Effectiveness and tolerability of massed prolonged exposure therapy for PTSD in a CAF Veteran: A case report

Abstract

Posttraumatic stress disorder (PTSD) is associated with significant distress, impairment, and societal cost. Prolonged exposure therapy (PE) is a gold standard psychotherapy that has been validated for military/Veteran populations, has practical and clinical barriers, and has a moderate drop-out rate, in spite of its efficacy. Standard PE (SPE) involves 12-15 weekly sessions, while massed PE (MPE) involves daily sessions, typically offered over a two-week period. This case report examined the effectiveness and tolerability of MPE in a treatment-seeking Veteran. Baseline structured clinical interview and self-report questionnaire data were compared with post-treatment and follow-up data, with the primary outcome measure being the change in PTSD symptom severity on a structured clinical interview. MPE resulted in reduced PTSD and associated symptom severity as measured at the end of treatment and at follow-up. MPE was described as tolerable, despite short-term discomfort associated with the intense format, and beneficial in facilitating efficient and effective clinical change. This case report demonstrated the effectiveness and tolerability of MPE in a treatment-seeking Veteran. It raises attention for clinical innovation in evidence-based practice and encouragement for empirical replication of this finding in a larger, representative sample.

Lay Summary

Posttraumatic stress disorder (PTSD) is a complicated diagnosis that is more common among military personnel and Veterans and causes significant individual, family, and societal impacts. Effective treatments have been developed to address the symptoms of PTSD; however, research has shown that military personnel and Veterans do not respond as well to these treatments as civilians do. The fact that military personnel and Veterans develop PTSD more often than civilians and do not respond as well to proven treatments suggests that there is a need to modify these treatments for this special population. One of the most effective treatments for PTSD in civilian and military/Veteran populations is prolonged exposure (PE) therapy. Standard PE is 12-15 weekly 90-minute therapy sessions with a goal of working through the trauma memory and addressing avoidance of day-to-day trauma reminders through between-session homework. Standard PE is effective, but some patients do not complete treatment and have shared other challenges related to the therapy. Massed PE (MPE) is daily sessions for two weeks and between-session homework. There is a lot of interest in understanding whether MPE would be beneficial with a military/Veteran population, and new research has shown that offering PE in a massed or intensive format is promising in terms of effectiveness, treatment completion, and patient satisfaction. It has been suggested that MPE may prevent the distraction, avoidance, and decreased motivation that can take place between weekly sessions and may increase commitment to treatment through daily sessions. This case report is the first examination of MPE in a Canadian Veteran and provides real-world evidence for the effectiveness and tolerability of MPE. It also acts as a call for future research of MPE in a larger sample of military personnel and Veterans.

Introduction

Posttraumatic stress disorder (PTSD) is a complex and debilitating diagnosis that is more prevalent in military/Veteran populations, and is associated with disability, impairment, and health service use.^1–4 Evidence suggests that military/Veteran populations are less responsive to evidence-based treatment compared to their civilian counterparts.⁵ Therefore, it is imperative to continue to innovate treatments that are effective, tolerable, and cost-effective. Prolonged exposure (PE) therapy is a manualized, trauma-focused cognitive-behavioural therapy⁶ validated for military/Veteran populations,^7–11 with sustained impact at five- and 10-year follow-ups.¹² Standard PE (SPE) involves 12-15 weekly 90-minute therapy sessions focused on engaging with/processing the trauma memory and addressing situational avoidance largely through between-session homework.⁶ In spite of its established efficacy, moderate drop-out rates and other barriers persist.^7,13

Delivering PE in a massed or intensive format (MPE) is a promising alternative to SPE, although research remains in its early stages.^7,8,13,14 MPE involves daily sessions, typically offered over a 2-week period, and associated daily between-session homework.⁸ Interest in empirically examining MPE in military/Veteran populations has increased, and growing evidence from the United States and Australia suggests that MPE is non-inferior to SPE.^7,8,14 Some findings indicate that, despite the short-term discomfort of the intense format, patients prefer and benefit from MPE.¹³ It has been hypothesized that MPE may address the distraction, avoidance, and decreased motivation that can occur between weekly sessions, and may increase commitment to and integration of the treatment via daily participation.^7,13,14

