Clinician Perspectives on Technology-Enhanced In Vivo Exposures during Prolonged Exposure Therapy for PTSD

Abstract

Objective:

To investigate clinicians’ perceptions regarding the use of mobile technology tools during Prolonged Exposure (PE) therapy to allow for monitoring and enhancing in-vivo exposures (IVEs).

Methods:

Clinicians with training in PE therapy (N = 32; average of 9 years of practice) completed surveys asking about their perspectives on the utility of virtually attending IVEs with patients while simultaneously having access to real-time subjective and physiological data (i.e., heart rate, galvanic skin conductance) to guide exposure exercises and assure optimal stimulus engagement.

Results:

Findings showed clinicians to have a favorable view of applying technology devices and systems to enhance IVEs of PE therapy. Most clinicians (93.8%) believed that real-time monitoring of IVEs—particularly monitoring patients’ subjective distress and completion of and duration of time in the IVE—would be useful and significantly enhance PE therapy.

Conclusion:

The positive perceptions toward integrating technology into IVEs in this study have important implications for the development and implementation of technology-enhanced PE therapy. A mobile technology system that incorporates real-time indicators of engagement (i.e., both subjective and physiological) during IVEs and allows clinicians to review recordings of, or virtually accompany, patients during IVEs has the potential to innovate and transform PE and other exposure-based treatments. Clinicians also believed that technology enhanced IVEs may help reduce early termination from PE.

Posttraumatic stress disorder (PTSD) is a debilitating and prevalent psychiatric condition. Approximately 8% of the general population will experience PTSD in their lifetime, and rates are even higher among certain subpopulations (e.g., military service members, veterans, first responders; Hoge et al., 2014; Kilpatrick et al., 2013; Pietrzak et al., 2011). Prolonged Exposure (PE) therapy is an evidence-based treatment for PTSD (Foa et al., 2019). Key components of PE include psychoeducation about PTSD symptomatology, imaginal exposures (i.e., revisiting the trauma memory during therapy sessions), and in vivo exposures (IVEs; approaching avoided but safe stimuli in the ‘real world’; Foa et al., 2007; Foa et al., 2019). Both imaginal and in vivo exposures are designed to reduce avoidance behaviors, activate pathological fear structures, and provide corrective information to alter maladaptive behaviors and thoughts (Foa & Kozak, 1986; Foa & McLean, 2016). Fear responses diminish and new inhibitory learning occurs through imaginal and in vivo exposures, including changes in trauma-related beliefs (Craske et al., 2008; Foa & Kozak, 1986; Hofmann, 2008). Although PE is highly efficacious at reducing PTSD symptoms (Eftekhari et al., 2013; Powers et al., 2010), 20-30% of individuals remain symptomatic after a full course of PE or dropout prior to treatment completion, with dropout rates being even higher among veterans (Hembree et al., 2003; Hernandez-Tejada et al., 2014; Larsen et al., 2016; Schnurr & Lunney, 2019; Watts et al., 2014). Leveraging technology may be one way to address these shortcomings and improve treatment outcomes. Thus, the current study explores clinicians’ perspectives on the use of mobile technology during a critical PE therapy component: in vivo exposure (IVE) exercises.

To date, technology has been applied in various ways to different components of PE. For example, PE delivered via telehealth is equally effective as in-person delivery and can remove barriers to treatment access such as transportation limitations or reaching patients in rural areas (Acierno et al., 2017; Morland et al., 2020). Smartphone and web-based mobile health (mHealth) applications, such PE Coach and PTSD Coach, have been developed as adjunctive tools for PE (Kuhn, Greene, et al., 2014; Reger et al., 2013). These applications have various features, including allowing patients to audio record the therapy sessions so they can listen to the recordings for homework. Some applications provide ways for patients to track PTSD symptoms, receive psychoeducation about PTSD, and/or learn coping skills, such as breathing retraining. Clinicians and patients rate these mHealth applications as acceptable, feasible, and highly promising (Keen & Roberts, 2017; Kuhn, Greene, et al., 2014). Additionally, technology in the form of virtual reality (VR) has been integrated into PE to enhance imaginal exposures (Difede et al., 2007; Loucks et al., 2019; Rothbaum et al., 1999; Rothbaum et al., 2001; Sherrill et al., 2019). Using a head-mounted display, VR allows patients to engage with computer-generated environments similar to the settings associated with their traumatic event (e.g., combat zone). Finally, physiological reactivity sensors have been integrated into PTSD therapy (Katz et al., 2020; Wangelin & Tuerk, 2015). For instance, Wangelin and Tuerk (2015) monitored physiological reactivity (i.e., heart rate, skin conductance) during imaginal exposures in a sample of veterans and found that veterans who completed PE demonstrated significantly diminished heart rate and skin conductance reactivity during imaginal exposures across therapy. They concluded that assessing physiological reactivity to imaginal exposures during PE therapy was feasible and served as a useful measure of successful treatment response. Altogether, this research suggests that technology-based enhancements for treatment delivery as well as the psychoeducation and imaginal exposure components of PE are feasible, effective, and acceptable by both patients and clinicians (Botella, et al., 2015). However, no research to date has focused on technology enhancements for the IVE component of PE.

