The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
Prolonged Exposure (PE) therapy is an exposure-based intervention used in adolescents (aged 13-17 years) and adults for the treatment of PTSD and related conditions that could develop after a traumatic event. This targeted intervention is a type of Cognitive Behavioural Therapy (CBT) that focuses on modifying the pathological fear/emotional structure that could develop following a trauma event. This is achieved by gradual exposure to the stimuli or cues that trigger memories of the trauma and emotional processing of the trauma event in order to prevent the elicitation of extreme negative responses. This approach therefore helps patients overcome the fear and emotional response triggered by the trauma memory, minimise avoidance behaviours and reduce symptoms of PTSD.
PE is a manualised intervention, delivered in an individualised format over 8-15 sessions (dependent on patient’s response). Sessions are delivered weekly and typically last about 90 minutes. PE content delivered during sessions consists of four main components; 1) Psychoeducation- education about the most common responses to trauma, and rationale behind the treatment provided; 2) Breathing retraining- equipping patients with skills needed to minimise physiological arousal and promote relaxation; 3) In vivo exposure- repeated engagement with triggers associated with the traumatic fear in order to address avoidance behaviour; 4) Imaginal exposure- systematic, repeated exposure to the trauma memory. Patients are encouraged to explicitly describe details of the traumatic event, discuss the emotions raised with the therapist, and emotionally process the trauma event. PE has a substantial homework component (including in vivo exposure) as this provides opportunities for patients to continue to process trauma memories and to challenge avoidance behaviour between sessions.
Fidelity
NICE recommends that trauma focused CBT interventions should be delivered by trained practitioner(s) with ongoing supervision, typically over 8-12 sessions (or more if clinically indicated). It is necessary that PE is delivered as per validated manual, and that stipulated content and structure are adhered to in order to ensure safe and consistent delivery of intervention.
Fidelity measures for PE determine adherence to PE therapy components, and assess practitioner behaviours that could affect treatment outcomes https://pubmed.ncbi.nlm.nih.gov/30516797/. A sample PE fidelity checklist is available online at https://deploymentpsych.org/system/files/member_resource/9-PE%20Fidelity%20Checklist_8_19_13_FINAL.pdf. The programme representative can also be contacted for fidelity measure
Modifiable Components
The individualised approach of PE allows modification of PE procedures to provide tailored treatment based on patient’s response to exposure. The individualised approach of the standard protocol also enables incorporation of issues associated with race motivated traumas and bias violence, facilitating PE delivery across diverse populations. Separate PE treatment protocols are available for adults and adolescents, with the adolescent treatment protocol also used in school aged children (https://www.sciencedirect.com/science/article/pii/S107772291400008X; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3144550/). There is evidence that PE improves symptoms of comorbidities associated with PTSD, including depression, dissociation, and substance use disorders (when offered along-side substance use treatments) https://www.tandfonline.com/doi/pdf/10.3402/ejpt.v3i0.18805?needAccess=true.
PE can be delivered face-to-face (e.g. outpatient clinic setting, residential treatment programmes, community setting, or at patient’s home [for older patients]) or via video-teleconferencing (see Hagerty et al. 2020 for guidance). PE can also be supported via mobile app (PE coach) while patients are receiving face-to-face or virtual therapy.
Supports - Rating: 4
4 - Supported
Some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention
Support for Organisation / Practice
Implementation Support
Implementation support is provided by Dr. Edna Foa, Dr. Sandy Capaldi, and other faculty staff from Centre for the Treatment and Study of Anxiety’s (CTSA), University of Pennsylvania. Implementation support provided include practitioner training, post-training consultation, as well as links to purchase programme resources (including PE Therapist Guide and Patient Workbook).
Start-up Costs
There are no start-up costs associated with training provided within university training programmes (if training is through an NHS place) or by NES.
Costs apply when training is provided by private organisations and may include a 4-day virtual workshop charged at $1500 per practitioner (includes training and supporting materials). There is also 1-day Prolonged Exposure for Adolescents Webinar at $400 per practitioner (includes training and supporting materials).
