an unhelpful way. Lastly, I did not know you could do the same exposure more than once. 

The McLean & Foa (2011) article discuss the efficacy of prolonged exposure (PE) for PTSD. This article also goes over emotional processing theory and practical issues such as dissemination of the treatment to the large number of untreated people living with PTSD. Here, the article asserts that stigma, lack of trained providers, and a lack of attention to dissemination strategies actively contribute to the high rates of PTSD. Concerning the process of PE and exposures, this article clarified the negative cognitions and predictability of the trauma, new inhibitory learning competition with the old memory, and psychoeducation. I liked that this article touched on the importance of psychoeducation, as these exposures, especially as the homework seems very challenging. Additionally, the psychoeducation piece feels like observational distancing to me, for the therapist is helping the client understand their antecedents, behaviors, and consequences in the chain of not only their avoidance, but what stimuli triggers their fear and how they react. SUD stands for subjective unit of distress. Concerning SUDs, I never though about the fact that starting low not only is good for ramping up later, but also to help the client build self-efficacy and confidence facing their fears. This sense of mastery and courage is something I did not think about. Additionally, the use of homework makes sense as they clarified the presence of a therapist can be a safety behavior. 

The Cooper et al., 2017 piece is an in-depth review of different active ingredients in PE, specifically looking at definitions of mechanisms of change and their efficacy in temporal behavioral outcomes. This study clarifies the difference between habituation and extinction, which is nice as the other studies did not necessarily use them distinctly. In general, I think this paper points to this theory being a strong theory in terms of Meehl's definition, or at least a good shot, for it has reached the stage where researchers can empirically test active ingredients that could be further isolated and (possibly) demonstrate if they have strong or weak evidence. Overall, the study found that belief change and between session habituation had the strongest evidence base, extinction and emotional engagement had an intermediate level of evidence, and trauma narrative change and within session habituation have a more weak evidence base. Sometimes, I question these studies as they use a behavioral outcome measure and then claim that the behavioral specific target did the best. However, this study seemed to incorporate more measures, and the within situation habituation vs. between demonstrates their attention to detail. Regarding testing theories again, this article highlights why it is critical to have clear definitions of constructs, for even though many of these concepts seem concrete (compared to emotions which are inherently much messier), there is still issues with definitional creep in the areas of cognitive change. Additionally, a lack of clear concepts can make neuroscience research harder, as neural network mapping is an inherently messy process. The neuroscience data they provided was also interesting to me, I found their arguments to be strong and not overgeneralized. 

Grade 24/25.