PE requires that patients overcome their natural tendency to avoid thinking and talking about the traumas that they experienced. The challenge for patients is the fact that avoidance has been the primary strategy they have used to cope with their trauma-related distress. Many of the procedures incorporated into the PE program, including the structure imposed by using a manualized treatment, provide a foundation for encouraging clients to overcome their avoidance in order to experience the exposure exercises. In addition to specific aspects of the PE program, numerous nonspecific factors can facilitate treatment. Basic therapeutic skills, such as empathy and active listening, are invaluable. Perhaps most important is the therapist's ability to convey confidence in the effectiveness of the therapy the client's ability to complete the treatment program, and expertise in conducting the treatment.
It is important to form a strong therapeutic alliance with the client during the first two sessions of PE. This may be quite challenging with survivors of interpersonal traumas, such as rape or physical assault, for whom trusting another individual may be particularly difficult and frightening. several aspects of the PE program are designed to foster this alliance. Among them are (1) providing a clear description of the therapy and the rationale for the procedures employed during PE; (2) conveying empathy for the difficulties of abandoning avoidance strategies; (3) communicating caring for the patient; (4) acknowledging the challenge presented by PE; and (5) recognizing the patient's courage in electing to participate in the treatment program. More generally, it is important for the therapist to take a strong empathic, nonjudgmental stance throughout treatment to foster communication. The therapist should work actively to build the alliance with the patient. For example, the therapist should use the patient's own experience to illustrate concepts such as common reactions to trauma or in vivo exercises, and convey a strong commitment to apply PE in a way that takes into account the client's unique experience. It is also extremely important to foster a sense of collaboration between therapist and patient throughout treatment. The therapist and patient should work together to select the situations to be used in the in vivo exercises and which aspects of the trauma memory to be included during imaginal exposure. The essence of the collaboration is that the therapist makes recommendations based on his or her experience in treating others with PTSD while taking into consideration the patient's unique presentation and needs.
As noted above, an important aspect of PE is the therapist's explanation of the rationale for the treatment and how the treatment addresses the factors that maintain PTSD. Similarly, it is crucial that the patient understands how in vivo and imaginal exposure will help him or her overcome chronic symptoms and related problems. If patients do not have a firm understanding of why they are asked to engage in exposure exercises, they may not comply with treatment demands. Therapists should also praise clients freely for engaging in and completing exposure exercises, especially very difficult assignments. It is important to remember that the structure of PE provides ample flexibility to accommodate the specific needs of patients. Although a detailed description of how to incorporate a flexible approach to exposure lies beyond the scope of this chapter (see Foa & Rothbaum, 1998; Hembree et al., 2003b), it is important to note that PE does not require that therapists abandon basic therapeutic skills. On the contrary, the techniques included in PE must be presented in a manner that reflects caring and respect for the individual experience of the patient and addresses his or her individual needs.
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