Other costs can include guidebooks: Prolonged Exposure Therapy for PTSD Therapist Guide at $44.19, Prolonged Exposure Therapy for Adolescents with PTSD Therapist Guide at $29.99; Prolonged Exposure Treatment Program Workbook at $27.62; Prolonged Exposure Therapy for PTSD: Teen Workbook at $19.46; and Post-Workshop Online PE Group Consultation at $600 USD per practitioner.
Building Staff Competency
Qualifications Required
PE is typically delivered by mental health professionals and practitioners that work under supervision. Practitioners applying for NES training should have had training in CBT (to Certificate level or above) and prior experience managing people who have experienced trauma(s).
Training Requirements
Practitioners attending NES commissioned training in Scotland typically attend 3 training days (2 workshops and a follow up day) covering the components of PE, skills practice and support with implementing PE in practice. It is recommended that practitioners access post-training supervision for support, consultation and feedback from a PE expert in addition to practice being supported through local supervision arrangements.
When accessing training through private providers, training typically involves 4 training days and post-training consultations which can involve 12 sessions, with each session lasting about 90 minutes. These sessions can be delivered via videoconferencing.
Private training providers may offer an additional 1-day training for practitioners delivering PE to adolescents. This is not currently available via NES.
Supervision Requirements
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/).
Practitioners accessing training through private providers can receive consultation from PE experts on submission of PE session recordings for two PE training cases. Consultation includes a review of the PE training cases and provision of feedback on the reviewed sessions. Consultation is delivered over 12 week in weekly 1.5hr Zoom meetings.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Evidence
PE is a type of Trauma-Focused Cognitive Behavioural Therapy (CBT-T). Evidence of clinical effectiveness for PE and other interventions within the CBT-T class have been explicitly detailed in the National Institute for Health and Care Excellence (NICE) evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the prevention and treatment of PTSD in adults.
Theory of Change
Prolonged Exposure (PE) is founded on emotional processing theory of PTSD. This theory poises that PTSD emerges from the development of a fear network in memory of the traumatic event, which in turn elicit avoidance and escape behaviours on exposure to reminders of the trauma. It proposes that enabling patients face their traumatic memory/ stimuli would result in desensitisation of their fear and alteration of their fear/emotional structure. PE therefore aims to modify the pathological fear/emotional structure that could develop following a trauma event. The process involves graded exposure of the patient to stimuli or cues that trigger memories of the trauma and encouraging emotional processing of the trauma event in order to prevent the elicitation of extreme negative responses. PE delivery is expected to help patients overcome the fear response triggered by the trauma memory, minimise avoidance behaviours, and reduce symptoms of PTSD.
Children and young people - Rating: 5
Research Design & Number of Studies – Children and Young People
Eleven RCTs evaluated trauma-focused CBT interventions against wait-list control for the prevention of PTSD in children and young people with ongoing exposure to trauma. Three RCTs evaluated trauma-focused CBT interventions against treatment-as-usual for the delayed treatment (>3 months) of non-significant PTSD symptoms. Nineteen RCTs evaluated trauma-focused CBT interventions against wait-list control, no treatment, or treatment as usual. These nineteen studies assessed the effectiveness of trauma-focused CBT interventions for the treatment of PTSD in children and young people when the interventions were delivered as delayed treatment (>3months). Evidence of effectiveness of all interventions classed as CBT with trauma focus (including PE) were combined and evaluated in meta-analyses, as they apply the same approach and their efficacies are expected to be equivalent. The observed outcomes have been summarised below. Complete information on studies included in the meta-analyses, and detailed results from the meta-analyses can be found within the NICE guideline evidence reviews 2018.
