Paper One.
Critical Literature Review – Published in the Counselling Psychology Quarterly. Distinguishing between treatment efficacy and effectiveness in Post-traumatic Stress Disorder (PTSD): Implications for contentious therapies. Mills, S., & Hulbert-Willaims, L. (2012). Distinguishing between treatment efficacy and effectiveness in Post-traumatic Stress Disorder (PTSD): Implications for contentious therapies. Counselling Psychology Quarterly, 25 (3), 319-330.
Abstract. Research psychologists often complain that practitioners disregard research evidence whilst practitioners sometimes accuse researchers of failing to produce evidence with sufficient ecological validity. We discuss the tension that thus arises, using the specific illustrative examples of two treatment methods for post-traumatic disorder (PTSD): Eye-Movement Desensitisation and Reprocessing (EMDR) and exposure based interventions. Contextual reasons for the success or failure of particular treatment models that are often only tangentially related to the theoretical underpinnings of the models are discussed. Suggestions regarding what might be learnt from these debates are put forward and implications for future research are discussed. KEYWORDS: Eye-Movement Desensitisation and Re-processing (EMDR), Post-Traumatic Stress Disorder (PTSD), Treatment Efficacy, Treatment Effectiveness, Qualitative. Introduction. In general terms, the term theory is defined as “a set of principles on which the practice of an activity is based” (Oxford English Dictionary, 2011). For Counselling Psychologists, who value inter-subjectivity, psychological theories are used to inform a practitioner’s therapeutic practice and provide “tools” that can be utilised in therapy (Moller & Hanley, 2011). Although the importance of theory in our profession is plain to see—it dominates our
language, informs therapeutic practice, and is a core component of any psychological training programme—it is not the only element that influences psychological therapy. Therapist factors such as competence have been highlighted as having an impact on therapeutic variance (Wampold, 2004) as have client factors such as personality and motivation (Onwuegbuzie & Leech, 2005). Other psychologists such as Rosenzweig (1936) and later Luborsky et al (2002), with the idea of the “Dodo Bird Effect”, have also sought to highlight the importance of commonalities in therapies such as a therapeutic alliance and allegiance. If one were to accept the “Dodo Bird Effect” as a valid description of the relative merits of different treatment models, one would have to conclude that other general factors such as a strong therapeutic alliance and allegiance are just as important as specific psychological models in determining treatment success (Wampold, 2004). Despite the regular resurgence of this idea, and regular repetition of Rosenzweig’s (1936) phrase, “All have won so all must have prizes”, applied psychology has accepted, to a great extent, the notion of evidence based practice (EBP; Newnham & Page, 2010). Derived from the medical model (Hemsley, 2010), EBP emphasises the need to find the most successful treatment method for a particular disorder as determined by the highest forms of evidence, the randomised control trial (RCT) and the meta-analysis. Such acceptance leads the National Institute of Clinical Excellence to expend effort in ensuring practitioners have up-to-date evidence on which to base their practice (Hemsley, 2010). Despite a great deal of rhetoric in applied psychology regarding the importance of evidence- based practice models, in real-world therapy settings not all practitioners rely on such evidence when choosing and delivering treatments (Newnham & Page, 2010). The current
trend for the adoption of EMDR as a treatment for PTSD is illustrative and will be taken up in this paper as an example used to demonstrate a set of more general points. Post-Traumatic Stress Disorder. Within the treatment arena of Post-Traumatic Stress Disorder (PTSD), there is a wealth of evidence that supports the use of exposure-based CBT for reducing the symptoms of PTSD and its sub-groups which include combat-related PTSD (Power et al., 2002). Such work remains topical today not least because of the recent wars in Iraq and Afghanistan. Exposure based interventions enjoy a sound theoretical grounding, having developed initially from behavioural movements with the more traditional techniques of flooding and implosion (Groves & Thompson, 1970), and later having developed alongside both cognitive and behavioural paradigms with the treatment protocol involving exposure to the feared stimuli combined with cognitive restructuring (e.g. Foa & Kozak, 1986). As well as general support for the broad theoretical orientation, which is at root an application of basic behavioural psychological principles, exposure based interventions for the treatment of PTSD also enjoy sound evidence of efficacy in the form of trial data (Foa, Dancu, Hembree, Jaycox, Meadows & Street, 1999; Foa et al 2005; Schnurr et al., 2007). In fact the research base which supports the use of exposure based interventions in the treatment of PTSD is so vast that some professionals are now terming it the zeitgeist of the disorder (Russell, 2008). Exposure based CBT: The zeitgeist of the disorder.
Studies examining the efficacy of this form of treatment go back to the early 1980s and include Frank and Stewart’s (1984) investigation into the desensitisation of female rape victims. More up to date research has reported on the success of exposure therapy when compared to other independent methods of treatment such as stress inoculation training (see Foa et al., 2005). For combat-related PTSD specifically, a number of studies report a similar trend. Research conducted by Cooper and Clum (1989) examined the effectiveness of imaginal flooding, a form of exposure therapy, over standard psychotherapeutic and pharmacologic approaches in the treatment of combat-related PTSD. The evidence from this study supported imaginal flooding in the reduction of symptoms relating to the traumatic event, including traumatic stimuli-related anxiety (F=5.58, p<.05), sleep disturbance (F=11.1, p<.01) and self-monitored nightmares (F=6.08, p<.05). Exposure therapy has also been reported as more successful in eradicating PTSD symptoms in female war veterans specifically when compared to person centred therapy. Schnurr et al. (2007) studied 277 female veterans and 7 active duty personnel with combat-related PTSD. Participants were randomly assigned to either a prolonged exposure or person-centred condition. Women who received prolonged exposure experienced a greater reduction in their symptoms than those assigned to the person-centred condition directly after treatment (d=0.29, p<.01) and this difference was maintained at 3 month follow up (d=0.24, p<.047). Despite the ascent of CBT and exposure-based therapies, and the solid evidence base they enjoy, a range of other treatment methods for PTSD have become popular during recent years. Several of these therapies have been grouped together under the title of “Power Therapies”. The Power Therapies, of which Eye Movement Desensitisation and Reprocessing (EMDR) is an example, share one thing in common: they claim to work more efficiently than the existing interventions for anxiety disorders (Herbert et al., 2000). These therapies have
been derided for a lack of adequate trial data, and for lacking theoretical substance (Devilly, 2005). EMDR: Theoretical substance. In 1989, EMDR was introduced into the therapeutic arena as a new treatment method for psychological trauma (Shapiro, 1989). Shapiro’s account of its discovery describes a happy accident, and a flash of insight. It was not based on pre-existing psychological theory (Muris & Merckelbach, 1999), and in this respect differs considerably from exposure therapy and CBT. The theoretical basis of EMDR has been challenged by component break-down studies which look to identify those mechanisms within a treatment protocol that are necessary and sufficient to achieve the established aims (Rogers & Silver, 2002). It would appear that where EMDR starts to become unstuck is in its suggestion that the dual stimulation e.g. eye movements, or finger tapping, are what makes the treatment unique and efficacious (see Herbert et al., 2000). Most studies, when testing this claim, have found that outcome is not dependent on the presence of this unique aspect of the treatment protocol though these findings are not universal (Rogers & Silver, 2002). For example, Wilson, Silver, Covi and Foster (1996) conducted a study which sought to identify the contribution of eye movements in the EMDR protocol. They compared EMDR to two identical procedures which omitted the eye movement component. The results of which indicated that the dual attention aspect of EMDR does contribute to treatment outcome as desensitisation rates were higher in the full
EMDR treatment condition than the other two conditions which omitted the use of dual stimulation. EMDR: Weaker evidence of efficacy. When comparing EMDR to the front-runner in PTSD treatment, that of exposure intervention, only a few studies have compared the efficacy of these two treatments directly. For reasons of space, it is not possible to document the results from all these comparison studies however a few will be discussed. Ironson, Freund, Strauss and Williams (2002) compared EMDR to prolonged exposure therapy in a sample of 22 traumatised out-patients. Both treatments appeared successful in reducing the symptoms of PTSD, with a larger pre- post effect size for prolonged exposure (d = 2.18, t = 5.27, p = .002) than for EMDR (d = 1.53, t = 3.36, p = .008, ds calculated by the current author). Ironson et al. (2002) compared the treatments by way of a multifactorial ANOVA which showed neither treatment to be statistically superior to the other (F=0.6, p<.82). Lee, Gavriel, Drummond, Richards and Greenwald (2002) found similar results. In their study of 24 participants, the EMDR group improved slightly more (d = 1.87) than the stress inoculation plus prolonged exposure group (d= 1.73), but the difference between the two active treatment groups did not reach statistical significance cut-offs (F =1.37, p=.29). Devilly and Spence (1999), in their comparison study, found exposure techniques when delivered through a CBT package, were superior to EMDR in reducing PTSD symptomatology, and in this case the difference reached statistical significance criteria [Λ(6,16)=.37, p < .007].
