Contact Information. - Please me if you have any questions, are interested in collaborating on research, or would like copies of my materials.

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1 Contact Information Want access to my PTSD materials? Want to discuss the protocol? to: Subject Line: TPA PTSD Workshop Coming soon: - Please me if you have any questions, are interested in collaborating on research, or would like copies of my materials. - I am in the process of creating a website: Eventually (perhaps in Dec 2016?) all my materials can be accessed there. - In the meantime, a video of this workshop and all my materials are stored in my DropBox. Upon request, I will provide you with the download link. - I live in Abilene, TX and am available to present this workshop (3-6 hours) to interested groups. I do not charge anything for my materials, nor do I request an honorarium. I do ask that the inviting organization reimburse my travel expenses and provide me with some place to sleep. - I revise my materials regularly, so don t be shy about asking for the latest versions.

2 EXECUTIVE SUMMARY Battlefield Variant (BV) Prolonged Exposure Therapy Lt Col (ret) Marlin K. Moore, Ph.D. While deployed to Afghanistan (2008), circumstances required a significantly abbreviated trauma treatment protocol. Faithful to Foa s PE theory, patients in this high-stress / high-threat environment were educated on PTSD, then trained to confront (vice avoid) their traumatic memories. Patients received one-to-three therapist-guided imaginal re-exposures, but the bulk of the treatment was done out-of-session, as written homework. For eight years, this protocol has delivered low attrition and robust efficacy with over 200 non-military adolescents and adults in both inpatient and outpatient settings. A free clinician training workshop is available online. Pt presents with ACR/PTS symptoms. Assess/Measure distress. Offer free, online informational presentation. In-Session review of informational presentation. SUDS instruction. Identify problematic trauma stories containing unfinished emotional business. Continues on next page The BV protocol is highly flexible, and has been successfully adapted for use in dynamic (wartime / critical incident) and traditional (inpatient unit / scheduled outpatient) settings. Trauma can be treated in isolation, or in tandem with other co-morbid conditions such as chronic pain, sleep disorders, obesity or tobacco cessation. Except with actively hallucinating patients, the protocol is typically tolerated well, and can produce rapid therapeutic gains (self-reported and observed). The Post Traumatic Checklist (PCL- 5) is a reliable and valid measure of post-traumatic stress symptoms. The Clinician Administered PTSD Scale (CAPS- 5), is a valid and reliable diagnostic instrument. Both instruments are available free through the VA. Providing a URL to the pre-treatment information I want patients to understand has enlivened interest in treatment, and also reinforces the message that the patient, not the therapist, is in control of the therapeutic process. Watching a presentation at home is much less threatening than discussing trauma with a therapist. And, patients can think about it before committing to begin treatment. As an added bonus, their significant other is also educated about PTSD (and is invited to attend the session(s), if the patient consents). Patients understand how long-term avoidance has maintained their symptoms and how habituation can decrease them. Discussing the presentation also allows me to assess their confidence / motivation for treatment, then immediately address any concerns or confusion. Teaching patients the Subjective Units of Distress Scale helps reinforce: 1) PTSD symptoms change over time; 2) PTSD treatment always occurs in the present moment; and 3) Thinking about the traumatic stories they ve tried to avoid is unpleasant, not dangerous. Patients are reminded that 98-99% of our traumatic stories resolve spontaneously. Then, encouraged to determine which of their stories still contain "unfinished emotional business, as evidenced by intrusive thoughts, nightmares, and stimuli avoidance. Rather than telling me their stories, I request (and record) only the unique story titles. Once again, patients deliberately re-expose themselves to all the stories they ve been actively avoiding, yet suffer no major ill effects. This violates their negative / catastrophic expectations, increases their confidence level, and enhances the therapist s credibility.

3 Assign SUDS ratings to each problematic trauma story title. Pick one story to work on during the therapy session. Imaginal re-exposure. Process imaginal re-exposure. Written homework assignment. Periodic telephone monitoring. Follow-up sessions, only as requested by the patient Patients are asked to combine both the new things we ve discussed so far. As I read off each story title, patients are instructed to engage in imaginal re-exposure silently, in their minds. Then, they are asked to provide me with the highest SUDS rating they experience right now, in this room, independent of what they experienced when the traumatic event occurred or at any other time since then. Patients are reminded that the primary purpose of this session is to acquire new skills the majority of their therapeutic work will be done out-of-session, as homework. I then review the range of SUD-rated stories, and ask which story s/he thinks we should work on together, and why s/he made that choice. Whatever they select is acknowledged positively, but I will recommend we select the LOWEST story, because this reduces the distraction of high-suds content, and maximizes the rapid acquisition of new skills. NOT processing the Index Trauma first is THE most significant difference between the BV, vice Foa s standard 12-session protocol. Considerably less face-to-face therapy time is required, and the magnitude of patient re-traumatization is significantly decreased. All of which contribute to faster treatment with less attrition. I guide the patient through a standard, imaginal re-exposure (IR) exercise; then we process their experience. Typically, patients provide a lower SUDS rating during the story title generation task, vice what they experience during the IR (i.e., without their customary emotional avoidance). Many patients are astonished by this. When patients experience, in-session, the (dis)functional role their avoidance-based survival strategy, has played, they immediately become more open to adopting an alternative confronting and habituating strategy. Most patients report feeling elated and empowered by their unexpected success during this first session. When I query how the session actually went, in contrast to their pre-session predictions, almost all report, That was a lot easier than I thought it would be! Enhancing patient self-efficacy motivates them and prevents relapse. Reiterating the importance of repeated and structured re-exposure experiences (i.e., as was just demonstrated to be an effective / efficient method for habituating leftover unfinished emotional business ) provides a natural segue into the written homework assignment. Patients are reminded that they now have all the skills required to jump start the natural process of habituation, which has been delayed. Before you go to bed tonight, please type out (on your computer) the story you just told me. After final editing, save the file as, Story One, Day One. Print a copy, and go to bed. [Using a computer is optimal, but hand-writing in a journal proved to be equally effective for psychiatric inpatients.] Tomorrow, fold up your printed story place it in your pocket or purse, then, read through it anytime you have a chance (e.g., waiting in a line, telephone hold, etc.). Record your SUDS ratings each time through. As stories are repeated, most people remember additional details. Note key words / phrases in the margins. Before bed, type in this new information, and save the revised file as Story One, Day Two. Repeat daily until your highest SUDS rating has habituated by at least 50%. Then, repeat the daily type-print-readrate-revise process with your next lowest story. Continue until all your stories have been habituated. [cf. Homework Handout for details]. For additional information, contact me: MKMooreTX@aol.com

