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. Author manuscript; available in PMC: 2026 Aug 6.
Published in final edited form as: Cogn Behav Pract. 2026 Jul 30;33(3):463–473. doi: 10.1016/j.cbpra.2025.12.005

Prolonged Exposure and Emotion Regulation Skills Training: A Pilot Study Among Veterans with Military Sexual Trauma-Related PTSD and Difficulties with Emotion Regulation

Amanda K Gilmore 1,2, Caitie Thompson 1,2, Juan Martinez 2, Jessica Prince 2,3, Wendy Muzzy 4, Stephanie Hart 4, Sally Murphy 4, Jonna Vaughn 4, Stephanie Hamski 4, Tristin Chipman 1, Edna Foa 5, Ron Acierno 4,6
PMCID: PMC13441421  NIHMSID: NIHMS2188438  PMID: 42559539

Abstract

Difficulty with emotion regulation is common among veterans with military sexual trauma-related posttraumatic stress disorder (PTSD). Although evidence-based treatments for PTSD are widely available for veterans with military sexual trauma, rate of treatment completion is low, particularly for those with problems of emotion regulation. Blending emotion regulation skills training with an existing evidence-based treatment for PTSD, such as prolonged exposure (PE), may be an innovative strategy for reducing PTSD symptoms, emotion dysregulation, treatment dropout. The current study describes a pilot of a blended PE and emotion regulation skills training treatment, including session-by-session descriptions, and presenting findings from an open pilot study. This pilot study assessed retention and changes in clinical symptoms after a blended PE and emotion regulation skills training treatment among veterans (n=27; 90% women) with military sexual trauma-related PTSD and emotion regulation problems. Rate of treatment completion for the blended PE and emotion regulation skills training treatment was 67%. Moreover, a blended PE and emotion regulation skills training treatment significantly reduced both PTSD symptoms, as well as difficulties with emotion regulation from baseline to post-treatment. This study demonstrated not only feasibility, but also preliminary treatment efficacy, despite the small sample size. Findings suggest that the efficacy of a blended PE and emotion regulation skills training treatment should be evaluated in a larger trial.

Keywords: military sexual trauma, PTSD, emotion regulation, veterans

Military sexual trauma is defined by the Veterans Affairs healthcare system as sexual assault or sexual harassment during military service (Veterans Affairs, 2024). A meta-analysis indicated prevalences of military sexual trauma of about 38.4% for harassment and sexual assault, 52.5% for harassment alone, and 23.6% for sexual assault alone (Wilson, 2018). Exposure to interpersonal violence and combat are associated with increased posttraumatic stress disorder (PTSD) severity among veterans (Kachadourian et al., 2023), but military sexual trauma is even more likely to result in PTSD in comparison to either exposure to civilian sexual trauma (e.g., Holder et al., 2023; Suris et al., 2007) or combat (e.g., Kang et al., 2005; Yaeger et al., 2006). Untreated PTSD can become chronic (Foa et al., 1995; Kornør et al., 2008) and contribute to significant mental and physical health disability and morbidity, which subsequently can diminish the quality of life among veterans (Frayne et al., 1999; Kimerling et al., 2000; Lang et al., 2003; Suris et al., 2008). Thus, to limit emotional and financial costs associated with these negative health sequelae, researchers must identify strategies to optimize effective treatments for PTSD. Dropout from evidence-based PTSD treatment is common, with a systematic review and meta-analysis indicating an average rate of dropout of 24% among military and veteran participants (Edwards-Stewart, 2021). Notably, dropout rates are even more pronounced for cases of military sexual trauma-related PTSD with rates ranging between 40–60% (Acierno et al., 2021; Holder et al., 2019; Maguen et al., 2019). This latter finding may be related to core components of evidence-based PTSD treatment (e.g., Prolonged Exposure), which include emotional processing and vivid review of traumatic events, and require patients to tolerate and regulate their emotions within and between sessions (i.e., during exposure to traumatic memories and when confronting external reminders of the event). There is a consistent association between difficulties in emotion regulation and PTSD symptoms (e.g., Cloitre et al., 2005; Meuleman et al., 2024); and veterans who have experienced military sexual trauma report more difficulties in emotion regulation than those who have not experienced military sexual trauma (e.g., Luterek et al., 2011). Further, veterans with military sexual trauma-related PTSD are more likely to drop out of PE if they have increased difficulties with emotion regulation (Gilmore et al., 2020). Importantly, PTSD treatment outcomes do not differ based on military sexual trauma status if evidence-based treatment is completed (Tiet et al., 2015). Thus, it is essential to investigate strategies to retain veterans with military sexual trauma-related PTSD in evidence-based treatment.

