Dr. Edna Foa on her technique for treating PTSD, Prolonged Exposure Therapy (PE).
By Emma Forrester and Edna Foa, Ph.D.
This year’s Lindenmann Lecture was presented by noted trauma researcher, Dr. Edna Foa. Dr. Foa’s lecture focused on her technique for treating PTSD, Prolonged Exposure Therapy (PE). She presented a general overview of the treatment as well as statistics supporting its efficacy in treating trauma. The following day, Derner doctoral students had the opportunity to attend a six-hour workshop with Dr. Foa, where she was able to explain the theory and administration of PE in more depth. During this workshop, first year student Emma Forrester sat down with Dr. Foa and spoke about her history in the field, her work with rape victims and veterans, and where she hopes to see trauma research and treatment go in the future.
Emma Forrester: Can you tell me how you became interested in studying trauma? I know you were working with other anxiety disorders before that.
Dr. Foa: Well, I actually was interested from a theoretical point of view. I started with a theory of emotional functioning and I thought “Well, how do people approach this, this interesting event?” And I didn’t think that it was trauma or not trauma, but the idea came to me that we don’t realy dwell on positive things. If you had a wonderful wedding you don’t think about it too much, but if you had a terrible vent you think about it, so, what’s the mechanism and the process to get over it? Then I decided that I would study rape victims because nobody paid a lot of consideration for them, and they would be more honest. I didn’t even know that I was studying PTSD at the time because it was before PTSD came into being. So that’s what my motivation was. And then once I saw these patients, I said “We need treatment for them.” And there was not treatment for them because this was 1980 and we didn’t have a treatment for PTSD. That’s how I started to develop a treatment for PTSD. It came from emotional processing theory.
EF: So coming from this theoretical standpoint, how did you go on to develop PE?
Dr. Foa: Well, I had seen rape victims before, and treated them as phobias. They were avoidant and they were upset, and so mostly I treated them with in vivo exposure because of the avoidance. Once I realized that these memories that are haunting them are something that doesn’t happen with phobias, I realized we had to do something with those memories. Then I came up with the idea that if we help them to repeat the memories, so many things happen. They create a story, they create a narrative which is easy to digest. They actually realize that a lot of the negative memories that they have were not so, and the reason why they kept on thinking it was their fault, their blame, is because they never really allowed themselves to go back into the memory and check what happened there. So the idea was that allowing them to check, and also the idea of imaginal exposure, it will help them differentiate between reliving or retraumatizing and telling a story about what happened in the past, and that they are survivors. They are not in danger from the story like they were in danger in the past.
EF: Now you’re working with veterans. How did you get interested in that?
Dr. Foa: The VA came to me. Actually, before that there was a study in the VA that compared PE to simple therapy. You know, treatment of talking about what happened, a kind of counseling. And I was asked to be the supervisor, to arrange all the supervision. So that’s how I got involved with the VA Later on, because the treatment was quite successful, the VA decided to disseminate PE, and that’s how I started to work with them. Then, in Israel, I was working with veterans because the treatment is really disseminating more among veterans than among civilians.
EF: Where do you see the field of trauma research going in the next few years?
Dr. Foa: Well, I think one of the very problematic issues is dissemination of information. Therapists don’t want change. If they learn psychodynamic psychotherapy and they are comfortable with it, or if they learn CBT and they don’t want to learn psychodynamic, people are reluctant to change. So that’s one barrier. The other barriers are the systems. If the system allows for once a week therapy, for example, in the VA it is easy, but in the Army it is more difficult. So you need disparate systems. And so there are lots of barriers for implementation. So that, I think, is one of the major issues that we will have to deal with, because we do have good services. They are not perfect, but there is no perfect service for therapy either. So I hope that we will go more and more towards evidence based treatments and that people will not be allowed to do psychodynamic therapy unless we have evidence that it works. Just like you are not going to use medication that you feel like you like and you feel comfortable with—if a physician has a patient with diabetes and he said, “I don’t really connect to insulin. I think that relaxation training and exercise would be enough.” But the patient has severe diabetes and relaxation training and exercise don’t reduce it. If he said “Im not connecting,” he would lose his license and there would be a complaint. In psychotherapy, this is not the case. Everybody can do whatever they want. So I’m hoping that the system will encourage evidence based treatment. And I hope that they will encourage people to study psychodynamic therapy to see what patients benefit from psychodynamic therapy and how to give psychodynamic therapy in a way that will be efficient.
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