"He grabs two glasses and breaks them," the patient said. "He's screaming and calling me all kinds of things. The next thing I know I'm bleeding. . . . I see all this blood coming out of my neck."
Edna Foa, one of the world's experts on treating PTSD, watched intently with 12 of her staff members at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania.
This meeting, held weekly, was less about the patients than about ensuring that therapists were making the most of the treatment Foa developed: prolonged exposure. It has earned her international acclaim and made her a sought-after speaker as the nation's long involvement in Afghanistan and Iraq has produced a new generation of emotionally wounded soldiers. But prolonged exposure is emotionally demanding for both patients and therapists. Foa, an intense woman who rarely sees patients now herself, takes this supervision meeting very seriously.
She already had chided one therapist for being too skeptical with a difficult patient and confirmed another's suspicions that her patient's real problem was obsessive-compulsive disorder, not PTSD. Now Foa, a fan of positive reinforcement, suggested more praise for the slashing victim.
"You probably could say once, 'You're doing great,' " Foa told Carmen McLean, a relatively new staffer.
Other therapists jumped in to gush about the patient. He had had the strength to tell his story to McLean several times in their first "imaginal" session, during which he tried to reexperience the trauma. The theory is that this repeated exposure would make the attack lose its power to frighten, much as repeated viewing makes a terrifying movie grow dull.
McLean restarted the tape. "He has some gems in processing I want you guys to hear," she said. Processing was next. Foa thinks it's not enough to reactivate a bad memory. You need to change how you think about it.
"I think what I got from it was there was nothing I could have done different," the patient said. "He's the bad person, not me."
"My reaction would be, 'Good for you,' " Foa said.
"I think this guy in five sessions will say goodbye."
In the vanguard, on the go
Promptly at 4 p.m., the meeting disbanded, and Foa rushed to another with Philadelphia officials to discuss teaching her protocols to employees of nine city agencies.
The next week, she and her staff would teach therapists from around the country.
"She's the premier expert in the field," said one of them, Cindy Haines of East Brunswick, N.J. "We studied her at school. She's Edna Foa. She's it, and there's everybody else."
Foa is a rare fusion of scientist, therapist, and teacher. She was among the first women to rise to the top ranks of research in psychology, and she did it, for a while, as a divorced mother raising three children. She was at the forefront of scientifically developing and testing mental-health treatments, and is much respected for honing effective counseling regimens. The Institute of Medicine has deemed exposure the only treatment for PTSD proven to work.
Foa has received awards from the American Psychological Association in recognition of both her scientific and clinical work. She helped shape the definitions of obsessive-compulsive disorder (OCD) and post-traumatic stress disorder in the DSM-IV, the bible of psychological maladies. She has systematically taught her methods to counselors who work with soldiers in Israel as well as to therapists in Veterans Affairs and the Army.
Last year, Time magazine called her one of the 100 most influential people in the world.
Yet her step-by-step, science-tested treatment - in contrast to traditional talk therapies that leave more room for creativity and meandering conversation - remains a tough sell in many mental-health quarters. She is devoting much of her life now to spreading her approach to worry gone wild.
The week after her center's seminar here in October, she flew to Los Angeles to conduct more training, then returned to serve as a trauma expert for lawyers representing people who had been involved in the BP explosion.
In 2009, she was invited to give 28 lectures, many of them in four-day workshops. She was in San Diego and Las Vegas in January; Miami and Minneapolis in February; Zurich and Copenhagen in March; Israel in June; San Juan in September; Jerusalem and Paris in October; Atlanta, San Diego, and New York in November; and Istanbul in December.
This for a woman in her 70s. Friends decades younger say they can't keep up with her. Tales abound of her formidable ability to combine hard work and world travel with dinner parties, the opera, art-house movies, museums, and shopping.
Yet she is neither jumpy nor nervous nor constantly in motion. She is engaged, curious, and focused, in what appears to be a calm, comfortable, stable way. The Edna Foa who pours wine at holidays doesn't seem much different from the Edna Foa who leads a seminar or answers questions during an interview.