Prolonged Exposure and Emotional Processing Theory

PE is grounded in emotional processing theory (Foa & Kozak, 1986; Foa et al., 2019), which notes that chronic PTSD is due to the use of more ineffective emotion regulation strategies, such as emotional avoidance, suppression, and rumination (Moore et al., 2008; Pugach et al., 2020). PE and other trauma-focused treatments require emotional engagement to activate and correct maladaptive fear structure confrontation of traumatic memories and stimuli. Individuals with emotion regulation difficulties show higher levels of avoidance behaviors during treatment, which may negatively impact treatment engagement and completion (Gilmore et al., 2020, Jaycox et al., 1998). Prior research recommended that trauma-focused treatment approaches emphasize adaptive regulation strategies to address dissociative and dysregulation symptoms in individuals with PTSD (Powers et al., 2015). Consistent with emotional processing theory and cognitive models of PTSD, emotion dysregulation plays a direct role in maintaining PTSD symptoms (Ehlers & Clark, 2000, Foa & Kozak, 1986). For example, emotional avoidance prevents activation of the trauma memory, which can block inhibitory and corrective learning, thus maintaining maladaptive fear structures and learning. Research indicates that emotion dysregulation can lead to premature avoidance or dissociation during exposure exercises, preventing full activation and modification of the trauma memory structure (Foa & Kozak, 1986). Similarly, avoidance of trauma-related cues provides short-term relief from distress; however, over time, this negative reinforcement of anxiety and fear-based avoidance perpetuates symptoms (Rauch & Foa, 2006). Longitudinal studies show that emotion regulation difficulties can worsen PTSD symptoms, which can in turn exacerbate emotion dysregulation (Bardeen et al., 2013). Therefore, incorporating evidence-based strategies to enhance emotion regulation abilities within trauma-focused treatment may increase distress tolerance, thereby facilitating engagement with trauma memories and related cues that is essential for reducing PTSD symptoms.

Emotion Regulation and PTSD Treatment

Emotion regulation is broadly defined as the set of self-regulatory functions related to emotional self-awareness and understanding, acceptance and tolerance of negative emotion, use of goal-directed behavior and management of impulsive behavior, and consideration of social context in the selection of emotion regulation strategies (Gratz et al., 2004). There is a consistent association between difficulties in emotion regulation and PTSD symptoms in general (Cloitre et al., 2005; Ehring & Quack, 2010; Tull et al., 2007) and among veterans with military sexual trauma specifically (Luterek et al., 2011; Turchik & Wilson, 2010). Veterans who have experienced military sexual trauma report more difficulties in emotion regulation than those who have not experienced military sexual trauma (Luterek et al., 2011; Allard et al., 2011). Therefore, enhancing emotion regulation skills through techniques such as those found in evidence-based programs (e.g., Dialectical Behavior Therapy [Linehan et al., 2015], Skills Training in Affective and Interpersonal Regulation [Cloitre et al., 2020], and Trauma-Focused Cognitive Behavioral Therapy [Cohen et al., 2017]), may provide substantial benefits, as adaptive emotion regulation mechanism can serve as protective factors mitigating PTSD symptoms (Ouhmad et al., 2023). A study examining predictors of treatment dropout among 136 military sexual trauma veterans with PTSD found that emotion regulation was associated with dropout from PE (Gilmore et al., 2020). Participants in that study were provided PE via in-person delivery or telemedicine delivery. Delivery modality was not associated with treatment dropout, but more difficulties with emotion regulation increased the odds of dropping out of treatment. On the other hand, greater emotion regulation abilities indicated a better response to PTSD treatment and greater reductions in PTSD symptoms (Cloitre et al., 2002; Theraud et al., 2024; Wisco et al., 2013). A study among veterans indicated that 45% of patients who did not complete a full course of PTSD treatment attributed dropout to emotional distress or avoidance (Eftekhar et al., 2019). Other studies have identified a similar pattern in which veterans cite difficulty tolerating distress, particularly when retelling details of the trauma, as a key reason for discontinuing treatment (Wells et al, 2023). Therefore, implementing targeted programs can be potentially helpful in reducing treatment dropout among veterans with military sexual trauma-related PTSD and difficulties with emotion regulation.