Given the prevalence and burden of PTSD in military/Veteran populations in Canada and the suggestion that evidence-based treatments for PTSD appear less effective in this population, ongoing local innovation within gold-standard psychotherapies is vital. This case report is the first published implementation with a Canadian Veteran, and an extension of the Australian and U.S. innovation of MPE to Canada. To date, there is no published MPE manual, and this report serves as an implementation resource. While a case report has known limitations, it provides real-world evidence of the effectiveness and tolerability of MPE in the unique Canadian military/Veteran mental health context. It also acts as a call for future systematic research of MPE and the integration of MPE into clinical practice in Canada.

Method

Participant

The patient was a 50-year-old male former member of the Canadian Armed Forces (CAF) who served for nearly three decades in multiple peacekeeping and combat deployments and rose through the officer ranks before his military release. Following his release, the Veteran made an objectively successful transition to civilian life as defined by his relatively stable occupation, housing, and family functioning. While the Veteran was medically released because of several physical health conditions, he was assessed at the specialized military/Veteran mental health clinic approximately five years following his release.

A baseline structured clinical interview (Clinician-Administered PTSD Scale for DSM-5; CAPS-5)¹⁵ confirmed a Criterion A trauma experienced during military service and a PTSD diagnosis (involving a critical incident in which he witnessed life threat and serious injury, which was exacerbated by an accumulation of trauma exposure, moral injury, traumatic bereavement, and organizational betrayal). This patient was also diagnosed with major depressive disorder, persistent depressive disorder, and alcohol use disorder (AUD) — rule out. He was maintained on a stable dose of psychotropic medications (i.e., an antidepressant and an alpha blocker to address PTSD-related nightmares) throughout treatment. The Veteran discontinued a previous course of SPE because of frequent work-related travel interruptions to his treatment that impacted the consistency of his sessions. He elected to take leave from work to engage in MPE given his strong motivation to address his PTSD. Informed consent for MPE was obtained. Institutional ethics approval was not obtained, given that MPE was part of the Veteran’s standard clinical care. To mitigate this, the Veteran signed consent to share anonymized details for this case report and was provided with an opportunity to review the manuscript before submission to validate his comfort with the included information.

Procedure

A pre-treatment baseline assessment was completed, including administration of the CAPS-5 and the completion of various self-report questionnaires on an online platform. Self-report questionnaires were completed on a weekly basis during treatment. A follow-up assessment was completed 12 weeks after MPE ended and included re-administration of the CAPS-5 and self-report questionnaires. Given that the Veteran remained in treatment at the clinic to address other psychosocial concerns, six- and 12-month self-report questionnaire data were also available.

Outcome measures

The primary outcome measure was the change in PTSD symptom severity on the CAPS-5 administered before treatment and at 12 weeks following the completion of treatment. Symptoms of PTSD, depression, and anxiety were assessed using the PTSD Checklist (PCL-5),¹⁵ Patient Health Questionnaire (PHQ-9),¹⁶ and Generalized Anxiety Disorder-7 (GAD-7),¹⁶ respectively. Treatment outcome and psychosocial functioning were evaluated by the Outcome Questionnaire-45 (OQ-45).¹⁷

Treatment intervention

MPE consisted of twelve 90-minute manualized therapy sessions delivered rapidly over two weeks and two days via a virtual video platform.^6,14 It should be noted that the treatment was scheduled to consist of eleven 90-minute sessions because of an a priori plan to divide the content of the second session into two sessions; however, an additional session was added because of a slight modification of session nine. This modification was requested by the Veteran, who showed trauma-related photos that he had avoided looking at since the deployment. While this was a deviation from the planned imaginal exposure of his first hot spot, the Veteran narrated the content and context of the photos, facilitating exposure and associated emotions and cognitions. The sessions followed the standard 10-session PE protocol, and the session content is outlined in Table 1. The virtual therapy sessions were digitally recorded using the PE Coach application on the Veteran’s cellphone, and listening to the therapy session was part of the required between-session homework. The Veteran was also required to complete one item from his in vivo exposure hierarchy each day.