The Effectiveness—Efficacy Distinction Applied to EMDR.
Whilst there is some promise in terms of EMDR’s efficacy from the research noted above, even a charitable interpretation would have to acknowledge that the evidence base for EMDR is weaker than that for exposure therapy, with respect to PTSD. Some psychologists go much further and describe EMDR as “pseudoscience” (Herbert et al., 2000) and urge the abandonment of research on EMDR and similar therapies categorised as such. We feel that such a position fails to take into account an important distinction between treatment efficacy and treatment effectiveness in psychological therapy. Taking physical medicine, where the terms efficacy and effectiveness are derived, as an accessible example: Drugs and procedures can often be efficacious, bringing about desired outcomes due to the nature of their chemical or mechanical properties, and yet lack effectiveness because they are not well adopted by doctors and patients. The classic example is poor treatment adherence due, for instance, to undesirable side effects. In medical research, it is widely accepted that an intervention might be highly efficacious, and yet have poor effectiveness in practice, whilst treatments of lesser efficacy might produce moderately successful outcomes in terms of practical efficacy (Marchand, Stice, Rohde & Becker, 2010). EMDR enjoys high client satisfaction with regard to dropout figures and treatment side effects (Marcus, Marquis & Sakal, 1997; Wilson, Becker & Tinker, 1995) and has seen a meteoric rise in the number of therapists trained to deliver EMDR. With this in mind, we suggest that EMDR might offer some advantages over exposure based therapies in regard of various contextual factors. A number of these contextual factors could be hypothesised to be
associated with the high acceptability of, and considerable therapist loyalty to, EMDR in light of the erstwhile acceptance of exposure-based treatments. The client experience. It is not a new suggestion that prolonged exposure is thought to be distressing and so is poorly tolerated by many clients (Scott & Stradling, 1997). Exposure therapies, particularly the more traditional methods of flooding, involve the client repeatedly re-visiting the memory that they find traumatic in an attempt to desensitise them to the feared stimulus. Pitman and colleagues (1991) in their study which examined six case vignettes found re-occurring complications which they believe to be “under-recognised” in flooding therapy for PTSD. For instance they document how this type of therapy can produce adverse consequences such as an exacerbation of feelings relating to guilt, self-blame and failure. Whilst some researchers such as Feeny and colleagues (2003) disagree, arguing instead that most clients can tolerate and do benefit from exposure based interventions, there is a good deal of commentary in the literature on how exposure therapy is not suitable for all PTSD sufferers (e.g. Litz et al., 2010). Client factors have been discussed in terms of treatment success for exposure based interventions. It has been suggested that clients presenting with anger (Jaycox & Foa, 1996), alcohol abuse (Pitman et al., 1991), suicidal ideation and avoidance, as measured through session attendance, (Tarrier, Liversidge & Gregg, 2006) may affect treatment outcome. Worryingly, Axis I disorders such as depression are often associated with PTSD (Strachan, Gros, Ruggiero, Lejuez & Acierno, 2011) and dysfunctional readjustment traits such as alcohol abuse are notably high in veterans returning from war in both the US and UK (Rona, Jones, Fear, Hull, Hotopf & Wessely, 2010; King’s Centre for Military Health Research, 2010).
Comparatively, within the United States at least, EMDR has been recognised by The Department of Veterans’ Affairs and Department of Defence (2004) as being less distressing than exposure therapy and suitable for those PTSD sufferers who might not benefit from exposure therapy (Russell, 2008). EMDR is considered more associative in nature compared to the directive aspects of exposure therapy and it focuses on brief rather than prolonged exposure to the traumatic memory (Rogers & Silver, 2002). Evidence supplied by Wilson et al (1996) found that the dual attention component of EMDR treatment is associated with relaxation in clients and as such is useful in regulating the level of distress caused by the exposure component of the EMDR protocol. The current evidence does not permit a strong conclusion, but it appears that EMDR may be less distressing than prolonged exposure, either because of the nature of the treatment or because a specific element of the treatment has a relaxing effect. The therapist experience. By most measures, the evidence base for exposure-based therapies, especially exposure-based CBT is stronger, but data suggest that only about twenty percent of practitioners who specialise in the treatment of anxiety disorders use this type of therapy to treat PTSD (Tarrier et al., 2006). For combat-related PTSD specifically, Fontana, Rosenheck and Spencer (1993) in their study of 4000 Veterans with PTSD, found that exposure therapy was used to treat fewer than 20% of this population and was the primary treatment in only 1% of cases. Therapist fears of addressing the trauma directly, a concern that the treatment will exacerbate the symptoms in sufferers, and the distressing nature of the treatment are highlighted as the main reasons for therapist reluctance in utilizing this type of treatment (Becker, Zayfret & Anderson, 2004).
