Academic journal article The International Journal of Behavioral Consultation and Therapy

Factors Associated with Choice of Exposure Therapy for PTSD

Academic journal article The International Journal of Behavioral Consultation and Therapy

Factors Associated with Choice of Exposure Therapy for PTSD

Article excerpt

In the U.S. population, lifetime prevalence rates of posttraumatic stress disorder (PTSD) range from 7% to 8% (Kessler et al., 2005; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995) and 12-month rates approach 4% (Kessler, Chiu, Demler, & Walters, 2005). Prevalence rates among returning military veterans are estimated to reach as high as 19.9% (Hoge et al., 2004). Despite this high prevalence, only 7.1% of individuals with PTSD make treatment contact within the first year of trauma exposure (Wang, Berglund, Olfson, Pincus, Wells, & Kessler, 2005). Further, the median time to seek treatment for PTSD is twelve years after disorder onset, with only 65.3% eventually seeking treatment and only 34.4% seeing a mental health specialist (Wang et al., 2005). Thus, it is of paramount importance that we begin to better understand how to help individuals with PTSD seek clinically appropriate care.

The need for such care is likely to increase in coming years given the large number of active military conflicts and peace-keeping missions currently underway. Indeed, in order to address the expected increased numbers of veterans needing empirically-supported PTSD treatment (Hoge et al., 2004; Tanaelian & Jaycox, 2008), the United States Department of Defense (DoD) and the Veterans Administration (VA) have created Mental Health Centers of Excellence and funded large-scale initiatives aimed at training practitioners to deliver evidenced-based PTSD treatment. This training largely focuses on cognitive behavioral interventions such as exposure therapy. Although a number of psychotherapies have strong efficacy data (e.g., Bradley, Green, Russ, Dutra, & Westen, 2005), the recent Institute of Medicine (IOM, 2007) report on PTSD treatment concluded that the only sufficiently validated treatment for PTSD at the present time is exposure therapy. Indeed, the efficacy of exposure treatment has been strongly replicated across gender and types of trauma (e.g., Foa et al., 1991; 1999; 2005; Marks et al., 1998; Resick et al., 2003; Rothbaum et al., 2005; Schnurr et al., 2007; Tarrier et al., 1999; Taylor et al., 2003). Thus, exposure-based therapy is one of the treatments of choice for chronic PTSD.

Yet, both clients and therapists may be reluctant to choose this treatment. Despite exposure therapy's proven benefits for PTSD, the treatment can be anxiety producing: clients are encouraged to directly and repeatedly approach the trauma memory (e.g., imaginal exposure) and trauma-related fears (e.g., in vivo exposure). Early commentators on the use of exposure therapy for PTSD voiced concerns about potentially retraumatizing the trauma survivor and increasing, rather than decreasing, his or her suffering. Specifically, Kilpatrick and Best (1984) suggested that high levels of anxiety during imaginal exposure may be a negative experience and result in an aversion to coming to therapy. Further, they suggested that some clients may exhibit more distress than they did before treatment and as a result, be less likely to seek treatment in the future. Although these fears have not been empirically supported, with exposure therapy failing to show more symptom worsening or treatment dropout (e.g., Foa, Zoellner, Feeny, Hembree, & Alvarez-Conrad, 2002; Hembree, Foa, Dorfan, Street, Kowlaski & Tu , 2004), concerns regarding the potential tolerability of exposure both for the therapist and for the client remain (e.g., Becker, Zayfert, & Anderson 2004; Tarrier et al., 1999; Pitman et al., 1991; 1996; Zayfert & Becker, 2000). Indeed, a recent survey of practitioners suggested that while lack of training in exposure therapy clearly plays a role in its under-utilization; even among therapists with such training fears about how the client will tolerate exposure appear to impact therapists' willingness to use it (Becker et al., 2004). Thus, based on these fears, clients and/or therapists may choose not to utilize exposure treatment for chronic PTSD. …

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