There is a current gap in the literature because although treatments have targeted emotion regulation deficits prior to trauma-focused treatment (Cloitre et al., 2002), no blended treatments exist to concurrently treat PTSD and emotion regulation for veterans with military sexual trauma-related PTSD who do not require a full course of intensive Dialectical Behavior Therapy treatment (e.g., Harned, Korslund, Linehan, 2014). To address this gap, we pilot-tested a blended treatment specifically designed for veterans with military sexual trauma-related PTSD experiencing emotion regulation difficulties. While there are several evidence-based treatments to consider when selecting a treatment to offer to veterans with military sexual trauma-related PTSD and emotion regulation difficulties, we selected to blend emotion regulation skills training from Dialectical Behavior Therapy and Prolonged Exposure (PE). PE is a gold-standard treatment for PTSD that is endorsed by the Veterans Affairs/Department of Defense Clinical Practice Guidelines (2023) as having “Strong” evidence for PTSD treatment, and at the time of the last systematic review four years ago, there were 17 trials testing the efficacy of Dialectical Behavior Therapy skills as a stand-alone treatment with diverse populations (Valentine et al., 2015), supporting the inclusion. Further, adding emotion regulation skills training represents a “light-touch” addition that can be easily implemented within Veterans Affairs clinics with little required additional training. However, individuals who experience difficulties in emotion regulation may be at risk for treatment drop out due to a perceived inability to tolerate the distress and negative emotions that arise from the initial application of these exposure emotional processing procedures (Brown et al., 2022; Hundt et al., 2018; Wells et al., 2023). This effect appears to be amplified for veterans with a history of military sexual trauma. Specifically, 40–60% of veterans with military sexual trauma dropout prematurely from evidence-based PTSD treatment (Acierno et al., 2021; Holder et al., 2019; Maguen et al., 2019). As mentioned, Gilmore and colleagues (2020) found that veterans experiencing military sexual trauma-related PTSD who have emotion regulation deficits are at significantly increased risk of premature dropout from evidence-based treatment. Therefore, it is imperative to research new strategies to increase treatment retention in this population.

Current Study

We blended an efficient, evidence-based strategy to increase emotion regulation skills (derived from components of Dialectical Behavior Therapy Skills Training; Linehan et al., 2015) and an evidence-based treatment for PTSD (PE; Foa et al., 2019). The blended treatment included 10 to 12 90-minute sessions. Of note, we did not delay starting PE with participants; rather, participants received PE in conjunction with emotion regulation skills training that was matched to the PE session topic. Participants included veterans with military sexual trauma-related PTSD with difficulties in emotion regulation. As the primary purpose of the current study was to improve treatment retention, the primary outcome was treatment completion. Secondary outcomes examined included changes in PTSD symptoms from pre- to post-treatment and changes in difficulties with emotion regulation from pre- to post-treatment. Further, we describe the blending of these two evidence-based treatments.

Methods

Participants

A total of 27 women and men veterans enrolled in the study from a Veterans Affairs clinic in the Southeast United States. Eligibility to participate included endorsement of an military sexual trauma-related index event, diagnosis of PTSD related to military sexual trauma assigned on the basis of the Clinician Administered PTSD Scale-5 (CAPS-5; Weathers et al., 2013), and difficulties with emotion regulation as identified by the Difficulties with Emotion Regulation Scale (DERS; Gratz & Roemer, 2004; although there is no clinical cutoff for the DERS, a total score of 99 is indicative of one standard deviation above average difficulties with emotion regulation).

Procedures

Participants completed an eligibility screener to determine eligibility with research staff. Eligible participants completed a baseline survey and all participants were assigned to receive the blended intervention. Participants completed a survey at post-treatment. If participants did not complete treatment, they were still asked to complete post-treatment survey. This study is a registered clinical trial (NCT04792775).