IVEs are a fundamental component of exposure therapy. They ensure that new knowledge and behaviors learned during therapy sessions are successfully transferred to patients’ real-world environments. Substantial gaps exist in our understanding of what occurs during IVEs, what makes for an effective versus ineffective IVE, and which physiological, behavioral, or contextual factors during IVEs predict positive treatment response. This critical gap in knowledge is due, in part, to the fact that IVEs are conducted between therapy sessions, outside of the office, and are typically ‘invisible’ to the clinician. In rare instances, clinicians accompany patients during IVEs, a technique called ‘therapist-directed exposure.’ More commonly, patients are given IVE assignments to complete before the next therapy session, and clinicians hope that the standard IVE’s intensity, duration, and relevance, per the PE manual, is therapeutic (Foa et al., 2019). There is no objective way to track or monitor the efficacy of IVEs for each patient. As a result, some patients may fail to attempt IVE assignments (e.g., given high avoidance symptoms), others may attempt the assignment but are under- or over-engaged, and still others may engage in rituals or use of safety behaviors that interfere with learning during the assignment. All of these issues confer suboptimal extinction learning and treatment response in PE (Hembree, Rauch, & Foa, 2003). Additionally, the reliance on retrospective self-report of how the IVE progressed is susceptible to inaccuracies.

There are several ways in which mobile technology could be incorporated into IVEs. First, mobile video conferencing technology could allow clinicians to accompany and provide direction to patients during IVEs. The ability for clinicians to virtually, or remotely, accompany patients during IVEs, perhaps between standard PE sessions, versus going in-person with the patient, offers increased flexibility (i.e., logistical and cost advantages). Second, potential integration of real-time subjective and physiological data combined with audio/visual observation of environments from the patient’s perspective (i.e., the clinician can see and hear what the patient is seeing and hearing) may enable clinicians to optimize IVEs. Additionally, real-time collection of subjective indicators (i.e., subjective units of distress, or SUDs) and physiological indicators (e.g., heart rate, galvanic skin conductance) of engagement during the IVE may help a clinician coach a patient so that they reach an optimal level of engagement over the course of an IVE. For example, numerous studies show that greater activation and reactivity to fear-provoking situations before and during PE therapy is associated with improved treatment outcomes (Foa, 1997; Jaycox et al., 1998; Maples-Keller et al., 2019; Norrholm et al., 2016; Rothbaum et al., 2014; Wangelin & Tuerk, 2015). Finally, the ability to record an IVE session and/or the collection of both subjective and physiological indices could eliminate challenges related to retrospective recall of the IVE so that both the clinician and patient can review the exercise in their following therapy session.

The absence of a technological tool, such as the one proposed above, presents an opportunity to enhance exposure-based PTSD treatment engagement and outcomes. To begin this work, this study aimed to preliminarily assess clinicians' perspectives of 1) the use of mobile technology tools during PE therapy, and 2) the usefulness of integrating the mobile technology features described above into PE therapy. Given the descriptive and exploratory nature of the study, no a priori hypotheses about clinician responses were generated.