Whilst there appear to be notable difficulties in matching the acceptance of exposure therapy from research into practice, it has been shown that when exposure therapy is used in real- world therapy settings it is successful in reducing PTSD symptomatology. A recent study by Tuerk et al. (2011) recruited 65 veterans of the recent Afghanistan and Iraq wars receiving care in a Veterans Administered (VA) Healthcare context to examine this point. Whilst they did not use a control group, Tuerk and colleagues did successfully manage to demonstrate that exposure therapy can be applied to real-world therapy settings by showing that prolonged exposure was as successful in reducing the symptoms of combat-related PTSD in this type of setting as in Randomised Control Trails (RCTs). Whilst this is the case, the aforementioned utilisation rates for exposure based interventions are concerning. Comparatively, it would appear that EMDR is warmly received by a substantial proportion of therapists. There is currently an international association, conference and journal devoted to EMDR for example (Becker, Darius & Schaumberg, 2007). For combat–related PTSD specifically, EMDR is now being recommended as a treatment option for combat-related PTSD in the US (EMDR Institute; Department of Veterans’ Affairs and Department of Defence, 2004) and is frequently offered in local Military Community Mental Health departments in the UK (Wesson & Gould, 2009). Numerous studies have compared the dropout rates in exposure based conditions with the dropout rates in other therapy conditions. Some of these studies have found increased dropout rates in exposure therapy when compared to supportive therapies for PTSD (Schnurr et al., 2007), with others finding no association between treatment method and dropout rates (Feeny, Hembree and Zoellner, 2003). Factors affecting dropout have also been researched.
Demographic factors (Tarrier, Sommerfield, Pilgrim & Faragher, 2000), pre-treatment symptom severity (Minnen, Arntz & Keijsers, 2002) and feelings of shame, anger and guilt (Jaycox & Foa, 1996) are just some of the variables thought to influence dropout rates in PTSD treatment. For EMDR, dropout rates have not been studied as extensively as they have for exposure therapy. A cursory cross-study comparison suggests 10% dropout rates can be expected from EMDR (Marcus et al., 1997; Wilson et al., 1995), compared to rates above 25% for exposure therapy (e.g. Foa, Rothbaum, Riggs and Murdoch, 1991). On the one occasion where dropout rates for these two therapies were compared within the same study, tentative evidence of higher dropout rates in exposure therapy is reported (Ironson et al., 2002). The EMDR Movement. Shapiro (2002) has claimed that approximately 25,000 therapists are now fully trained in delivering EMDR as a treatment method to clients. Anecdotal evidence and a cursory perusal of any psychological training bulletin board would support such a number. It has been accepted into the National Institute of Clinical Excellence guidelines (NICE, 2012) as a recommended treatment method for PTSD alongside exposure therapy and is quickly gaining recognition in US and UK military settings (Russell, 2008). Alongside its recommendations for PTSD and combat-related PTSD, it is also being more widely used in the treatment of other common psychological disorders such as Phobias (Muris & Merckelbach, 1997) and Panic (Feske & Goldstein, 1997), although it has not yet gained acceptance by NICE for these disorders (Nowill, 2010). With these points in mind, few psychologists would argue the point made by McInally (1999) that EMDR “has grown quicker than the psychoanalytic and behavioural movements”.
Despite the contentious issues which surround EMDR in terms of theoretical grounding and efficacy, there is evidence to show that the therapy is gaining quick momentum, as highlighted above. In addition to the aforementioned intrinsic factors relating to the therapy’s processes, some professionals have also posited a sociological explanation for its rapid growth. In his article entitled “Power Therapies and possible threats to the science of psychology and psychiatry”, Devilly (2005) refers to some common social factors deployed by certain pseudoscientific therapies, of which he includes EMDR, to explain the adherence of clients and therapists to these therapies. With reference to these factors, Devilly (2005) refers to the hard hitting article made by Pratkanis (1995) that puts forward nine necessary qualities that a pseudoscience must possess so that people can “buy into the concept”. The factors highlighted by Pratkanis (1995) include such terms as “creating a phantom”, by which he describes developing a concept that brings hope to something that appears hopeless. In the context of EMDR Devilly (2004) connects this to Shapiro’s claim that the therapy was 100% successful after one session. Something which gave other professionals hope in the otherwise hopeless domain of treatment for such a complex disorder. Whilst the likely existence of contextual and social factors such as those identified by Pratkanis (1995) and their relevance to the adoption of EMDR as described by Devilly (2005) should be acknowledged, labelling EMDR mere ‘pseudoscience’ may in fact exacerbate the in-group out-group thinking of therapists trained in this tradition and further alienate them from a discourse on the evidence for and against the EMDR model. For applied psychologists who place high value on the scientist–practitioner model of research and therapy (Moller & Hanley, 2011), these strong social concepts cannot be ignored if we want to retain our professional standing. The question of whether a therapy is adopted for purely
pseudoscientific reasons, for contextual reasons to do with the distinction between efficacy and effectiveness, or because of experimental evidence, goes to the very heart of whether psychologists can truly describe themselves as scientist-practitioners. It is crucial that EMDR and other power therapies be studied for what they are, for what they might offer, and for how they have achieved such popularity in such a short time, though this is no reason to dispense with inquiry. Other researchers too (e.g. Sikes and Sikes, 2003) have contrasted exposure based interventions and EMDR in terms of efficacy, theoretical grounding and effectiveness, suggesting that this relative mismatch needs to be explained. The “wagging finger” need not be pointed at new and innovative ideas but instead be pointed at the way in which psychological research is conducted in general. With this in mind, it has been suggested that therapies such as EMDR, might be better suited to a practice-based evidence (PBE) mode of enquiry rather than from the traditional evidence based practice (EBP) perspective (Nowill, 2010). The transition from EBP to PBE is thought to be a worthy one as ever increasingly EBP is being criticised for being compatible with certain modes of treatment akin to the medical model such as CBT, and not with others (Newnes, 2007; Hemsley, 2010). Alongside the suggestions made for a change in how psychological research is conducted with respect to PBE, it is also argued here that there is a need for client-centred research to be more widely adopted in the PTSD treatment arena. Client-Centred Research. For some time, a number of practitioners have been calling for an enhanced place for the client perspective in the science of psychological intervention (Stewart and Chambless,
2010). Such research would help us answer the question we have posed: why are theoretically sound and efficacious treatment methods in PTSD sometimes not terribly effective in practice? To date, very little is known about the client experience of trauma therapy. Becker et al. (2007) examined client preferences for exposure versus alternative treatments for PTSD, including EMDR, in individuals with varying degrees of trauma history. Their participants were asked to imagine undergoing a trauma, developing PTSD and seeking treatment. Participants showed a preference for exposure therapy over EMDR, though Becker and colleagues acknowledge the lack of ecological validity of their findings since their sample did not include participants suffering from PTSD, and relied instead on participants imagining themselves in the situation. Qualitative psychological methods, especially phenomenological ones, offer tools to examine the client experience and generate insights into the efficacy-effectiveness question in an inductive manner (see Hanson, 2004). Whilst this is the case, qualitative methods are underutilised in research. This is demonstrated by a lack of available qualitative research published (Rennie, Watson & Monteiro, 2002). It is suggested that this bias is due to the traditional views that “good” research is based on falsifiable theories and outcome measures that can be generalised to the wider population, all of which sit comfortably within an EBP framework (Fairfax, 2008). For the treatment of PTSD, it would appear that the research base has followed this trend. Whilst there is a wealth of quantitative research documenting the efficacy of treatment protocols, there is little evidence aimed at un-picking the reasons for the
efficacy/effectiveness anomalies presented in this article. By drawing upon other research which has documented the usefulness of qualitative enquiry by allowing a more intricate understanding of the ingredients and processes within therapy (see Berry & Hayward, 2004), it is suggested that this might be a worthy transition in the field of PTSD research. This seems even more relevant when we look at the growing appreciation, within psychology at least, that generalised findings from RCTs are inhibited because of individual differences found in both therapist and client (Fairfax, 2008). Conclusion. The importance of finding appropriate treatment methods that can be used to help clients presenting with the symptoms of PTSD is considerable. The evidence base is currently dominated by RCTs where client satisfaction, therapist burden, dropout rate and other similar factors are far from the primary outcome measures, and are often considered extraneous. In these studies, exposure based interventions have proven to be the gold standard, not only because of their proven efficacy but also because of their strong theoretical underpinnings. It has been proposed that the poorer uptake of these treatments, as compared with EMDR in the current example, reflects a research base which does not adequately take account of the distinction between efficacy in research settings and effectiveness in real-world therapeutic settings. Throughout the current paper it has been suggested that PTSD research would benefit considerably from an increased attention to practical effectiveness. This will require the adoption of a client-centred research model where the client experience is central.