She says she's not after fame - although she admits she likes accolades - and friends agree.
"I'm not a fan of going on television and stuff. Most of the time, I send other people," Foa said one day in her West Philadelphia office. She wore one of the signature outfits she finds in Israel - a billowy skirt topped with a black sweater with sleeves that end in balloons of gauzy gold fabric. She sat with a leg tucked in a position that most women her age - any age, really - would find impossible. "It's not my thing."
Richard McNally, a psychology professor at Harvard University, remembers mentioning the Social Sciences Citation Index to Foa in 1991. "What's that?" she asked. The index records how many times papers have been cited by others and is a measure of a professor's influence. Few academics would have to ask what it is.
Foa's work has been cited more than 13,000 times, putting her influence in the top one-tenth of one percent, according to Thomson Reuters, publisher of the index. Other writers have footnoted her landmark 1986 paper with Michael Kozak, "Emotional Processing of Fear: Exposure to Corrective Information," more than 1,000 times.
Foa is not someone who will be famous for a single great idea, said Kozak, who is now at the National Institute of Mental Health. She has spent her career refining concepts that began with others. "You have to look at Edna's career as a cumulation of different works that, taken together, are very important."
War and awakening
Foa was born in what is now Israel when Zionist immigrants like her parents were infused with idealistic, can-do spirit.
"My mother was telling me stories about how at nighttime everybody was dancing on the dunes in Tel Aviv," said Foa, whose accent and syntax still bear a strong imprint of her native Hebrew. Her prominent cheekbones and strong chin give her face an angular look even though she is an ample woman. Toward the end of a long day, her eyes were still lively and sharp.
"It was a pioneer time. Everybody thought they were doing wonderful things."
She remembers a happy childhood in Haifa surrounded by her mother's large family from Poland. Fourteen first cousins would summer together at family farms.
Her father, also from Poland, lost most of his relatives in the Holocaust. He was depressed, but she didn't notice.
When she was 10, the idyll ended. Her brother and two cousins died in the 1948 war. The rural summers stopped. "Our family, like many families in Israel, was in mourning," Foa said.
Four years later, her father died of a heart attack at 50, and Foa learned a lesson about friendship. Her father had been an important, popular union leader. His friends often filled their house.
"When he died, the house got totally empty," Foa recalled. "My mother did not have friends of her own. She didn't have her own life. We were her life."
Foa swore that would not happen to her. "I think that I will always have lots of friends, and they will be mine," she said. "That actually clearly influenced my life. I make clear that wherever I am, I'll have at least five very good friends who I'll see a lot."
Her teenage years did not foretell an academic superstar or a woman who would ease pain. "I got an excellent education when I went to school, but I skipped," she said with a smile. "There are things I skipped completely. I don't know anything about chemistry."
She had a "very intense social life" hanging out with a left-wing youth group. "For me it was wonderful," she said, "because my mother was so depressed, and then I could just live my life and not be burdened by her depression." Only later did she feel guilty about that.
After high school, Foa wanted to join the army, but her mother insisted she go to college. Thus began what Foa described as a serendipitous journey that eventually brought her to PTSD.
She started with an interest in delinquent children, but quickly learned they could be big and intimidating. She switched to psychology and met Uriel Foa, who had moved from Italy to run the psychology department at Bar-Ilan University. He was 20 years older, charming, and worldly. "He opened the world of art and music and antiques, things that I had never heard of," she said. "He took me out of the country for the first time."
They married when she was 24 and then moved for his job at the University of Illinois. "When I was young, he was a wonderful mentor," Foa said. He insisted she get a Ph.D. "just in case."
By the time they moved to Philadelphia in 1971, she had the doctorate. She needed a job and discovered that Joseph Wolpe, a founder of behavior therapy and an anxiety expert, was at Temple University. "If a person invents a whole new therapy," she reasoned, "then he must be bright and interesting."
The first patient he gave her had OCD, and Foa was hooked.