Table 1.

MPE session description

Session no.	Content
1	Treatment rationale, trauma interview, diaphragmatic breathing
2	Common reactions to experiencing a trauma (psycho-education)
3	In vivo exposure rationale and development of hierarchy
4	Imaginal exposure rationale, implementation + processing
5	Imaginal exposure + processing
6	Imaginal exposure + processing
7	Imaginal exposure + processing
8	Hot spot #1
9	Hot spot #1 — Modification (Patient requested to share trauma-related photos instead of imaginal exposure of the first hot spot)
10	Hot spot #2
11	Hot spot #3
12	Final session

Quantitative outcome

As indicated in Table 2, the Veterans CAPS-5 score decreased by 30 points, representing both clinically significant and reliable change based on published guidelines.^18–19 Self-report questionnaire scores are also reflected in Table 2, and demonstrated a reliable and clinically significant reduction in the Veteran’s PCL-5 and OQ-45 scores, respectively, when comparing pre-treatment to end-of-treatment scores, and this symptom improvement was maintained at 12-week, six-month, and 12-month follow-ups.^15,17 It is noteworthy that the Veteran’s PCL-5 score increased between the six- and 12-month follow ups, and this was largely attributable to persistent occupational and relationship stress; however, the 12-month score remained clinically significant and improved compared to his pre-treatment score. Table 2 also demonstrates incremental decreases in the Veteran’s PHQ-9 and GAD-7 scores between pre-treatment and 12-month follow-ups, although reliable and clinically significant change metrics have not been established for these measures.

Table 2.

Quantitative data summary

Administration time	CAPS-5	PCL-5	OQ-45	PHQ-9	GAD-7
Pre-treatment	74	63	120	19	16
End of treatment		54	102	17	14
12-week follow-up	42	50	107	15	12
6-month follow-up		29	109	14	7
12-month follow-up		47	104

CAPS-5 = Clinician-Administered PTSD Scale for DSM-5; PCL-5 = PTSD Checklist for DSM-5; OQ-45 = Outcome Questionnaire-45; PHQ-9 = Patient Health Questionnaire-9; GAD-7 = Generalized Anxiety Disorder-7.

SUDs = subjective units of distress; S3 = session 3; F = follow-up.

It is also striking that the Veteran significantly reduced the frequency and volume of alcohol consumption over the course of this treatment and consequently met the criteria for early remission of his diagnosed AUD at the 12-week follow-up.

Qualitative outcome

Challenging situational and cognitive avoidance and facilitating shifts in trauma-related cognitions have been identified as core mechanisms of PE. MPE efficiently and effectively reduced the subjective units of distress (SUDs) that the Veteran used to rate various items on his in vivo exposure hierarchy (see Table 3), which demonstrated his progress in challenging situational avoidance. It is notable that there is no metric for evaluating reliable or clinically significant change in SUDs. Repeated imaginal exposure resulted in significant progress in the Veteran’s cognitive avoidance, as reflected by the following quotes: “I think it will always suck … How could it not?,” “the memory is hard but manageable,” and “the weight of the incident has diminished … I no longer fixate on details.”

Table 3.

In vivo exposure hierarchy sample items

	Item	SUDs (S3)	SUDs (F)
1	Singing the national anthem	90	70
2	Going for a walk alone in the woods	85	60
3	Talking to a friend on the phone	85	40
4	Watching Hyena Road	80	60
5	Hearing unexpected fireworks	80	60
6	Attending a military social event	65	50
7	Being surrounded by crowds at the mall	65	45

SUDs = subjective units of distress; S3 = session 3; F = follow-up.

Over the course of MPE, the Veteran also made significant cognitive shifts. At the start of treatment, he made the following statements: “I didn’t lead myself,” “I am responsible for the outcome,” “I am broken,” “I am an incompetent leader,” “I lost my faith,” and “every day, for years, I am trying not to kill myself.” At the end of treatment, the Veteran showed noteworthy progress in his cognitions about self, others, and the world with the following quotes: “I can reflect upon what we went through. This happened to me not because of me,” “honestly, I did the best I could,” “we played the cards we were dealt … we were dealt shitty cards,” “it was a fucked up war, in a fucked up country, with a fucked up enemy,” “war is incredibly random and unfair,” and “now my thoughts are not consumed by suicide. I am not a risk to myself.”

