Working with traumatic memories: KISS (keep it simple, stupid) and the virtues of straightforward prolonged exposure

"Simplicity is the ultimate sophistication."  Leonardo da Vinci

"It seems that perfection is reached not when there is nothing left to add, but when there is nothing left to take away."  Antoine de Sainte Exupery 

I have just written a series of three posts on Arntz & Jacob's new book "Schema therapy in practice"  This led to a query about when we should use direct exposure to trauma memories, when introduce more deliberate cognitive restructuring of linked trauma beliefs, and when add in more complex rescripting as, for example, described by Arntz & Jacob?

Well I guess the first point I'd like to make here is not to underestimate basic straightforward prolonged exposure to the traumatic memory (somewhat as one might treat a phobia).  Professor Edna Foa is the major player in this area and she has contributed to research study after research study that has underlined the value of often keeping psychological treatment of PTSD simple.  So the 2010 paper "A meta-analytic review of prolonged exposure for posttraumatic stress disorder" concludes "Two decades of research demonstrate the efficacy of exposure therapy for posttraumatic stress disorder (PTSD). The efficacy of prolonged exposure (PE), a specific exposure therapy program for PTSD that has been disseminated throughout the world, has been established in many controlled studies using different trauma populations. However, a meta-analysis of the effectiveness of PE for PTSD has not been conducted to date. The purpose of the current paper is to estimate the overall efficacy of PE for PTSD relative to adequate controls ... There was no significant difference between PE and other active treatments (CPT, EMDR, CT, and SIT) ... The average PE-treated patient fared better than 86% of patients in control conditions at post-treatment on PTSD measures. PE is a highly effective treatment for PTSD, resulting in substantial treatment gains that are maintained over time." 

Foa's earlier paper "Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring" had found that "The addition of CR (cognitive restructuring) did not enhance treatment outcome."  And as one might expect with less complex therapies like Prolonged Exposure "Treatment in the hands of counselors with minimal cognitive-behavioral therapy (CBT) experience was as efficacious as that of CBT experts."  Counter-intuitively, in her study "Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder" the authors concluded "As hypothesized, treatment that included prolonged exposure resulted in clinically significant, reliable, and lasting reductions in negative cognitions about self, world, and self-blame as measured by the Posttraumatic Cognitions Inventory. The hypothesis that the addition of cognitive restructuring would augment cognitive changes was not supported."  There are understandable concerns that such a "straight-up-the-mountain" confrontation with traumatic memories might be liable to result in symptom exacerbation and high drop-out rates.  Interestingly & reassuringly these concerns seem not to be of much significance - see "Does imaginal exposure exacerbate PTSD symptoms?" and "Do patients drop out prematurely from exposure therapy for PTSD?"

It does seem to be true that having a comorbid personality disorder or a history of childhood trauma or poor social support may interfere somewhat with achieving the same level of benefit when treating adult PTSD with prolonged exposure.  This is where Marylene Cloitre's research is so relevant.  However the notion that repeated exposure to traumatic memories can lead to very encouraging therapeutic results underpins the development of a recent written self-help treatment for PTSD - see the two blog posts beginning with "One of the most exciting therapeutic writing studies for years".  And this year's paper "Treating PTSD in suicidal and self-injuring women with borderline personality disorder: development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure Protocol" highlights that prolonged exposure also has a potential part to play in treatment of borderline symptoms - the home base of Arntz's more complex rescripting approach to trauma memory.

Kelly Johnson, lead engineer at the Lockhead Skunk Works, was making a good point with his KISS design principle "Keep it simple, stupid".  Fascinatingly there is some evidence that PTSD sufferers with severe negative trauma-related cognitions actually do better if they simply receive prolonged exposure rather than adding in cognitive restructuring as well.  This is reminiscent of the finding that behavioral activation for depression may actually achieve somewhat better outcomes for the more severely depressed than a full cognitive-behavioral package does.  It links too with the way that straightforward applied relaxation is pretty much as effective as full CBT for generalized anxiety disorder.  And all three of these areas have particular relevance when one is thinking about the training demands of providing more therapists able to deliver effective psychological treatments for these common disorders.  Of particular relevance is last year's paper "Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and meta-analysis" with its abstract reading "BACKGROUND: There is growing evidence of the effectiveness of Cognitive Behavioural Therapy (CBT) for a wide range of psychological disorders. There is a continued controversy about whether challenging maladaptive thoughts rather than use of behavioural interventions alone is associated with the greatest efficacy. However little is known about the relative efficacy of various components of CBT. This review aims to compare the relative efficacy of Cognitive Therapy (CT) versus Exposure (E) for a range of anxiety disorders using the most clinically relevant outcome measures and estimating the summary relative efficacy by combining the studies in a meta-analysis. METHODS: Psych INFO, MEDLINE and EMBASE were searched from the first available year to May 2010. All randomised controlled studies comparing the efficacy of Exposure with Cognitive Therapy were included. Odds ratios (OR) or standardised means' differences (Hedges' g) for the most clinically relevant primary outcomes were calculated. Outcomes of the studies were grouped according to specific disorders and were combined in meta-analyses exploring short-term and long-term outcomes. RESULTS: 20 Randomised Controlled Trials with (n=1,308) directly comparing the efficacy of CT and E in anxiety disorders were included in the meta-analysis. No statistically significant difference in the relative efficacy of CT and E was revealed in Post Traumatic Stress Disorder (PTSD), in Obsessive Compulsive Disorder (OCD) and in Panic Disorder (PD). There was a statistically significant difference favouring CT versus E in Social Phobia both in the short-term (Z=3.72, p=0.0002) and the long-term (Z=3.28, p=0.001) outcomes. CONCLUSIONS: On the basis of extant literature, there appears to be no evidence of differential efficacy between Cognitive Therapy and Exposure in PD, PTSD and OCD and strong evidence of superior efficacy of Cognitive Therapy in Social Phobia."

Leonardo da Vinci said "Simplicity is the ultimate sophistication" and today's blog post underlines how this can often be the case in psychological treatment.  However yesterday's discussion of Marylene Cloitre's research shows that sometimes adding in approaches like "skills training in affect and interpersonal regulation (STAIR)" to PTSD trauma-processing work can be well worthwhile.  In tomorrow's post - "Working with traumatic memories: trauma-focused CBT and an introduction to rescripting" - I want to talk further about more complex interventions like trauma-focused cognitive therapy and introduce Arntz & Jacob's schema therapy memory rescripting approach.