Methods

Participants

Clinicians (i.e., mental health professionals) with training in PE and treating patients with PTSD, as evidenced by self-report, were recruited locally through e-mail announcements sent to mental health providers at an academic medical center and a Veterans Affairs Medical Center (VAMC). A total of 50 clinicians responded to the study advertisement and of those 50 clinicians, 39 completed the survey (78%), and 32 (64%) reported prior training in PE and/or use of PE to treat PTSD. Data from 32 participants with experience with PE were included in the analyses.

Procedures

Clinicians who agreed to participate in this study received a statement of research approved by the Institutional Review Board (IRB) at the Medical University of South Carolina (informed consent was waived by the IRB as identifiable information was not collected). All participants completed an anonymous survey related to their treatment preferences for PTSD and their thoughts and views about integrating technology into PE therapy. The first 12 clinicians who participated in the study were invited to complete the study in person. In addition to the survey, in-person participants were asked open-ended questions about their experiences with PE (e.g., challenges in conducting PE) and thoughts about integrating technology into PE therapy (e.g., how they think various types of technology could enhance different components of PE) in a focus group setting. At the onset of the COVID-19 pandemic in 2020, data collection was modified from in-person to online collection for the remaining participants, prohibiting the focus group portion of the study for the remaining participants. These participants only completed the survey. Thus, only data from the survey are analyzed and reported here.

Measures

Enhancing Prolonged Exposure Therapy Using Mobile Technology.

All clinicians completed a survey assessing demographics, training/background, employment setting information, and their experiences with PE therapy. The survey included 16 dichotomous questions to assess perspectives on the effectiveness of and challenges related to conducting PE (e.g., “Do you think PE would be as effective without the IVE exercises?”, “Do you believe that some patients who fail to complete PE do so because of difficulties associated with in vivo exposure exercises?”), their current use of technology in clinical practice (e.g., “Do you currently integrate mobile self-help apps into your therapeutic practice?”), and their perspectives on the usefulness of integrating various mobile technology features (e.g., “Do you think a mobile device that would allow for real-time, therapist-guided in vivo exercises would be helpful?”) into components of PE therapy. An additional 13 items assessed the importance of including various features (e.g., real-time assessment of physiological data, ability for clinician to virtually accompany patients during IVEs, ability to receive reports on patient’s completion of IVEs) in a mobile technology system for IVEs and were rated on a 0 (“not important”) to 10 (“extremely important”) scale (Cronbach’s α = 0.94).

Results

Demographic and descriptive information about the sample is presented in Table 1. Participants were primarily female, white, and employed full-time. On average, clinicians were 37.1 years old and had 8.6 years of clinical experience. Seventy-eight percent of participants had a Ph.D., 12.5% had an M.D., and 6.3% had a Master’s degree.

Table 1.

Participant Demographics and Characteristics (N = 32)

	N (%) or M (SD)
Gender
Male	8 (25%)
Female	24 (75%)
Age, years	37.06 (9.60)
Race
White	30 (93.8%)
American Indian or Alaska Native	1 (3.1%)
Other	1 (3.1%)
Educational Degree
Masters	2 (6.3%)
PhD	25 (78.1%)
MD	4 (12.5%)
Other Professional Degree	1 (3.1%)
Years of Clinical Experience*	8.56 (8.93)
Years of Experience Treating PTSD*	8.67 (7.05)
Employment Status
Full-time	31 (96.9%)
Part-time	1 (3.1%)
Primary Work Setting
PTSD/Trauma Clinic	16 (50.0%)
General Mental Health Clinic	5 (15.6%)
Substance Abuse Treatment Clinic	4 (12.5%
Other	7 (21.9%)
Work with Veterans
Yes	16 (50%)
No	16 (50%)

^*Years post-graduate degree.

All clinicians (100%) agreed that PE is an effective treatment for PTSD. Most clinicians (96.9%) believed that IVEs are a critical component of PE and 91.7% believed that PE would not be as effective without the IVE component. When asked about potential reasons for dropout from PE therapy, most clinicians (87.5%) believed that difficulties associated with exposures, namely IVEs, may be a reason.