Intervention

We blended an evidence-based strategy to increase emotion regulation skills (Dialectical Behavior Therapy Skills Training; Linehan et al., 2015) and an evidence-based treatment for PTSD (PE; Foa et al.,2019). The blended treatment included 10–12 90-minute sessions.. As noted, we did not sequence treatments. Rather, participants received a blended PE and emotion regulation skills training treatment that was matched to the PE session topic. See Table 1 for description of sessions.

Table 1.

Brief Description of Blended PE and ER Skills Training Session Components

Session PE Session Component ER Session Component
1 PE session 1a (Psychoeducation on PTSD) Emotional regulation skills: Understanding and Naming Emotions
2 PE Session 1b (psychoeducation on PE) Emotion Regulation Skills: Reducing Vulnerability to Emotion Dysregulation
3 PE Session 2a (begin in vivo hierarchy) Emotion Regulation Skills: Experiencing and Changing Emotions
4 PE Session 2b (complete in vivo hierarchy) Brief Emotion Regulation Skills Review
5 PE Session 3
6 PE Session 4 Brief Emotion Regulation Skills Review
7 PE Session 5
8 PE Session 6 Brief Emotion Regulation Skills Review
9 PE Session 7
10 PE Session 8 Brief Emotion Regulation Skills Review
11 PE Session 9
12 PE Session 10–12 Brief Emotion Regulation Skills Review
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Dialectical Behavior Therapy emotion regulation skills training provides skills to understand, name, experience and tolerate emotions, as well as skills to change negative emotional responses and to reduce vulnerability to emotion dysregulation (Linehan et al., 2015). The standard Dialectical Behavior Therapy emotion regulation skills training is a 6–8 week group training that includes 2.5 hours of skills training and homework review. However, the standard Dialectical Behavior Therapy emotion regulation skills training was made for difficult-to-treat, highly suicidal patients. Therefore, the modified treatment includes an adapted 3-session individual emotion regulation skills training intervention implemented concurrently with PE, and consists of initial teaching/instruction and brief skills review for the remainder of PE treatment. Skill trainings were selected and timed to not only focus on key emotion regulation skills, but also for synergy with skills being taught in PE during each session. While a brief description is included in Table 1, additional detail is provided below for each emotion regulation skills training session blended with PE.

Understanding and Naming Emotions.

Session 1a of PE focuses on psychoeducation of avoidance and PTSD symptoms and explores the rationale for treatment. Consistent with the goal of psychoeducation in session one, the Dialectical Behavior Therapy skill “Understanding Emotions” was included to provide psychoeducation on emotions. This session reviews the purpose of emotions, how to describe emotions (common words, prompting events, interpretations, biological changes and experiences, expressions and aftereffects). This session includes handouts 3, 5, and 6 of emotion regulation skills in Dialectical Behavior Therapy. Worksheet 4 for homework ensure that participants get practice and feedback on understanding and naming emotions.

Reducing Vulnerability to Emotion Dysregulation.

Session 1b of PE focuses on psychoeducation of PE. Consistent with the content provided in that session, the emotion regulation training selected was to reducing vulnerability to emotion dysregulation to help clients better engage in PE. This includes the ABC PLEASE Skill (handout 14 in emotion regulation skills of Dialectical Behavior Therapy). A (accumulating positive emotions), B (build mastery), C (cope ahead of time with emotional situations), and PLEASE (taking care of your mind by taking care of your body: treat physical illness, balance eating, avoid mood-altering substances, balance sleep, and get exercise). Because in vivo hierarchy development in itself may cause emotional distress for individuals who have difficulties regulating their emotions, the ABC PLEASE skills is used to provide participants with emotion regulation skills prior to starting in vivo hierarchy building so that they are able to prepare for and understand how to begin regulating their emotions for the in vivo exposures in PE. Worksheets 13 and 14 for homework ensure that participants get practice and feedback on ABC PLEASE skills.

Experiencing and Changing Emotions.

