Over the course of PE, you as the clinician will be asking patients to do things they desperately do not want to do. Therefore, establishing a therapeutic alliance with your patients is paramount to the therapy's success. If your patients don't trust and respect you, they may be less willing to undertake the often emotionally challenging tasks you will be asking of them.
Presenting a rationale for PE typically happens in the first session. The goal is to gain patient buy-in for PE treatment.
If the patient does not give buy-in, he or she is much more likely to drop out of treatment.
The fewer reservations a patient has during treatment, the more effective PE is likely to be.
While explaining the components of therapy and the treatment schedule, these techniques can help you address patient concerns:
Be up-front that PE is emotionally challenging.
Explain the trade-off of short-term stress for long-term benefit.
Explain the underlying theory of PE.
Ground the theory in the patient's experience. For example, "Can you think of things you've been avoiding?"
Present efficacy data.
Get patients to self-assess. For example, "So you've been avoiding things. Has that increased or decreased disruption to your life?"
Draw avoidance spikes and habituation curves for the patient.
Provide analogies. For example, ask how they would help a child overcome fears.
It is also critical that you as the clinician believe in the treatment without reservation. If you have concerns about PE, you should resolve them. Some common concerns are listen below:
Concern: PE is too challenging.
Evidence suggests that PE can be learned and successfully conducted after only a few days' intensive training and by a wide range of people.
Moreover, in a 2005 study, both doctoral-level clinicians and masters-level therapists had identical patient outcomes with PE after only five days' training.
Concern: PE is ethically unsound.
If this were true, there would be evidence of higher dropout rates, symptom exacerbation, patient preferences, and ethical complaints. There is no such evidence.
After decades of extensive clinical use, there has not been a single court case related to PE.
Concern: PE exacerbates symptoms.
Research shows that only a small fraction of patients beginning imaginal exposure experience an increase in symptoms. In these cases, the increase is modest and short-lived.
The increase does not affect treatment outcomes or dropout rates.
Concern: PE has high dropout rates.
Empirical evidence shows that PE does not have high dropout rates.
Analysis of multiple trials shows that exposure-based therapies for PTSD, including PE, have the same dropout rates as non-exposure therapies, if not lower. This rate is 21%.
Concern: PE is manualized and inflexible.
PE is structured because it leverages fear extinction and learning, which are common to all patients.
PE does maintain a degree of flexibility. In fact, it is recommended that therapists adjust the program of treatment to best meet each patient's needs.
It is absolutely possible to be more than a technician; to follow therapy procedure while caring for and supporting patients.