More than half (56.3%) of the participants reported that they currently integrate mobile technology, such as mobile phone applications, into clinical practice. Most clinicians (84.4%) thought that mobile technology could help reduce dropout from PE. Most clinicians (87.5%) agreed that a mobile device that would allow for real-time, therapist-guided IVEs would be helpful, and 93.8% reported that they would be willing to use a device to virtually accompany and guide patients during IVEs. Moreover, most clinicians reported that they thought patients would be more likely to attempt IVEs (84.4%) and successfully complete IVEs (87.5%) if the therapist was able to virtually accompany them. When asked about real-time input of patients’ physiological reactivity, such as heart rate and skin conductance, 81.3% believed it would be helpful for IVEs. Overall, 93.8% of clinicians agreed that mobile technology could be used to make IVEs more successful.

Using a Likert scale (0 = “not important” to 10 = “extremely important”), clinicians rated how important they thought it would be to integrate various technical components into a mobile device to facilitate IVEs. Average ratings for each item are presented in Table 2. The ability to monitor patients’ subjective distress (i.e., SUDS ratings) during the IVE was rated as most important (M = 7.9, SD = 1.84), followed by the ability to monitor whether the patient attempted or completed the IVE (M = 7.78, SD = 2.07), and the ability to monitor how long the patient stayed in the IVE exercise (M = 7.78, SD = 2.06). Clinicians also rated the ability to assess under-engagement during IVEs (M = 7.29, SD = 2.36), “coach” or support patients through IVEs (M = 7.13, SD = 2.39), and intervene during the IVE exercise (M = 7.00, SD = 2.17) as highly important.

Table 2.

Clinician Ratings of Importance for Proposed Mobile Device Components to Optimize In Vivo Exposures in Prolonged Exposure Therapy

Proposed Mobile Device Component or Feature	M	SD
The ability to monitor the patient’s subjective distress during the IVE (e.g., their SUDS or self-reported anxiety levels).	7.91	1.84
The ability to monitor whether or not the patient attempted/completed an IVE.	7.78	2.07
The ability to monitor how long (e.g., number of minutes) the patient stayed in the IVE.	7.78	2.06
The ability to review the recording of the patient’s IVEs with them at the next therapy session.	7.74	2.13
The ability to receive reports each week on the patient’s completion of IVEs.	7.56	2.44
The ability to assess patient’s under-engagement during IVEs.	7.29	2.36
The ability to “coach” or support the patient through IVEs.	7.13	2.39
The ability to intervene and re-calibrate or re-design the IVE.	7.00	2.17
Audio conferencing capabilities to intervene verbally or help the patient modify an IVE in real-time, if necessary.	6.81	2.46
Video conferencing capabilities to intervene or help the patient modify an IVE in real-time, if necessary.	6.53	2.53
The ability to monitor the patient’s physiological reactivity during the IVE (e.g., their heart rate, respiration, galvanic skin conductance).	6.47	2.61
The ability to assess patient’s over-engagement during IVEs.	6.13	2.79
The ability to assess the safety of the environment of the IVE.	5.81	2.69

Note. IVE = in vivo exposure. Responses were rated on Likert scale from Not Important (0) to Extremely Important (10).

Discussion

IVEs are a crucial component of PE therapy for the treatment of PTSD. However, no studies to our knowledge have examined clinicians’ perspectives on the potential use of mobile technology tools to enhance the effectiveness of IVEs. The current study assessed clinicians’ current use of technology in clinical practice and their perspectives on the usefulness of integrating mobile technology features (e.g., real-time assessment of subjective and physiological data, ability for clinician to virtually accompany patients, ability to record sessions for the purpose of later review) into the IVE component of PE. Study findings indicate that clinicians had overall positive reactions to the application of technology enhancements to IVEs in PE therapy. Most clinicians thought that the ability to virtually accompany patients on IVEs would be beneficial and may help promote adherence to, and effectiveness of, the IVE exercise. Clinicians thought that a mobile technology system that integrated the ability to monitor subjective distress (i.e., SUDS), whether the IVE was attempted/completed, and for how long the patient stayed in the IVE exercise were most important.