Paper Two. Research Report. How do veterans make sense of their disengagement from traditional exposure therapy and their subsequent engagement in a non-exposure based intervention for Post- traumatic Stress Disorder (PTSD)? An Interpretative Phenomenological Analysis.
Abstract Exposure therapy is a proven efficacious treatment for PTSD however its effectiveness in real world practice is limited by high rates of premature dropout, particularly for veterans of war. The current study aimed to explore this anomaly by qualitatively examining how veterans make sense of their engagement or disengagement from PTSD treatments; Exposure Therapy and Spectrum Therapy. Semi-structured interviews were conducted with seven veterans who had dropped out of exposure therapy and the transcripts were analysed using Interpretative Phenomenological Analysis (IPA). A number of corresponding themes were grouped together into four super-ordinate themes: The Importance of Control, The Importance of Positive Change, The Problem with Emotion and The Importance of Relationships. From these findings we draw a number of suggestions for improving engagement including the importance of explaining the rationales behind the treatment protocols and the importance of teaching techniques to manage, rather than avoid, emotions generated through therapy. The findings may help therapists to further explore the difficult matter of improving therapy for this client group so that drop-out rates can be reduced and engagement increased. KEYWORDS: Posttraumatic Stress Disorder (PTSD), Combat, dropout, engagement, efficacy, effectiveness, Interpretative Phenomenological Analysis (IPA). It remains evident that, as a profession, we have at our disposal a highly successful treatment method for reducing the symptoms of PTSD; exposure therapy (see Bradley et al, 2005; Bisson and Andrew, 2005; Schnurr et al, 2007). Specifically, in the domain of combat-related
PTSD, exposure-based interventions have proven useful for soldiers presenting with the symptoms of PTSD in the aftermath of both the Gulf and Vietnam wars (Yoder et al, 2012). Moreover, in relation to veterans returning from the wars in Iraq and Afghanistan, Rauch et al (2009) found traditional exposure therapy to be successful in reducing the symptoms of PTSD in a naturalistic setting, albeit through a modest sample size (N=10). Owing to successful trial data and meta analyses of such data, exposure therapy has been accepted by the National Institute of Clinical Excellence guidelines (NICE, 2008), as an evidence-based treatment for PTSD in general populations and is recommended by the Department of Veterans Affairs for use within the military (Garcia, Kelley, Rentz & Lee, 2011). Exposure Therapy might not be the whole answer. Despite the supportive trial data regarding the efficacy of exposure techniques in reducing PTSD symptoms, there is some evidence that this type of therapy is not as successful when applied to real world clinical populations (see Cook, Schnurr & Foa, 2004). It has been reported for combat-related PTSD specifically that therapists are reluctant to apply this therapy in military settings (Fontana, Rosenheck and Spencer, 1993). Therapist fears of addressing the trauma directly, a concern that the treatment will exacerbate the symptoms in sufferers, and the distressing nature of the treatment are highlighted as the main reasons for therapist reluctance in utilizing this type of treatment (Becker, Zayfret & Anderson, 2004). In addition, dropout rates from exposure therapy have been reported as higher than those from supportive therapy in female war veterans (Schnurr et al, 2007). Dropout figures and reduced session attendance from exposure therapy are reported as higher for veterans returning from the recent wars in Iraq and Afghanistan than for those veterans returning from the Vietnam War (Erbes, Curry & Leskela, 2009).
How can future research help address the efficacy-effectiveness distinction in the treatment of PTSD? There appears to be a clear disconnect between what is accepted in clinical practice in the treatment of PTSD by both clinician and client, and what is supported through research trials. On the other side of this debate are those therapies that have been shown to be less scientifically coherent or even less efficacious than exposure therapy but are more widely accepted by both clinician and client in the treatment of PTSD. EMDR for example is acknowledged as having a less solid evidence base than exposure therapy (see Devilly & Spence, 1999) and its mode of action i.e. the dual stimulation aspect of therapy, has been critiqued (see Herbert et al, 2000). Regardless of these scientific problems, EMDR enjoys higher client satisfaction as determined by dropout rates and rapid therapist adherence in real- world practice (Marcus, Marquis & Sakal, 1997; Wilson, Becker & Tinker, 1999). Other therapeutic approaches which can be compared to EMDR on the grounds of this efficacy- effectiveness distinction are also enjoying great success at present, not least in UK charity organisations for the treatment of combat-related PTSD. A cursory perusal of the available treatment methods for PTSD through internet search engines would support such a claim. One such treatment method that currently has no evidence of efficacy but has high anecdotal client satisfaction is Spectrum therapy. Spectrum therapy is a treatment package specifically designed for war-related PTSD that is currently being used in UK charity organisations. Spectrum Therapy is marketed as a non- exposure based therapy for veterans with PTSD because the client is not asked to move repeatedly through their traumatic memories with the therapist. Instead the principles behind
Spectrum therapy are based on an emotional-focussed model of treatment,1 where clients are encouraged to associate with all emotions attached to the traumatic event, including anger, sadness, guilt, shame and fear, rather than the details of the event itself. This distinction between Spectrum therapy and traditional exposure therapy seems important, not least because of the recognised role of not only fear, but other negative emotions in PTSD such as shame, anger, guilt and sadness (Lee, Scragg & Turner, 2001; Beck, McNiff, Clapp, Olsen, Avery & Hagewood, 2011). A further distinction between Spectrum therapy and traditional exposure based therapy is that Spectrum Therapy is delivered by practitioners trained in Neuro-Linguistic Processing (NLP), who once served in the military, rather than qualified psychologists. Whilst the fact that the therapy is run by non-psychologists might be frowned upon by professional psychologists, it is interesting to explore this innovation since researchers have often described this client cohort as being mistrusting of civilians (e.g. Coll et al, 2012). It is also recognised that NLP, like EMDR, has been labelled by some in the literature as a pseudoscientific “Power Therapy”. A term used to describe a therapy with no theoretical or scientific substance (see Devilly, 2005). Whilst these points are not refuted by the current author, it is argued that therapies which appear to enjoy high client satisfaction in the absence of any efficacy trials could help develop our understanding of what makes a PTSD treatment method effective in real-world practice. 1 This description is based on the researcher’s own observations; it is not used in reference to Greenberg & Johnson’s Emotionally-Focussed Therapy (EFT).