Outcomes Achieved – Children and Young People
Compared to wait-list control, no treatment, or treatment as usual, the following outcomes were observed;
- Significant reduction in PTSD symptoms following delayed treatment (>3months) for single incident trauma and multiple incident trauma, and trauma with unclear multiplicity. Effects were observed at endpoint, and sustained at 1-3 months follow-up, and up to 12-months follow-up (3)
- Significant reversal of PTSD diagnosis following delayed treatment, for single and multiple incident traumas, at end point and at 1-3 months follow-up (3)
- Significant increase in number of people much/very much improved at endpoint, after delayed treatment, for single incident trauma and multiple incident trauma (3)
- Significant reduction in anxiety symptoms following delayed treatment, for single and multiple incident traumas, at end point and up to 1-year follow-up (3)
- Significant reduction in depression symptoms following delayed treatment (>3 months), for single and multiple incident traumas at end point. Overall effect, inclusive of all multiplicities of index trauma, sustained for up to 1-year follow-up (3)
- Significant reduction in emotional and behavioural problems (for multiple index traumas) following delayed treatment. Effects were observed at endpoint for internalising problems, and at 3-months follow-up, 6-months follow-up, and 2-years follow-up for externalising problems (3)
- Significant improvement in overall effect on quality of life following delayed treatment (3)
- Significant reduction in functional impairment following delayed treatment for single incident trauma and multiple incident trauma. Effects were observed at endpoint, and sustained at 3-months and 12-months follow-up (3)
- Significant improvement in global functioning following delayed treatment for single incident trauma and multiple incident trauma. Effects were observed at endpoint for single and multiple incident trauma, and sustained at 3-months follow-up for multiple incident trauma (3)
- Significant reductions in PTSD symptoms, in PTSD diagnosis, in functional impairment, and in symptoms of comorbidities associated with PTSD (including depression and anxiety) in children and young people with ongoing exposure to trauma (4)
- Significant reductions in PTSD symptoms and depression symptoms in children and young people with non-significant PTSD symptoms (4)
Adults - Rating: 5
Research Design & Number of Studies - Adult
Eight RCTs evaluated trauma-focused CBT interventions (alone or in addition to treatment-as-usual or psychoeducation) against treatment-as-usual, attention placebo, psychoeducation, waitlist, or no treatment, for the early prevention (initiated ≤ 1 month) of PTSD in adults. Six RCTs evaluated trauma-focused CBT interventions against wait list, attention-placebo or psychoeducation for the delayed treatment (>3 months) of non-significant PTSD symptoms in adults. Thirty RCTs evaluated trauma-focused CBT interventions against wait-list control or no treatment control. These thirty studies assessed the effectiveness of trauma-focused CBT interventions for the treatment of PTSD in adults when the interventions were delivered as early treatment (1-3 months) or delayed treatment (over 3months). Evidence of effectiveness of all interventions classed as trauma-focused CBT interventions (including PE) were combined and evaluated in meta-analyses, as they apply the same approach, and their efficacies are expected to be equivalent. The observed outcomes have been summarised below. Complete information on studies included in the meta-analyses, and detailed results from the meta-analyses can be found within the NICE guideline evidence reviews 2018.