Session 2a of PE is when clients begin their in vivo hierarchy. To assist individuals who have difficulties with emotion regulation, it is essential to provide supplemental skills to effectively experience emotions during in vivo and imaginal exposures. Skills to experience emotions supplement the skills taught in in vivo exposures. This includes mindfulness of current emotions which is handout 22 of emotion regulation skills in Dialectical Behavior Therapy. Further, opposite action, a skill that teaches individuals to engage in the opposite of the action urge for the emotion, will be taught (handouts 10–11 of emotion regulation skills in Dialectical Behavior Therapy). In vivo exposures in practice are opposite action of fear, therefore, teaching the skill of opposite action solidifies this teaching within PE Session 2a to ensure that participants understand the value of the emotion of fear as well as other emotions that they have difficulty regulating. Worksheets 7 and 15 for homework ensure that participants get practice and feedback on mindfulness of current emotions and opposite action.

Brief Emotion Regulation Skills Review.

Participants complete their choice of emotion regulation skills handouts for homework to review in session (worksheet 4, 7, 13, 14, or 15).

Therapist Training

The study therapists were master's level licensed providers who were already trained in PE. Therapists received a two-hour training via videoconferencing to equip them with the knowledge and skills to disseminate the intervention protocol. During the training, they were provided in-depth instruction on emotion regulation strategies, PTSD symptoms, and the principles and techniques of Dialectical Behavioral Therapy skills training. As part of the training, therapists were introduced to the study manual, which outlined the intervention protocol, session structure, and therapeutic techniques to be employed. They were provided with training videos for how to effectively implement the manual's content, ensuring consistency and fidelity in their delivery of the study's therapeutic framework. This comprehensive training ensured the therapists were well-prepared to deliver skilled and consistent treatment throughout the study.

Integrating into Clinical Practice

A validated self-report measure, such as the Difficulties in Emotion Regulation Scale (DERS), is recommended to evaluate emotion regulation abilities prior to treatment. Although there is no clinical cutoff for the DERS, a total score of 99 is indicative of one standard deviation above average difficulties with emotion regulation, and was used as an eligibility criteria for the current study. Once a patient has been identified as having difficulties with emotion regulation in addition to meeting criteria for PTSD, treatment would begin with a standard PE session, and the incorporation of the Dialectical Behavior Therapy skill “Understanding Emotions.” For example, in addition to providing psychoeducation on avoidance and the rationale for the components of PE (i.e., in vivo and imaginal exposures), the clinician would also provide psychoeducation on the function of emotions and present a Dialectical Behavior Therapy worksheet for building emotion awareness. By doing so, the clinician would present a model for describing emotions and then prompt the patient to fill out the worksheet during the session on a recent situation related to the traumatic event. For homework, the patient would be asked to complete the standard PE assignments for session one and complete the “Observing and Describing Emotions” worksheet from Dialectical Behavior Therapy on at least one emotion related to the index trauma. Clinicians would continue through the procedures described in the “Intervention“ section above for each session. In addition to monitoring PTSD symptoms, we evaluated changes in emotion regulation throughout treatment, consistent with recommendations.

Measures

Posttraumatic stress symptoms were assessed using the Clinician Administered PTSD Scale (CAPS-5; Weathers et al., 2013). The CAPS-5 is a structured interview designed to evaluate both the diagnostic status and severity of symptoms of posttraumatic stress disorder (PTSD). CAPS-5 has been validated and demonstrates strong internal consistency (α = .88), interrater reliability (κ = .78), and test-retest reliability (κ = .83; Weathers, Keane, & Davidson, 2001; Weathers et al., 2018). Comparative studies reveal that CAPS-5 has high convergent validity with other PTSD assessment tools such as the PTSD Checklist for DSM-5 (PCL-5) and good discriminant validity (Lee et al., 2022; Resick et al., 2023).

Difficulties with emotion regulation were assessed using the Difficulties with Emotion Regulation Scale (DERS; Gratz & Roemer, 2004). The DERS is a self-report questionnaire designed to assess an individual's ability to manage emotions across different domains, including emotional awareness, acceptance, impulse control during negative emotions, and access to effective emotion regulation strategies (Gratz & Roemer, 2004). Higher scores on the questionnaire indicate greater challenges in regulating emotional states in different situations (Gratz & Roemer, 2004). The DERS demonstrates good test-retest reliability (ρI = .88, p < .01), high internal consistency (α = .93) as well as adequate construct and predictive validity (Gratz & Roemer, 2004; Gratz & Tull, 2010).