4 HOMEWORK INSTRUCTIONS Battlefield Variant (BV) Prolonged Exposure Therapy Lt Col (ret) Marlin K. Moore, Ph.D. Congratulations on taking the courageous first steps to obtain relief from your posttraumatic stress symptoms! As you ve already experienced in the session, our memories of past traumatic events may be unpleasant to recall, and make us temporarily uncomfortable, but the process of remembering things will NEVER be dangerous. You have already survived the worst part of the story! The historical reality will never change, it is behind you, and it will NOT be repeated, regardless of how many times you might think about it later! Tonight, before you go to bed, I d like you to type out your story, just like you told it to me in first person, present tense. Format the document with one inch margins all around and use double-spacing for the text. Edit the story until it is the way you want it to read, and then save the file as, Story One, Day One. Print the file, (single-sided pages), then set the document aside with your clothes for tomorrow, and go to sleep. Tomorrow, when you wake up, fold up your story so it will fit neatly into your pocket or purse. Carry it around with you all day. Anytime you have a few spare minutes (e.g., waiting in line, sitting at a red light, etc.), pull out the printed story and read through it as many times as you can. As you read through the story, be sure to pause occasionally to assess your current SUDS score, and record several of your scores in the margin. Be sure to write down scores EACH time you read through the story. Most people will remember new details from the story as they rehearse it over and over. Make a note of these key words/phrases in the margin, so you won t forget them. At the end of your day tomorrow, open the original file on your computer (Story One, Day One), and type in all the new information you remembered throughout the day. Edit your revised story until it is the way you want it to read, and then save the longer file as Story One, Day Two. If 12 point print is too small to read, consider 14 point or 16 point. As you did before, print the story and go to sleep. The next day, read through the newest printout as often as your time allows. Continue this same pattern (i.e., type, print, read, rate, and revise) for however many days it takes for you to reduce your highest SUDS score by at least 50%. That is, if your highest SUDS score in the story was an 80 the first time through, stick with the same story until the highest score drops to 40 or less. Once your first story drops by 50% or more, type your next (lowest) story into the computer and save it as Story Two, Day One. Repeat the type, print, read, rate, and revise process with the next lowest story. After Story Two habituates, repeat the same process with all your remaining stories until you run out! Once you ve confronted and resolved all the leftover unfinished emotional business in the remaining 1-2% of your trauma stories, the PTSD symptoms should be noticeably reduced, and some patients have reported their PTSD symptoms resolved completely! Turn this page over more information on the back!

5 Important Tips! - CONTACT ME if things go differently for you at home than they did in my office! [My phone is: , extension 2143] Some patients prefer to review their stories with someone else, while others find it more convenient to work on their own. As always, you are WELCOME to follow-up with me for ANY reason, if that would be helpful to you! - KEEP your old story printouts together in a folder. As you see your typed narratives get longer, while also observing your SUDS ratings get lower, you will have objective proof that your PTSD is improving! - MEASURE other indicators! After beginning treatment, many patients report their sleep quality quickly improves. Others might not feel that much differently during the day, but a bed partner may observe fewer nightmares/awakenings or declining restlessness. Also pay attention to the frequency, intensity, and duration of intrusive thoughts/anxiety while awake. - CHOOSE your own treatment timeline. There is NO REQUIREMENT to practice the protocol every day! Give yourself 24 hours, a weekend, or even a week off sometimes! You didn t DEVELOP PTSD overnight, and you won t DISPOSE of it overnight either! Pausing treatment will NOT cause you to lose your gains. In fact, taking a break will let you to test out life WITHOUT the additional burden of all your (previously) unfinished emotional business! - TRUST the protocol! Sometimes patients will follow the protocol they learned in session with the first few of their lower-rated stories, then alter what they do (e.g., analysis and overthinking!) when working on their higher-rated stories. FAIL! The protocol you learned IS THE MOST EFFECTIVE AND EFFICIENT way to habituate the unfinished emotional business in high and low-intensity stories. However, if you really believe you want to try something different, then that would be a good reason to meet with me again, so we can experiment with this together. That appointment will probably save you some time, and it will also make me smarter about options that might help other patients later. - REMEMBER what you learned! If, in the future, you experience a NEW traumatic event, you will ALREADY KNOW how to deal with it quickly and effectively: type, print, read, rate, and revise!