The positive perceptions towards technology-enhanced PE observed in this study have important implications for future mechanistic research that incorporates technology to identify processes of change in PE and for improving treatment outcomes and reducing dropout in PE therapy. Substantial gaps exist in our knowledge base of what makes an IVE effective vs. ineffective. Most work on the mechanisms of action for PE has focused on within- and between session extinction as assessed by change in peak SUDS to final SUDS within a given imaginal exposure or between sessions, respectively. This research has shown that within-session extinction is not related to positive treatment outcomes (van Minnen & Foa, 2006; Nacasch et al., 2015); but that between-session extinction is associated with superior outcomes in PE therapy, including loss of PTSD diagnosis and reductions in PTSD symptoms across treatment (Cooper et al., 2017; Gallagher & Resick, 2012; Harned et al., 2015; Nacasch et al., 2015; Rauch et al, 2004; van Minnen & Foa, 2006). Despite the importance of these findings, these mechanistic studies are limited due to a lack of “enhanced measures of mechanisms and outcome variables […] to identify processes of change” (Cooper et al., 2017, p. 118). According to Cooper et al. (2017), such “enhanced measures” are “…multimodal assessment techniques, including observer ratings, psychophysiological metrics (i.e., heart rate), and neurobiological assay…” and are critical to identifying and understanding change processes in PE therapy (p.118). As such, our study directly adds to the literature by demonstrating how a technological tool with such enhanced measurements is of interest and acceptable to clinicians to advance research in PE mechanisms.

Technology enhancements for PE therapy, specifically IVEs (that occur between-session), may serve as a multimodal assessment technique to help optimize patient engagement, improve treatment outcomes, and mitigate dropout from PE therapy through several ways. For example, a technology system with the capability to track IVEs and record the amount of time spent in the IVEs could help clinicians ensure that IVEs are being attempted (accountability) and successfully completed. Clinicians also reported positive perceptions of technology that would allow them to virtually attend IVEs with a patient. This capability would allow the clinician to “see” what the patient is experiencing and address possible patient avoidance or “safety behaviors” that may hinder IVE engagement and effectiveness. This will allow IVEs to be personalized to each patient in real time—a key element of PE therapy (Foa et al., 2007). Moreover, real-time subjective and physiological data would allow clinicians to ensure that engagement is optimal, and patients are not over- or under-engaged during the exercise, as optimal engagement is required to activate fear structures that allow patients to modify and integrate new information (Foa & Kozak, 1986). A few studies have linked engagement to better treatment outcomes, but these studies have only focused on in-session engagement during imaginal exposures (Harned et al, 2015; van Minnen & Hagenaars, 2002; Rauch et al., 2004; Pitman et al., 1996; Foa et al., 1995). No research to date has examined engagement between-session (i.e., during IVEs) and how it relates to treatment outcome, likely due to inadequate assessment tools. Thus, in addition to possible benefits associated with real-time monitoring to ensure optimal engagement, such technological tools may also allow for theory testing concerning engagement during an IVE.

Additional benefits to the incorporation of a technology system into PE include the shortening of the treatment protocol and mitigating dropout. The standard protocol of PE includes 8-15, 90-minute sessions (Foa et al., 2019; Foa et al., 2018; Hembree et al., 2003). If integrating a mobile technology platform during IVEs enhances symptom reduction because of having more engaging and therefore effective IVEs in-between therapy sessions, fewer PE therapy sessions may be needed to achieve PTSD remission. This would lead to reduced healthcare costs and clinician time. In addition, consistent with therapists’ anticipations of the clinical benefit of mobile technology, technological enhancements for PE therapy may also help prevent dropout. While previous research has shown that imaginal exposure contributes to dropout from PE therapy (Hundt, et al., 2022), clinicians in this study expressed that difficulties with engaging in or completing the IVE component of PE may be also be a contributing factor to dropout in PE. No studies have systematically examined the association between IVEs and dropout during PE treatment, but Hernandez-Tejada et al. (2014) examined barriers to treatment completion associated with telehealth vs. in-person delivery of evidence-based treatment for PTSD in combat veterans. Their results showed that problems with IVEs (e.g., patients indicating inability to tolerate IVE assignments) led to dropout, and having support (e.g., peer support) during an IVE might help prevent dropout. Thus, there is high potential impact of technology in IVEs for PE. Indeed, when technology has been used to enhance and deliver behavioral therapies for suicidality and other psychiatric disorders, such as substance use and mood disorders, there have been substantial gains in treatment outcomes (Callan et al., 2017; Carroll et al., 2008; Kay-Lambkin et al., 2009; Kazemi et al., 2017; Kreuze et al., 2016).