The patient was smart, beautiful, and "contaminated by death." She was not afraid of dying, but of funerals. She feared flower shops because people buy flowers for funerals. If she passed a hearse on the road, she could no longer use that road. By the time Foa met her, almost everything made the patient feel dirty, and she spent hours washing herself.
The patient's husband brought her to Philadelphia to see Wolpe, who delegated much of the work to Foa. "When I met her, she was naked in bed, but she was covered with bedsheets," Foa recalled. "She would not allow anyone to touch her. Her husband would feed her because she did not want to touch the utensils."
Wolpe was a proponent of systematically desensitizing patients to things that frightened them. So Foa got a small stone from a cemetery and tried almost every day for three months to inch it toward the bed. It didn't work. Meanwhile, Foa was reading studies that showed that "flooding," or much more intense exposure, was helping patients, but Wolpe was worried that it would be too much. He told the patient that her only options were brain surgery and flooding. She chose surgery.
That didn't work, either. The patient went back to Foa and tried a form of exposure therapy that was faster and harder than Wolpe's treatment, but less intense than flooding. Right away, Foa asked her to touch stones from a cemetery and flowers. "Within three weeks, we went to funeral homes," Foa said. The patient could take these steps because she had decided to try and realized she'd have to work to get well.
When the treatment was finished, Foa sent the patient home to her husband and gave him instructions to change their life: Stop living in hotels and get a house, buy her a car, and take her out frequently. He didn't do it, and the patient relapsed. "After that, she didn't get better," Foa said.
Foa swears she was not drawn to psychology to combat her own demons. She cured her one irrational fear - heights - by standing at the top of the leaning tower of Pisa for three hours.
Still, something about anxiety felt right to her. She had not clicked as well with patients with schizophrenia or depression. "Anxiety feels like it can happen to me tomorrow. It feels familiar," she said. Depression is also universal, she said, but she prefers the energy of anxious people. "They're excited in a negative way and a positive way," she said. "There's a lot of emotion going on."
Foa set about studying what worked in anxiety therapy and, more novelly, what didn't. She grew increasingly interested in the processes that underlie anxiety disorders - how we experience fear and give it meaning. She founded the Center for the Treatment and Study of Anxiety while at Temple and eventually moved it to Penn.
As her career was taking off, her husband's was winding down. His mercurial temperament and quick temper were wearing on her. After more than 20 years, they divorced. "It was just too difficult, especially as I started to be successful," she said.
They remained close, and she was with him one day three years later when he had terrible back pain. He asked her to take him to an osteopathic hospital where he had gone before for manipulation.
She sat for hours in the waiting room, without much concern. When doctors told her that they had ruled out everything serious, she went home. The next morning she learned he was dead of an aortic aneurysm.
"It was so traumatic . . . the guilt," she said. "Why didn't I have the sense to take him to a better hospital? Why did I listen to them?"
How did Foa handle her own trauma? "I remember asking friends, 'What can I learn from this?' " The answer was that everyone should have a good family doctor. Uriel Foa had hated doctors and didn't have one.
And she talked about it to her new husband, Charles Kahn, "a lot," she said.
She had met the Penn philosophy professor through a mutual friend. Thin and courtly, Kahn spoke five languages and shared many of her cultural interests. The only drawback was his Greek girlfriend in Sweden. "Well, she had to go," Foa said with a laugh.
Her life experiences have shaped Foa into a gracious woman who loves antiques, fine arts, oriental rugs, and the barely tamed garden she has fashioned at her home in Penn Valley. Every piece of her furniture seems to have a story and a foreign origin, like many of her friends. A big cabinet is from France. The distressed dining room table is from San Antonio. Even her two Balinese cats are from Florida.
She does not mince words.
In typical forthright Foa fashion, she said she was "unhappy" with the way the Army had structured its PTSD program, particularly the supervision. "I don't think the Army is doing it well."
She's just as direct with friends.