Results

See Table 2 for full descriptive statistics. Treatment completion rate was 67% (18 of 27 participants). Among those who dropped out of treatment, participants completed between 1 and 8 sessions, with 3.56 sessions completed on average (SD=2.01). Among those who completed post-treatment assessments (n=20), the blended PE and emotion regulation skills training treatment resulted in significant reductions in PTSD symptoms as evidenced by reductions on the CAPS score from baseline (M=39.70; SD=6.77) to post-treatment (M=31.60; SD=13.03), t(14)=−3.16, p=.005, demonstrating a medium effect size (Cohen’s d=.71). Most importantly in terms of mechanism considerations, the blended PE and emotion regulation skills training treatment resulted in significant reductions in difficulties with emotion regulation from baseline (M=118.26; SD=12.90) to post-treatment (M=102.00; SD=16.63), t(13)=−4.72, p<.001, demonstrating a large effect size (Cohen’s d=1.08). No adverse events occurred during the pilot study.

Table 2.

Participant Descriptives

Variable N/Mean % / SD
Demographics
Gender
 Woman 25 93
 Man 2 7
Age 27 46.03
Race and Ethnicity
 White 9 33
 Black/African American 15 56
 Asian 0 0
 Pacific Islander or Native Hawaiian 0 0
 More than one race or Other 3 11
 Latine 2 7
Branch
 Air Force 7 26
 Army 15 56
 Navy 3 11
 Marine Corps 2 7
CAPS Score
 Baseline 39.70 6.77
 Post Treatment 31.60 13.03
DERS Score
 Baseline 118.26 12.90
 Post-Treatment 102.00 16.63
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Case Example

All identifiable information was altered to protect privacy. Eva (pseudonym) is a White, straight, woman Veteran in her late 40's who served in the Army. She presented with a history of military sexual trauma, posttraumatic stress disorder (CAPS = 41), and difficulties in emotion regulation (DERS=111). Eva also reported a history of intimate partner violence. She was seeking treatment because she was having relationship issues with her husband and hadn't dealt with the previous traumas.

Session 1a. Per the manual, Eva received the PE psychoeducation of avoidance and PTSD symptoms as well as the rationale for treatment. She was aware of her avoidance but lacked insight into the ways this avoidance impacted her relationships, especially with her husband. She went through great lengths to minimize conflict in her relationships, and although she recognized the turmoil this caused sometimes, she was unable to stop these behaviors. After completing the PE portion of the session, Eva received psychoeducation on understanding emotions including how to describe emotions using the script provided in the DBT Skills manual and reviewed handouts 3, 5, and 6 using that script. Eva reported having skills in naming emotions, but had challenges in experiencing emotions. She specifically reported challenges with jealousy, sadness, and anger. Per handout 3, Eva was asked what emotions do for her and used the example of avoidance to tie to the PE content presented earlier. Per handout 5, the therapist reviewed the model for describing emotions and discussed biological changes to increase awareness of fear, anger, jealousy, and sadness emotions. Per handout 6, Eva was taught words to describe emotions, prompting events for emotions, expressions of emotions, and after effects of emotions. Specifically, fear was reviewed to tie to PE psychoeducation as well as anger, jealousy, and sadness, which she avoided due to difficulties experiencing and regulating these emotions.

Session 1b. After completing the PE portion of the session, which was continuing psychoeducation on avoidance, the therapist reviewed the homework assigned in Session 1a. Eva connected her feelings of insecurity to invalidation of emotions that repeatedly occurred in her previous marriage. During the discussion, she identified posttraumatic stress symptoms and avoidances that stemmed from previous traumas and gained a better understanding of how these symptoms were impacting her current functioning in relationships. She reported feeling emotions intensely (e.g., feeling rage when insecure) and indicated that she had practiced naming emotions in the past week. For example, if her husband came home late from work, she would experience intense emotions of jealousy and anger and then ignore him to avoid conflict. The homework helped her observe her emotions and understand the biological expression of emotions without judgment and through a lens of trauma. This skill was beneficial in reducing negative thoughts of self that often followed these events with her husband and connected them to previous traumas. The therapist then taught the ABC PLEASE Skill to reduce vulnerability to emotion dysregulation. Eva indicated that she would benefit from taking better care of herself, including exercising and eating well because she was aware that exercise and healthy eating helped her mood. Therefore, the therapist focused on the “PLEASE” portion while also teaching coping ahead as part of the preparation for PE. The PLEASE skills helped Eva become more self-focused as she moved away from the constant focus on her husband’s behaviors. She found coping ahead for stressful events easier when she took care of her own needs. She was gaining a better understanding of how the need to control was a fear response to trauma.