Several limitations of this study warrant consideration. The sample size is small and consisted of primarily female, white clinicians with a Ph.D., who had prior training in treatments for PTSD and were recruited from an academic and VA medical centers. As such, these clinicians may have greater privilege and access to training and medical resources than clinicians in other settings. Results may not generalize to other samples of clinicians. It will be important for future work to gauge the feasibility and receptivity of technology enhancements for IVEs among diverse clinicians in various treatment settings. Further, we did not assess the number of years clinicians were experienced in delivering PE, specifically, nor what type of PE training they received. Future research should assess this information as it may be related to clinicians’ willingness to use mobile technology in their work. In addition, this study did not evaluate patients’ perspectives. Although technology is generally viewed as acceptable and feasible among patients, some previous research on patient perceptions of using technology in mental health treatments (i.e., not specific to PE) is mixed and includes responses primarily from veterans (Connolly et al., 2018). Nevertheless, one recent study examining patient perceptions, including the potential acceptability of wearable devices for the treatment of psychiatric disorders from a large community sample (N = 427), reported strong interest in wearables and a general preference for clinicians to help guide use of the technology (Hunkin et al., 2020). Thus, an examination of patients’ perceptions of the use of technology to enhance IVEs during PE is a critical next step.

While the idea of incorporating mobile technology into PE therapy is appealing to clinicians, additional future work is needed in product development and clinical implementation. Such work will require iterative pilot testing and feedback from both patients and providers in the clinical setting. A tool such as the one proposed in the current study could be developed by a technology company or organization (e.g., VA, medical university) and would likely require input from an interdisciplinary team of clinicians, physiologists, software developers, user experience researchers, etc. (Back et al., 2022). Additionally, more research is needed to assess clinicians’ perceptions on the usability and implementation of this kind of technology. For instance, additional work is needed on if clinicians would schedule separate appointments, if clinicians would accompany their patients, how clinicians can bill insurance, and if this adds extra burden to the limited time of clinicians already have to understand the technology system, use it, and then interpret the data to be clinically relevant to patient progress. There is also the question of for which patients do clinicians think this type of technology might be most useful and for how many sessions should a clinician virtually accompany their patient on an IVE. Having clinicians virtually accompany patients during an IVE may be perceived as a safety behavior and therefore hinder patient progress over time. Possible solutions to these potential implementation challenges could be the implementation of an IVE “coach” who virtually accompanies and guides patients, using real-time subjective and physiological data, during IVE exercises while the clinician completes the therapy sessions. Another solution could be insurance coverage and reimbursement for this type of technology. Indeed, the Food and Drug Administration (FDA) Digital Health Center of Excellence (DHCoE) encourages the advancement of healthcare by fostering responsible and high-quality digital health innovations such as the one proposed here.

Finally, additional research is also needed to explore how to best integrate such a device into standard PE and other trauma-focused, exposure-based treatments for PTSD. Clinicians in this study rated the integration of physiological measures into a mobile technology system favorably, and research shows it may be helpful to routinely incorporate physiological measures during imaginal exposures because it is an indicator of treatment outcome (Wangelin & Tuerk, 2015). Thus, developing a mobile technology system that is flexible enough to be used in the office during imaginal exposures as well as during ambulatory IVE exercises holds the possibility of transforming PE practice, patient engagement, clinical outcomes, and retention. It will be imperative for future research to assess clinicians’ perspectives on usability of such a system and complete clinical trials investigating the use of such technology with PE (Saraiya et al., 2022; Back et al., 2022).

Taken together, these findings suggest a mobile technology tool may help boost engagement in IVEs, allowing researchers and clinicians the opportunity to address gaps in extant knowledge about mechanisms of change and engagement between visits. Moreover, clinicians appear open and willing to utilize such a technology, anticipate clinical benefits to its use, and may express comfort with already integrating mobile tools into treatment. The current study highlights various potential features in a technology device that may be worth future researchers developing and testing. Future clinical research could clarify how such mobile tools could be most feasibly and smoothly integrated into treatment (e.g., how this remote clinical time is billed). Future research may also shed light on whether mobile technology may be positively received, feasible, and accessible to bolster other exposure-based treatments beyond PE.