Barbara Rothbaum, a psychiatry professor at Emory University in Atlanta who worked with Foa on her first paper on PTSD at Penn, laughed about Foa's assessment of Rothbaum's Hebrew after her son's bar mitzvah seven years ago. "After the service, Edna looked at him and said, 'You were perfect. You didn't make a single mistake,' and then she looked at me and said, 'but you did.' "
That, Rothbaum said, "was just Edna telling it like it is. You always know where you stand with her. You always know where she stands. . . . It's just all right there."
The candor, tempered with motherly support, makes Foa a great mentor, former underlings said.
Martin Franklin, an anxiety expert at Penn, remembers taking to her a paper he hoped to publish when he was a very junior professor. He waited as she scrolled through the file. "She stops, and she looks me dead in the eye and said, 'I think you don't understand something. . . . This is not supposed to be a literature review. It's supposed to be a logical argument that sets up a study, and it's not,' " Franklin said, chuckling. Then she added, "Let's take some time right now and fix it." They worked side by side for nine hours.
Friends and colleagues say Foa remains open to new ideas and increasingly focuses on helping others.
"Some people, as they get success, get harder, tougher, more imperious, more impervious," said Suzanne Miller, a psychologist at Fox Chase Cancer Center who is a close friend. "Edna has softened and used success to help others."
How her treatment works
It is natural to run from things we fear, Foa said, but many of us know intuitively that what really robs pathological fear of its power is confrontation. Avoiding what frightens us is exactly the wrong thing to do.
Her interest lies in the relationship between something scary, our reaction to it, and the way we think about it. She was originally intrigued by why people get mired in bad memories but not good ones. She began studying rape to understand "how people process and overcome difficult emotional experiences" before the concept of PTSD had been introduced into the DSM. It was not until 1982 that she began to view the emotional reactions to rape as PTSD. That spurred her interest in developing treatments.
From an evolutionary perspective, negative experiences are especially important because they can help us make smarter decisions - decisions that might ensure survival - in the future, she said. Most of us easily process good experiences, because it's fun to talk and think about them. But talking about traumas is painful, she said, and people don't like to listen to them much, either.
She discussed the interplay of meaning and emotion at her seminar in October.
Suppose a tiger - "a big animal that is known to kill people" - entered the room, she told the therapists. "We are all going to be very excited. We will be looking around to see if we can hide or escape." Heart rates will rise. People will sweat.
That is our response to the "meaning of the tiger: Tigers are dangerous. Tigers can kill."
But let's say you go out for a morning run. Your heart rate will go up. You will sweat. "This is good," you will think. "I'm doing aerobics."
And if you see a tiger in a zoo, you might feel nothing but calm awe. "What a beautiful animal," you'd think.
"The context," Foa told the group, "the meaning, is important."
In pathological anxiety, something goes awry with context. For example, she treated a woman who had been raped at gunpoint by a tall, bald man. Later, the patient became afraid of all tall and bald men. The goal, Foa said, is to learn that guns are indeed dangerous, but that most tall, bald men are OK.
The trick, Foa says, is to activate our fears and then change how we think of them in the same way that we call up a file stored in our computers before we can revise it. You do this by exposing someone to whatever he fears in a nonthreatening way so he can see it's not as bad as he thinks.
If, for example, someone has a phobia of small dogs, his therapist would need to expose him to a nice, small dog. A big dog, which does not activate the fear, would do no good. Nor would a small dog that bites.
"Exposure is bad if it doesn't match the fear structure of the person and if it does not have corrective information," Foa said at the seminar. "With PTSD, you do not want the biting dog."
It may seem that people who have flashbacks and nightmares about traumatic events confront their fears all the time, but, Foa said, many are "super avoiders."
The treatment she developed for them, prolonged exposure, requires them to describe their traumatic memory repeatedly, in present tense with their eyes closed. Then they say what they think about it. During the treatment, they must also visit places that frighten them.
The treatment, Foa said, helps patients correct misconceptions about what is dangerous. They can see the traumatic experience as something that happened in the past and is no longer making everyday events feel dangerous.