How can research explore client satisfaction of therapies? Research into client experiences of therapy has, to date, mainly been conducted through quantitative hypothesis-testing designs whereby pre-defined categories have been used by the researcher to identify client satisfaction of therapy (McLeod, 2001). Whilst this research is important, not least because of the expectations placed on practitioners in modern healthcare settings to report on outcome measures and client satisfaction, it is argued that qualitative methods are more suited to such an inquiry because they allow for a more detailed understanding of the client’s subjective experience (see Berry & Hayward, 2004). Very little work has been done to date to explore client experiences of exposure therapy. Of the one study known to the current author that qualitatively explored client experiences of exposure therapy, Shearing, Lee and Clohessy (2011) report the experiences of clients who have stayed engaged with exposure therapy to be positive once they had overcome their scepticism of, and fears about, engaging in the re-living process. Investigating the experiences of those who do not drop out of exposure therapy in this way, may help allay the fears therapists have about using this treatment with PTSD sufferers in practice (Becker et al, 2004). Such work however is not likely to help gain the trust and engagement of clients unless it results in changes to the treatment model and how it is delivered (see Becker & Zayfret, 2001).
The aim of the current study.
In the absence of any efficacy trials it will be interesting to examine what it is about Spectrum therapy that has kept veterans, who previously dropped out of exposure therapy, engaged in this treatment method. It is hoped that this qualitative exploration of client experiences will add to our knowledge of client engagement in combat-related PTSD which will aid future theory development, and eventually lead to improvements in our existing efficacious therapeutic methods for PTSD, such as exposure. It is believed that such an inquiry will help bridge the gap between efficacy and effectiveness in the arena of combat- related PTSD treatment, which is currently a widely held concern for practitioners and researchers alike (Becker et al, 2004; Garcia et al, 2011; Shearing et al, 2011). Method Participants To obtain a purposive sample, therapists trained in Spectrum Therapy in north-west England gave information sheets to potential participants, seven of whom consented to take part in the study. Smith, Flowers and Larkin (2009) describe the main feature of IPA as gaining a thorough understanding of individuals’ experiences through a case by case analysis which can be restricted in sample sizes exceeding eight participants. Participants were eligible for the current study if they had been diagnosed with PTSD, had disengaged from a course of exposure therapy in the past and had subsequently engaged in a full course of Spectrum therapy. In addition, as the focus of this study was to examine war veterans experiences of PTSD treatment, all participants needed to have served in a military setting for at least 2 years and experienced a traumatic event within this setting that triggered the symptoms of
PTSD for which they were seeking treatment. No attempt participants, however due to the nature of the client group, refer to Table 1 for participant demographics.
was made to restrict the gender of all participants were male.
In accordance with IPA principles, open-ended, broad ranging, questions were developed in a bid to gain information relating to the research question whilst also allowing for detailed subjective responses to be given. All interviews took place over Skype in order to reduce any unnecessary anxiety for participants travelling to unfamiliar locations and lasted between 30 and 60 minutes. Recorded interviews were conducted and transcribed by the first author to ensure reliability and to enhance familiarisation (Smith & Osborn, 2003).
Data Analysis The first author analysed and coded the data in accordance with the principles of IPA outlined by Lyons and Coyle (2007) and Smith et al (2009). The first stage of analysis involved the researcher reading and re-reading the transcripts in order to immerse oneself in the data. From this, the researcher then started to summarise the content of the transcripts and report on any initial interpretations from the original data set. Emerging themes about participant experiences were recorded and subsequently grouped together in accordance with similarity and relationships with one another. The grouping of data led to several clearly defined categories, termed sub-ordinate themes, which were appropriately entitled to encapsulate the meaning of each theme. The final stage of coding involved the researcher making connections across the sub-ordinate themes through the process of abstraction (Smith et al, 2009). This involved generating clusters of themes based on similarity from which larger super-ordinate themes were generated. These larger, super- ordinate themes were then titled to capture the nature of the sub-ordinate themes associated with this larger grouping. Owing to the nature of the study, where participants were asked to comment on factors that both helped or hindered engagement in PTSD treatment, polarisation (Smith et al, 2009) was often adopted, as the factors related to each sub-ordinate theme were sometimes discussed on the grounds of opposition. Throughout all stages of data analysis, the first and second authors met to discuss the emergent themes and to reflect upon the lead researcher’s interpretations of data to help validate the analysis phase.
Results
In order to ensure anonymity throughout the research, and so direct examples from the transcripts can be used to illustrate the points made, all participants will be referred to using pseudonyms. A thematic representation of themes can be found in Table 2.
Table 2. Thematic diagram of Themes. Super-ordinate Themes The Importance of Control The Importance of Positive Change The Problem with Emotion The Importance of Relationships Theme: The Importance of Control
Sub-ordinate Themes Whose Agenda is it Anyway? Concerned for recovery.
A Bright Future.
Feeling unable to cope with feeling. Not wanting to Share. Military/Civilian Divide.
Feeling supported in recovery.
The Importance of Understanding the Rationale.
All participants described the importance of control when describing either their engagement in, or disengagement from, the therapeutic process. This sense of control is concerned with the choice they felt they had in the respective therapies and gaining an understanding of the rationales behind the treatment protocols that they were being asked to engage in. Whose Agenda is it Anyway?
The majority of participants report feeling reluctant to engage in the re-living aspect of exposure therapy. This conflict is represented through narratives of feeling forced to engage in the re-living process of exposure work. Luke: This way, the major thing was revisiting things that, places that I didn’t want to go then. When describing how they felt in Spectrum therapy, a very different set of narratives emerged, which relates to participants’ positive experiences in therapy owing to a sense of choice they felt they had in the sessions. Luke: like the process you know, you’re pretty much, doing all the work yourself they are just directing you. For Frank and Matt, a sense of control was generated through Spectrum therapy because they felt they were not working to somebody else’s agenda and timescales. Frank: By being given the space to reflect and connect with myself at my own pace instead of being bombarded with questions about what exactly had happened to me in the army This sense of choice and flexibility that participants felt they had in therapy seemed to make the therapy feel individualised as all participants describe their wants and needs being incorporated into the therapeutic process. Sam: Yes that was something I chose to do, but yes that was something I suggested that I would like to do and they put it into intervention to make that happen. In addition, feeling in control of the therapeutic process in Spectrum therapy seemed to generate positive feelings about the therapist and the therapeutic relationship, where an equalizing of power was described between client and practitioner.