Session 2a. Per the PE manual, the therapist assisted Eva in developing an in vivo hierarchy. Eva focused on being able to trust people more when starting to brainstorm what would be on her in vivo hierarchy. The therapist also reviewed the common reactions to trauma with Eva. Mindfulness of current emotions was taught to Eva and was tied to the PE treatment to encourage Eva to stay with in vivo exposures long enough for the subjective units of distress to decrease by half. Eva was encouraged to attend to body sensations, to not judge the emotions that come up during exposures, and to accept the emotion as part of the experience. Previously, she would get caught up in the emotion very quickly and unable to use her wise mind or to check the facts of the situation. Finally, opposite action of fear was taught and tied to in vivo exposures as in vivo exposures are essentially opposite action to fear. Eva was encouraged to use the opposite action steps, which include identifying the opposite action of fear, which is to approach and not avoid the fear cue if it is indeed safe. The steps are to name the emotion, check the facts and remind herself that she is safe in this moment if that is true, identify and describe the emotion (fear) action urges, ask wise mind if acting on this emotion (fear) is or isn't effective, and then to act opposite all the way by stepping toward the fear to reduce fear. This taught Eva the importance of in vivo exposures in a different way and allowed Eva to notice the biological expression of emotions (fear) while re-learning that a trauma cue may no longer indicate danger. She would have negative thoughts connected to her previous trauma that would spur emotions of fear, jealousy, sadness, and anger that didn't fit the current situation. Therefore, learning opposite action was incredibly helpful as it allowed her to be mindful of her emotions and how they led to unhelpful behaviors.

Sessions 3 and beyond. Every other session (2b, 4, 6, 8, 10, and 12 if there was a 12th session, see Table 1) Eva chose a homework assignment from the emotion regulation skills training. Most of her assignments focused on practicing the PLEASE skill, ABC skill, and opposite action throughout the treatment. She improved in regulating her emotions and indicated that by the end of the treatment, she was using the skills even outside of her current relationship. For example, she indicated that she was better able to regulate her emotions in situations that previously would have made her very angry. She was now able to look at situations objectively and could understand when she was being validated or not and how that would impact emotions. She even noticed this change when interacting with strangers.

Eva graduated from therapy with a CAPS score of 34 and a DERS score of 85, both indicating reductions in symptoms. She was able to cope ahead in situations that she knew was going to be stressful and was able to handle that stress in a positive way. Important to Eva, her relationship with her husband improved. She no longer avoided conflict as she had done when entering therapy. Overall, Eva reported that her quality of life improved from the treatment and she was practicing daily self-care.

Discussion

The current study provides initial evidence for the feasibility of a blended PE and emotion regulation skills training treatment with veterans who have military sexual trauma-related PTSD and difficulties with emotion regulation, a sample that has historically evinced difficulty completing evidence-based treatments for PTSD. Rates of treatment retention in the blended PE and emotion regulation skills training therapy were 67% in our pilot findings. It's important to note that the blended PE and emotion regulation skills training therapy did not lengthen the session or the number of sessions, which is an important point when focusing on treatment retention and implementation feasibility. There were medium effect size reductions in both PTSD symptoms and difficulties with emotion regulation from baseline to post-intervention, suggesting preliminary efficacy of a blended PE and emotion regulation skills training therapy. Given that PE is already an evidence-based treatment with a large base of efficacy and effectiveness (e.g., Foa et al., 2005; McLean et al., 2022), it is not surprising that if we are able to keep participants in treatment, they are likely to improve. The “light touch” of blending PE and emotion regulation skills training, as opposed to developing an entirely new treatment for individuals with emotion regulation difficulties and PTSD, or requiring two entire evidence based treatments (DBT, then PE) in sequence has a potentially large public health impact. PE is already widely implemented within large healthcare systems like Veterans Affairs clinics and the Department of Defense, and has an existing dissemination and implementation infrastructure to train new therapists. Therefore, this “light touch” addition of adding emotion regulation skills training would require minimal additional new training to therapists while potentially having a large impact on reducing PTSD symptoms among individuals with PTSD and emotion regulation difficulties.