Outcomes Achieved - Adult
- Significant reduction in PTSD symptoms following early treatment (1-3 months) and delayed treatment (>3 months), for single and multiple incident traumas, at end point and up to 1-year follow-up (1)
- Significant reversal of PTSD diagnosis following early and delayed treatment, for single and multiple incident traumas, at end point and up to 8-months follow-up
- Significant reduction in depression symptoms following early and delayed treatment (>3 months), for single and multiple incident traumas, at end point and up to 1-year follow-up (1)
- Significant reduction in anxiety symptoms following delayed treatment, for single and multiple incident traumas, at end point and up to 1-year follow-up (1)
- Significant reduction in dissociative symptoms and functional impairment following delayed treatment. Effects on both outcomes were observed at endpoint, while sustained effect on functional impairment was observed at 6-months follow-up (1)
- Significant reduction in relationship difficulty and significant improvement in global functioning following delayed treatment (1)
- Significant improvement in quality of life following delayed treatment. Sustained effect was observed at 3-months follow-up (1)
- Significant reduction in PTSD symptoms, PTSD diagnosis, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following early initiation of intervention (i.e. <1 month) (2)
- Significant reductions in PTSD symptoms, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following delayed initiation of intervention (i.e. > 3months) in adults with below threshold PTSD symptoms (2)
Need
Comparable Population
Prolonged Exposure (PE) therapy is an exposure-based intervention used in adolescents (aged 13-17 years) and adults for the treatment of PTSD and related conditions that could develop after a traumatic event. Effectiveness of PE was assessed within the wider trauma-focused CBT (CBT-T) class. CBT-T interventions were shown to be effective in the early prevention (initiated ≤ 1 month) of PTSD in adults; in the delayed treatment (>3 months) of non-significant PTSD symptoms in adults; as well as in the early and delayed treatment of PTSD in adults. Effectiveness has also been shown in the prevention of PTSD in children and young people with ongoing exposure to trauma; in the delayed treatment (>3 months) of non-significant PTSD symptoms in children and young people; as well as in the delayed treatment (>3months) of PTSD in children and young people.
Desired Outcome
Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) interventions have been shown to effectively reduce acute stress disorder diagnosis, PTSD diagnosis, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following early initiation of intervention (≤1 month). TF-CBT interventions have also been shown to reduce PTSD symptoms, reduce symptoms of comorbidities associated with PTSD (including depression and anxiety), and reverse PTSD diagnosis following early (1-3 months) and delayed treatment (≤ 3months). Effects have been sustained at follow-up.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Prolonged Exposure (PE) therapy is an exposure-based intervention used in adolescents and adults for the treatment of PTSD and related conditions that could develop after a traumatic event. PE is a specific type of Cognitive Behavioural Therapy (CBT) that is founded on emotional processing theory of PTSD.
Priorities
PE is a trauma-focused psychological intervention that aims to treat PTSD and related conditions. It focuses on modifying the pathological fear/emotional structure that could develop following a trauma event by applying techniques including imaginal exposure and in vivo exposure. PE helps patients overcome the fear/emotional response triggered by the trauma memory, minimise avoidance behaviours, and reduce symptoms of PTSD.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
PE is typically delivered by registered mental health professionals. Practitioners should have prior experience managing people who have experienced trauma(s). PE is delivered weekly or twice weekly, over 8-15 sessions (dependent on patient’s response). To support PE delivery, practitioners receive at least 3 days of workshops. An additional 1-day training is available to practitioners delivering PE to adolescents. Practitioners can access post-training consultation (this may be through video) to get support, consultation and feedback from a PE expert.
Technology Support
Practitioner training and consultation/supervision may be delivered virtually. PE delivery to patients could be face-to-face or virtually (via tele-videoconferencing). PE sessions should be recorded on a suitable device. PE support can also be accessed via mobile app (e.g. PE coach) while patients are receiving face-to-face or virtual therapy.
Administrative Support
PE is delivered bi/weekly, over 8-15 sessions. Face-to-face therapy sessions can be held in several settings including outpatient clinic setting, residential treatment programmes, community setting, or at patient’s home (for older patients)
Financial Support
There are financial supports covering training costs and follow up consultation for NHS or partnership staff when accessing training though NES.
Costs apply when accessing training, consultation or supervision through private providers. Costs can include costs of 4-day virtual workshop charged at $1500 per practitioner (includes training and supporting materials); 1-day Prolonged Exposure for Adolescents Webinar at $400 per practitioner (includes training and supporting materials); costs of guidebooks (Prolonged Exposure Therapy for PTSD Therapist Guide at $44.19, Prolonged Exposure Therapy for Adolescents with PTSD Therapist Guide at $29.99; Prolonged Exposure Treatment Program Workbook at $27.62; Prolonged Exposure Therapy for PTSD: Teen Workbook at $19.46); and Post-Workshop Online PE Group Consultation at $600 USD per practitioner.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