Sam: It was like the approach he used I felt very much equal to the person who was treating me. The Importance of Understanding the Rationale. For some participants it would appear that developing a thorough understanding of the usefulness of the therapeutic protocols involved in exposure therapy was an important factor that was missing from this therapy as they discuss feeling ambivalent towards the value of the therapeutic protocols in their recovery. Throughout these narratives there is a strong sense that the participants didn’t understand why re-visiting their traumatic memories was necessary. Ben: it was like putting me back in there you know ...so close your eyes get back in there.... and why would I want to do that you know? For another participant, ambivalence is presented through a sense of frustration aimed at the therapist for “repeatedly” asking him to talk about his experiences. This participant describes his mental model of how therapy should work being at odds with that of the therapist. Owing to this, the authors are left with the impression that not only is he confused about the benefits of the re-living process, but that he also believes engaging in such a process will hinder his recovery. Gary: Yes I mean just asking what I had been through, all the time asking about what I had experienced....and erm.... I just thought it was all totally irrelevant to what...... I was trying to get well, in myself like......I become resentful of counselling for years I just thought what a waste of time you know.
For Ben, being informed of the therapeutic protocols involved in exposure therapy seems particularly important as he felt that the therapist was asking him to disclose his traumatic experiences for their value instead of his own. Ben: what (name of Spectrum therapist) seemed to do was like... so like ask me to pick a certain memory, when you felt this... ok then.... now he didn’t want you to openly discuss this....see that’s privately for you with the feelings and that, so which was a great thing, I thought to myself wow these aren’t asking me to go into details as if they are not just after a gory story kind of thing you know. In congruence with this point, two other participants described the importance of being informed of the rationale behind the therapeutic protocols in Spectrum Therapy in helping them engage and feel more comfortable with what they were being asked to do. This seems to give participants a sense of control over the process which subsequently gives them confidence to engage in therapy. Thomas: Well it wasn’t difficult...erm I mean I understood why I was doing these things that I was being asked to do so I felt ok in doing them you know. Theme: The Importance of Positive change. When discussing the factors that influenced their engagement within therapy, all participants either spoke of a concern for their recovery or seeing a bright future as factors which affected their engagement. Concerned for recovery. For some, feeling unable to cope with the re-living process of exposure therapy was connected to a fear that they would be unable to cope with the after effects of engaging in this therapeutic protocol once out of the session and thus their recovery would be impeded.
Matt: You are trying to get your head together on your own and if I had all that messing around with my head again it was just like here we go again For the majority of participants, they reported being concerned about engaging with the actual re-living process itself because it felt too overwhelming for them. For these participants this was represented through a feeling that the re-living process was all consuming. Sam: Well it was like you were still there, I just remember every time I had to talk about it I used to get the intensity of being there again. The researcher observed that some participants spoke about how the reliving process impacted on their ongoing lives by bringing the trauma to the forefront of their minds. Luke: it just revisited everything and brought it all back to the surface so then when I was coming away it may have made it worse. A Bright Future. Conversely, many participants reported seeing positive change after Spectrum therapy which encouraged them to continue with the process. For many, the importance of seeing quick change in therapy seemed to prove as motivation to actively engage in the treatment protocols. Ben: then once you notice that it is working you can’t wait to go on and do some more and see what else you can dispel kind of thing. When discussing the positive effects of Spectrum therapy, a feeling of empowerment was related to the brighter future participants felt was now possible. Some participants spoke
about this feeling of empowerment after Spectrum Therapy when talking about how confident they felt in their abilities to get better autonomously without the help of a therapist. Frank: It’s helping you because you know that actually you can put in place what you were taught when you were away The Problem with Emotion. Participants document a desire to stay disconnected from their emotions in exposure therapy. Feeling unable to cope with feeling. In several of the narratives, there is an underlying sense that participants view their emotions as debilitating and therefore they want to avoid connecting with them. Frank: ....it felt... it was easy to talk about if I stayed disconnected, you know without opening myself up to how I was feeling. Interestingly, when talking about their positive experiences of Spectrum therapy, many participants describe how the therapeutic protocols involved in this therapy changed the fearful relationship they once felt they had with their emotions. Frank: This was my own piece of learning that Spectrum Therapy helped me to uncover....that my emotional world was not something to be afraid of. For Gary, it would appear that he took comfort in the Spectrum therapists abilities to be able to contain his anger which in turn gave him encouragement to express his anger instead of avoid it. Gary: I mean they would tell me that it was ok to feel it as erm...as it was all about feeling my emotions so I felt it was ok to express my anger.
Generating an understanding of one’s emotions and the ability to manage the Self were noted by several participants as the most useful part of staying engaged in Spectrum therapy. This emotional awareness for many of the participants seems to be one of the most influential factors in their recovery as they report feeling in control of their emotions instead of their emotions being in control of them. Ben: Now what the erm...Spectrum therapy did was make sure you are in control of your emotions, they teach you to deal with the emotions. Participants spoke about how the re-living element of exposure therapy generated specific un- wanted emotions. In particular shame, anger and guilt were highlighted as hindering their engagement in exposure work. For two participants, a feeling of guilt relates to their military experiences which seem to be all consuming after engaging in exposure therapy. For these participants it feels as though exposure therapy changed the relationship they had with the memory of the military in a negative way, which in turn had an effect on how they viewed the Self. Matt: Well it like you feel bad because you’re faced with all the bad things that have gone on and it makes you not want to erm....open yourself up anymore do you know what I mean? For others, the presence of anger was believed to be generated from the re-living process. For those that reported anger as consequential to the re-living process of exposure therapy, this was described as influencing their decision to disengage from the therapy. Owing to the way these participants describe their anger, the reader is left with the impression that this emotion is viewed by the participants as unacceptable and is subsequently something that needs to be avoided. Luke: they had quite a few no shows as well coz I was getting so badly worked up after it.
In addition to guilt and anger, five out of the seven participants reported how the presence of shame made it difficult for them to engage in the re-living process of exposure therapy. For some, shame seems to be generated by the re-living process itself. Sam: See every time you tell it you get the same burst of emotions that you had when you were there, the main thing is you’re not there so the shouting and the erratic behaviour is now making you look quite like there’s something wrong with you. For three participants shame was generated through exposure therapy because their suffering was brought to the forefront. For these participants there seems to be reluctance in engaging with this suffering because they attribute this to a sign of failure. Frank: after normal therapies that I have known in the past I have felt dirty and hateful and horrible and didn’t like myself because how I have allowed all this to happen to me, how have I allowed myself to be so ill For Gary, it would appear that sharing his experiences means he will need to share what he sees as a horrible secret relating to his actions in the military. For this reason, he found the internal nature of Spectrum therapy particularly useful as he was able to keep his experiences hidden from the therapist which then seemed to encourage engagement in the therapeutic protocols. Gary: before, when I was asked to talk about my experiences I felt ashamed....like what I had done, was bad...but in Spectrum I didn’t have to talk about my problems. Not wanting to share. Participants reported how the internal nature of Spectrum therapy helped them connect with their emotions. The narratives associated with this point state the importance of an internal
process in Spectrum therapy, where participants were not asked to share their experiences with the therapist, as helping them feel able to cope with emotion. Sam: you are not verbalising it you can cope with it you can’t take away the emotions or you know, change anything that’s ever happened, but you can cope with it because you are not verbalising it, the emotions are not being shown so you are able to go through it without the intensity, without any emotion being present really. Theme: The Importance of relationships. Participants described two main factors associated with Spectrum therapy that enhanced their therapeutic relationship and subsequently encouraged them to engage with the therapeutic process. This super-ordinate theme has therefore been broken down into two sub-ordinate themes which relate to Military/Civilian Divide and Feeling Supported in Recovery. Military/Civilian Divide Many participants described the importance of the therapist being a veteran in Spectrum therapy in helping them feel connected to the practitioner. This connection seems to be generated by a shared understanding of military experiences between the participants and the Spectrum practitioner. Luke: Yeah because it was ex-forces erm, who were delivering the treatment so obviously the understanding was there, it helped then you know. Some participants placed trust and understanding as the main reason for their engagement in therapy. This is summed up in Matt’s narrative when he talks about how he would feel if his therapist didn’t understand him. Matt: Frustrated, despondent, uncomfortable, you name it, angry........ it’s everything.