Based on qualitative feedback on MPE, the Veteran shared that he found this treatment to be effective and to have accelerated his progress. While he noted that MPE was intense and acknowledged experiencing some increased distress because of its format, he shared that there was less opportunity to avoid his feelings, to disengage from his trauma memory, or to be non-compliant with homework. The Veteran mentioned that the support he received during sessions somewhat mitigated the intensity and supported his engagement. Last, the Veteran shared that the daily sessions facilitated a kindling effect on trauma processing and expedited the changes in his trauma-related cognitions.

Discussion

This case report demonstrated the effectiveness and tolerability of MPE in a treatment-seeking CAF Veteran, with quantitative and qualitative data indicating rapid and sustained symptom improvement in PTSD, depression, anxiety, and psychosocial functioning. The patient achieved reliable and clinically significant reductions in clinician- and self-rated PTSD symptom severity within 2 weeks. These findings echo existing literature on MPE’s potential to expedite recovery and highlight the value of “rapid evidence-based therapy which relies on frequent contact and active engagement between therapist and client [and] may serve as a mechanism for keeping clients in treatment long enough to receive the full dose of treatment.”⁷ This aligns with prior research on MPE’s feasibility and tolerability in military/Veteran samples^7,8,13,14 and contributes long-term follow-up data.

This case report is an example of successful implementation of MPE with a strong and sustained treatment response and provides some encouragement for additional empirical research and dissemination of MPE. Although based on a single case, it supports U.S. and Australian findings on MPE’s efficacy and effectiveness and highlights the value of offering intensive treatments that align with the work and life demands of those who need them.⁷ By offering an intensive, condensed approach, MPE may reduce dropout and be especially promising for those unable to commit to months of standard therapy.

While this case report has strength in its long-term follow-up data and demonstration of MPE implementation, it is limited in generalizability given that MPE was delivered to one Veteran by one clinician without a control, and the outcome was favourable. Further investigation is warranted to replicate these positive outcomes in a broader Canadian military/Veteran context, clarify which patient characteristics are best suited to MPE, and bolster the overall evidence for intensive trauma-focused treatments.

To date, there is no published account of the impact that MPE has on clinicians. In this case report, the clinician experienced some expected PE-related fatigue, and this was slightly exacerbated by the intensive format. This was strongly mitigated by the Veteran’s rapid treatment response and engagement, as well as the clinician’s habituation to the details of the Veteran’s trauma memory. Research that includes an evaluation of the impact of MPE on clinicians could lead to the development of practice guidelines that provide recommendation on the frequency, number of, and/or trauma type of MPE cases.

Given that there is no published MPE manual, this case report can also serve as an implementation guide and to encourage dissemination. Widespread dissemination across Canadian military/Veteran mental health clinics and providers will require the development of a structured treatment manual and/or structured training workshops that extend beyond the protocols published in research and case reports.

In conclusion, this is the first published case report of MPE in a Canadian Veteran and suggests that this treatment is effective and tolerable in the Canadian military/Veteran mental health context. This case report contributes to a growing momentum to innovate within the scope of evidence-based treatments for PTSD and should be a catalyst for clinical interest in intensive or massed treatment and a call for future research.

Biography

Maya Roth, PhD, CPsych, is an affiliated researcher with the MacDonald Franklin OSI Research and Innovation Centre, associated with Toronto Metropolitan University and Western University, worked at the St. Joseph’s OSI Clinic as a clinical psychologist from 2009 to 2024, and is a Canadian Institute for Military and Veteran Health Research Fellow. Dr. Roth is an expert in traumatic stress, is a passionate advocate for military/Veteran evidence-based practice and research, and has been engaged in provincial and national knowledge translation. She has published widely and been recognized by numerous provincial and national organizations.

Funding Statement

No funding was received for this article.