Not everybody jumps at the opportunity to try Foa's process, and that's why her current efforts at disseminating her ideas are challenging.
Carolyn Becker, a psychologist at Trinity University in Texas, surveyed therapists in 2004 about how they were treating PTSD. She found that only 17 percent used imaginal exposure. She doubts the numbers have changed much, she said.
About 1,000 counselors in the Department of Veterans Affairs have been trained in Foa's methods since 2008, with an additional 2,000 trained in cognitive processing therapy, which does not include imaginal exposure. But therapists can still choose the method they like best, and some worry that prolonged exposure will be too hard on patients.
"I have to say that the people who've gone through the training love it. They can see what a difference it makes for the veterans they work with," said Antonette Zeiss, deputy chief of mental health services for the VA. The number of VA patients found to have PTSD grew from 205,104 in 2004 to 365,836 in 2009. But, Zeiss added, prolonged exposure "is an emotionally demanding experience. . . . We're not going to tell everybody this is the treatment they will do."
Psychologists said making people relive the darkest moments of their lives can feel cruel. They worry in particular about patients who have suffered multiple traumas. And some therapists find highly structured or "manualized" treatments like Foa's less creative.
"There are a lot of people that just can't tolerate prolonged exposure," said Bruce Wampold, a professor of counseling psychology at the University of Wisconsin who has studied the effectiveness of mental-health treatments. He said too many people dropped out or chose another treatment because exposure was unappealing. "It's a very difficult protocol."
He thinks every treatment for PTSD encourages patients to confront and reconfigure their fears, he said. The VA, he said, would do better to spend money on more therapists rather than on training therapists in specific types of treatment.
Another critic of prolonged exposure, Drew Westen, a psychology professor at Emory, called Foa's work "extremely valuable" and said it could be effective for people exposed to only one trauma. But he said he didn't think it addressed a prime vulnerability factor for PTSD: personality. And he thinks people with other emotional problems or multiple traumas need more help than prolonged exposure.
It is not enough to stop the nightmares, Westen said, if patients still can't form close relationships or hold a job.
Supporters of exposure think the gain is worth the pain.
"The disorder is always worse than the thing you fear," McNally said. "If you think exposure is bad, try suffering with OCD."
A former patient credits Foa with saving her life. She was a virgin when a fellow student she trusted raped her in 1991. She could barely function afterward and left college.
Foa encouraged her to talk about the rape. "It was horrible," the patient said. "It was really horrible, but she explained to me that the goal was to have this one day be a strand of spaghetti in my brain . . . meaning this is just going to be a piece of my life. It's not going to define my life." The patient stuck with it and soon was able to return to school and finish classes.
Now she and her best friend invoke Foa's name whenever they steel themselves to confront a difficult situation. "Are you going to do a Foa?" they ask.
Foa, who does not claim hers is the only effective treatment for PTSD, said that studies showed prolonged exposure also reduced depression, anger, and anxiety, but that she didn't think the treatment had to do everything. "You won't hear criticism that when you have a treatment for cancer that it treats only the cancer, it doesn't treat the depression or the high blood pressure," she said.
She said she understood why therapists might find it more personally rewarding to "sit back on your chair and ask your patients what happened this week or deal with what their fathers and mothers did to them in childhood." But she said therapists should study what really helps.
"Psychologists should really want to learn how to best help people, not how to best have interest in people," she said. "That hasn't happened yet enough."
Criticism or not, Foa said she enjoyed spreading the word and thinks her work is important. She also feels no sense of urgency that her time might be running out.
"If I die tomorrow, I think that what I have achieved is fine," she said. "If I don't die, I don't need to stop."
Contact staff writer Stacey Burling
at 215-854-4944 or firstname.lastname@example.org.
The phone number for the Center for the Treatment and Study of Anxiety at Penn is 215-746-3327. The center is recruiting patients for a study of people with PTSD who smoke and a study of adolescents with PTSD related to sexual abuse or rape.