Thomas also believes trust to be a central part of treatment engagement, particularly in trauma work as he felt he was exposing himself to his therapist in this type of therapy. Thomas: they are asking you to re-live and going through processes which are very personal to you, I know for a fact that if I haven’t engaged with someone on a level I am comfortable with and I trust that individual I would go no further, you know my own defence mechanisms would kick in. The importance of building a trusting relationship where the participants felt they would be understood seems to be particularly important as the majority of participants described feeling unsafe to discuss their experiences with civilians for fear that they will judge them. Ben: And as well when I feel...errr...if you’re trying to talk to a civilian, somebody who has not been through it they might feel you are being farfetched kind of thing, like you are exaggerating the story or something like that so you clam up and just tell them the basics. Feeling supported in recovery. For participants the structure of Spectrum Therapy and the availability of their Spectrum therapists generated a feeling of safety in therapy as they felt supported in their recovery. Luke: Yeah, so its erm, it’s as though if, if something’s brought up then you know that the following day it can be talked through and helped with and that you don’t have to wait 6 days or however long to, to revisit the problem. These narratives give the impression that some of the participants felt alone in their recovery in exposure work and that often this would prevent them from engaging in the process because they didn’t feel supported. This seems to be an important feature for Ben that he felt was missing in exposure work.
Ben: they brought them all to the top and you talked about them and then that’s it, they say ok then thanks very much I’ll see you in a weeks’ time and so I say ok I’ll see you later. The second way some participants documented feeling supported was through being given hope in their own recovery. For Ben and Matt this hope seemed to be generated through the comparisons between their own, and their Spectrum therapist’s experiences of PTSD and the military. Ben: So I thought right all these people here have been that angry ex-soldier that I have been for twenty years so I thought you’ve got to give this a bash. Comparisons between the clients themselves also seemed to encourage engagement in the process as their experiences of the therapy could be normalised. Matt: I had a little chat with another guy on the course one night and said what do you think of this, he said I really don’t know what it is, but something’s happening, so we basically said to each other well you know lets go for it then. Discussion. The current study had one aim; to explore how veterans make sense of their disengagement from traditional exposure therapy and their subsequent engagement in a non-exposure based intervention for PTSD. The findings from the current study indicate that there are a number of similarities in the experiences of the participants as represented through the shared themes. The Importance of Control
Participants in the current study often decided to disengage from exposure therapy because they experienced a conflict when their avoidant style coping mechanisms were challenged by the therapist. For participants in the current study re-visiting memories that they wanted to forget seemed anathema to them and in some cases impacted on the therapeutic relationship, as participants felt the therapist had control over their treatment plan. This subsequently seemed to generate feelings of frustration or left participants questioning the therapist’s intentions for asking them to engage in the re-living process. This finding agrees with Murphy, Rosen, Thompson & Rainey’s (2004) suggestion that clients with PTSD are often ambivalent about changing the coping strategies that maintain their symptoms. For combat- related PTSD in particular, addressing ambivalence about changing a veteran’s coping mechanisms is recognised as being an important first step in the treatment plan of this client cohort, as they often present with strong beliefs that their coping mechanisms are functional rather than dysfunctional (Murray et al, 2004). The current data would tend to strengthen this contention, suggesting further that if this ambivalence is not addressed, dropout can occur. This seems particularly true for those veterans who strongly believe that avoidance is imperative to their survival. Participants’ in the current study report feeling unaware of the benefits of the therapeutic processes involved in exposure work and how this impeded on their engagement. This lack of understanding seemed to contribute to their frustrations in exposure therapy as they were being asked to engage in a process which went against their internal model of coping. For this reason it seems that gaining an understanding of the rationales behind the protocols in exposure work was an important aspect of therapy that was missing for participants. This finding was surprising given that one of the outlined components of exposure therapy is the presentation of the overall treatment model, including rationales and goals (Foa & Rothbaum,
1998). This said, with increasing pressures for treatment methods to be delivered in a timely and cost-effective format, the process of describing the treatment model to the client is advised to take no longer than one session (see Cook et al, 2004). For the client cohort in the current study, it would seem that a continuing narrative on the usefulness of the re-living protocols was vital to their engagement in such a fear-evoking process. The majority of participants explicitly mentioned the importance of feeling certain of the rationale for each therapeutic act both in relation to disengagement from exposure-based therapies, and engagement with Spectrum therapy. The Importance of seeing Positive Change. Participants report a fear of their symptoms getting worse or feeling over-whelmed by the re- living process as reasons for their disengagement from exposure therapy. Such fears have been noted in the literature as being “common appraisals” made my PTSD sufferers (Ehlers & Clark, 2000). Contrary to cognitive theories of PTSD, which postulate that a client’s fears of facing their trauma memory will be worse than the reality of doing so (e.g. Ehlers & Clark, 2000), participants in the current study report their fears being actualised in therapy. These findings, whilst contrary to the standard cognitive model, are not entirely unpredicted. Indeed, cautionary notes regarding the use of exposure therapy appear throughout the literature on the grounds that the re-living process can be an over-overwhelming experience for clients (see Hembree et al, 2003). Some participants reported experiencing a worsening of PTSD symptoms during re-living, a finding which confirms the fears expressed by clinicians as a reason for not adopting this type
of therapy in real world practice (see Becker et al, 2004). Conversely, seeing quick change in their symptomatology in Spectrum therapy contributed to participants continued commitment to this therapy. Seeing change in Spectrum therapy gave participants a feeling of empowerment and hope for the future as they started to realise that their suffering could be altered. This finding is important to consider in line with not only the current participants’ feelings of a lost future when describing their experiences of life with PTSD, but with this being present in PTSD sufferers in general (Rauch & Foa, 2006). With some research showing that PTSD symptoms worsen before reducing after exposure therapy (e.g. Shearing et al, 2011), and with findings which document a gradual decrease in PTSD symptomatology from exposure therapy (e.g. Speckens, Ehlers, Hackman, & Clark, 2006) it would seem important for the exposure therapist to be transparent and discuss this potential outcome with the client throughout therapy before potential dropout occurs. The Problem with Emotion. All participants discussed having a maladaptive relationship with their emotions and how this impeded their engagement in exposure therapy. For participants in the study there seemed to be a fear of feeling as they felt unable to cope with the negative emotions generated through exposure therapy, such as shame, anger and guilt. This sits comfortably with the findings by Price, Monson, Callahan and Rodriguiez (2006) that a “bi-directional relationship” between emotional functioning and PTSD is evident in this client group. Price and colleagues (2006) discuss how a fear about experiencing strong emotions and a concern about controlling one’s reactions in response to emotions in therapy, may impact on the client’s successful completion of PTSD treatment.