While the findings are promising, there are limitations to the current study. First, participants were recruited through Veterans Affairs clinics, so it is not representative of veterans who receive treatment outside of Veterans Affairs locations. Second, this was a pilot study, so it was not fully powered to detect changes in symptoms and did not include a control condition. Therefore, no direct comparison can be made to standard PE. Future research should include a fully powered trial comparing PE with and without emotion regulation skills training for veterans with military sexual trauma-related PTSD and difficulties with emotion regulation. Third, while the current study used a score that was indicative of one standard deviation above the published average (Gratz & Roemer, 2004) as the inclusion criteria, there is no established cutoff for clinical levels of emotion regulation difficulties. Fourth, no data on satisfaction of the treatment was collected so we cannot report on whether the participants were satisfied with the treatment. Fifth, PE can reduce difficulties with emotion regulation skills (Lopez et al., 2022). However, even with reductions in difficulties with emotion regulation skills, rates of treatment dropout remained high, suggesting that targeting emotion regulation skills in treatment may uniquely help with treatment retention even more so than the potential effects of reductions in difficulties with emotion regulation skills after completing the full course of PE. Finally, while our sample was diverse in terms of race and ethnicity, with 70% identifying as a racial or ethnic minority, future research should ensure that participants with gender diversity and sexual orientation diversity are included.

While the current study focused on PE specifically, it's important to note that there are several evidence-based treatments for PTSD that could be accessed by veterans with military sexual trauma-related PTSD. While dropout rates for veterans with military sexual trauma-related PTSD in evidence-based treatments range from 40%−60% (Acierno et al., 2021; Holder et al., 2019; Maguen et al., 2019) and are within that range irrespective of the treatment (e.g., Cognitive Processing Therapy and PE are within that range), it's likely that different treatment augmentations would be required to address treatment dropout in different therapies given that they target different mechanisms of change and use different theoretical perspectives. For example, for PE research has found that difficulties with emotion regulation are associated with dropout (Gilmore et al., 2020), while in Cognitive Processing Therapy it has been found that posttraumatic cognitions are associated with treatment dropout among veterans with military sexual trauma-related PTSD (Holder et al., 2019). Other evidence-based treatments, like Written Exposure Therapy could be considered as well, but to our knowledge there have been no established rates of dropout or treatment completion among veterans with military sexual trauma specifically. Further, it is possible that different treatment delivery methods (e.g., massed/intensive/accelerated treatment formats) of PE could increase treatment retention in itself. However, this may not be practical for all veterans with military sexual trauma-related PTSD to attend; therefore, this approach may be an alternative to consider for veterans that cannot attend those intensive treatment models. Nonetheless, this may be important for future research to consider. Overall, the findings from this pilot study are promising and suggest that blending PE and emotion regulation skills training is both feasible and potentially useful in reducing both PTSD symptoms and difficulties with emotion regulation among veterans with military sexual trauma-related PTSD and emotion regulation difficulties. While more research is needed using a fully powered large randomized controlled trial, the current work suggests that this light touch addition of emotion regulation skills training to PE has the potential to have a large public health impact with little costs.

Highlights.

  • Military sexual trauma (MST) can result in posttraumatic stress disorder (PTSD)

  • MST-related PTSD is associated with emotion regulation (ER) difficulties

  • We pilot tested a blended ER skills training with Prolonged Exposure (PE)

  • We found reductions in PTSD symptoms and ER difficulties

  • Blending ER skills training and PTSD treatment may be a useful approach

Acknowledgements:

Research reported in this publication was supported by the Office Of The Director of the National Institutes of Health under Award Number T32AA031818. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

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