Interestingly, participants felt more able to engage in Spectrum therapy which, as a therapeutic method, explicitly encourages the recognition of emotions attached to the traumatic event. Not only did participants stay engaged in this treatment method, they report gaining recognition, understanding and being able to reframe their emotions to be the most useful aspect of Spectrum therapy. In conjunction with the literature, this finding is congruent with a “staged approach to PTSD treatment” (Cloitre, Cohen, Koenen & Hyemee, 2002). Such an approach suggests that exposure techniques should be offered alongside other therapeutic concepts from different therapeutic packages to help improve client engagement. Becker and Zayfret (2001) advocate the use of Dialectical Behavioural Therapy (DBT) to help retain client engagement in exposure for instance. Within this therapy, concepts such as validation, mindfulness and the dialectic of acceptance and change in relation to a client’s relationship with their emotions is encouraged (Linehan, 1993). If the findings of the current study are found to generalise, such an approach could help clients presenting with similar difficulties stay engaged in exposure therapy by equipping them with the relevant skills needed to stay with their emotions instead of avoid them. The findings of the current study could therefore be used to expand on the recognised importance of acceptance in general psychological wellness (Hayes, Strosahl & Wilson 2012), by tentatively suggesting that increasing a veteran’s acceptance of emotions might encourage adherence to exposure therapy. Alongside this recognition is the importance of the internal nature of Spectrum Therapy in encouraging participants to connect with their emotions. Participants in the current study identified the benefits of not having to disclose their emotions to their Spectrum practitioner as helping them connect with their emotions. This finding suggests that treatment packages such as EMDR which requires clients to hold their memories or emotions in their mind
instead of verbally express them (Shapiro, 1995) might prove more attractive to this client cohort and thus improve client engagement to this type of therapy. The Importance of Relationships. For participants in the current study, the development of a trusting, emphatic relationship seems to be developed through a shared understanding of military life between themselves and the Spectrum therapy practitioners. Conversely, when describing their experiences in exposure therapy, participants describe a concern that civilian therapists will not understand their military experiences and may in fact judge them for these experiences. In the literature this military/civilian divide is recognised as a consequence of the severity of military experiences, where serving officers are often exposed to situations that are so far removed from everyday civilian experiences that they feel disconnected from society once leaving the military (Litz et al, 2009). This seems to be the case for participants in the current study as they describe how the military environment felt like a family unit with unparalleled levels of trust formed between themselves and the other veterans. In their relationships with civilians they describe this camaraderie as being absent and report struggles fitting into civilian life. Feeling connected to the therapist, and indeed the other clients engaged in Spectrum therapy at the level of military experience, seemed to provide participants with hope in their own recovery as their experiences of therapy could be normalised. This normalisation process subsequently motivated participants to engage with the therapeutic protocols involved in the
therapy. This finding supports other research which has highlighted the positive influence of a group programme in helping increase veterans’ motivation to engage in therapy (see Erbes et al, 2009). In relation to the set-up of Spectrum therapy, participants highlight the on-going availability of their Spectrum Therapy practitioners over the four day treatment programme as encouraging disclosure of their problems. This structure, which differs from the weekly sessions offered to participants in exposure therapy, seemed to generate a feeling of safety as participants described feeling reassured that if they were to disclose their problems, they would get resolved. Implications for Practice. From the findings of the current study, it is evident that participants enjoyed, and found it easier to engage in, a process which seemed to be more in-keeping with their avoidant style coping mechanisms. In the face of considerable and growing evidence of the psychologically salutary effects of acceptance and the damaging effects of avoidance (e.g. Foa & Kozak, 1986; Hayes, Wilson, Gifford, Folletee & Strosahl, 1997), as a profession we cannot advocate avoidance in the treatment of PTSD. Instead what seems to be an important aspect of treatment, particularly from the experiences of participants in the current study, is facilitating an environment where the client feels in control of the therapeutic protocols being asked of them and equipping them with the tools to manage the emotions generated by therapy, which Spectrum Therapy appears to offer.
The findings of the current study suggest that therapeutic engagement to exposure therapy could be increased through a continual narrative on the importance of the therapeutic protocols and their usefulness in reducing symptoms. Whilst informing our clients of the rationales behind exposure therapy is documented as an initial stage in the treatment plan (Foa and Rothbaum, 1998), it maybe that this is not emphasised enough, particularly for clients who present with strong avoidant styles of coping. In this instance it could prove useful for exposure therapy to take a lead from other psychological treatments such EMDR and Acceptance and Commitment Therapy (ACT) where detailing the model of treatment and the benefits of such a model for specific symptoms, is recommended in the first few sessions of treatment (Shaprio, 1995; Hayes et al, 2012). Finally, it is evident from the findings in the current study that participants feel there is a clear divide between people who have served in the military and civilians. This divide is connected to a belief that civilians, including any civilian therapist, would not understand their military experiences due to not having witnessed such extreme events. In the current study this had an effect on the development of trust in the therapeutic relationship and in some cases led to participants fearing judgement from their therapist for having such experiences. When veterans feel that their experiences of war are so far removed from the everyday experiences of their therapist, not explicitly having to recount their traumatic memory seems to be beneficial. Internal investigations, as featured in both Spectrum therapy and in EMDR (Shapiro, 1995) may therefore prove a worthy addition to exposure therapy to help improve its practical effectiveness.
Limitations and Implications for Future Research.
Due to the guidelines of IPA where purposive sampling is encouraged (Smith et al, 2009) we recruited a relatively homogenous sample. All participants were male (though this was not deliberate), of working age and had been involved in combat from which their symptoms of PTSD had derived. Transferability of findings should therefore be considered within this context. Future research may want to build on the findings from the current study and observe whether similar qualitative themes arise from those clients who have dropped out of exposure therapy within different PTSD cohorts e.g. rape or road traffic accidents. Not least because of the recognised differences between combat-related PTSD and other PTSD client groups (see Litz et al, 2009), such an exploration could help further our understanding of why clients dropout of exposure treatment. This could help increase our knowledge base of client reasons for the success or failure of a particular therapeutic method and help answer the question posited throughout this research dossier: why are efficacious therapies for PTSD, not as effective in real-world practice? References Beck, G.J., McNiff, J., Clapp, J.D., Olsen, S.A., Avery, M.L. & Hagewood, J.H. (2011). Exploring Negative Emotion in Women Experiencing Intimate Partner Violence: Shame, Guilt and PTSD. Behaviour Therapy, 42, 740-750. Becker, C. & Zayfret, C. (2001). Integrating DBT-Based Techniques and Concepts to facilitate Exposure Treatment for PTSD. Cognitive and Behavioural Practice, 8, 107-122.
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