Healing found in having patients relive their pain over and over

Dr. Edna Foa, in her office at the Center for the Treatment and Study of Anxiety at Penn, developed the therapy that requires patients to relive a horrific event over and over to lessen its power.
Dr. Edna Foa, in her office at the Center for the Treatment and Study of Anxiety at Penn, developed the therapy that requires patients to relive a horrific event over and over to lessen its power. (VIVIANA PERNOT / Staff)
Posted: July 07, 2014

Tyhira Stovall closed her eyes. Yawned. Swiveled back and forth in her chair. Played with the edges of her jacket. Sighed.

"Ok" she said, taking a breath of courage. "Ok."

But no words came. The thoughts, though, did. Poison whispers drifting out of shadows, through the cracks in the closed doors inside her head. She covered her face with her hands. Turned her head to the wall.

"Oh God," she said, and began to sob.

She was 17. It had been less than a year since her boyfriend had set her up, handing her off to friends who stripped her, forced her to dance and raped her.

Tyhira had dropped out of school. She had trouble sleeping. Fearful that someone dangerous would be lurking behind her, she could not sit with her back to the door. And she could not bear to have anyone touch her. Even her grandmother, gently brushing her arm would send the girl into a panicked rage.

Finally, the psychic pain became so intolerable, she thought about killing herself.

A week in the hospital and months of regular counseling had barely put a stitch into the gaping wound.

Which is how, and why, in February 2008, Tyhira found herself in this chair at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, midway through an intensive 14-week treatment known as prolonged exposure therapy.

The therapeutic technique, developed and refined by Edna Foa, a renowned post traumatic stress disorder expert at Penn, had been used for decades to treat adults. In her native Israel, Foa had adapted it for children and adolescents, some of whom had been sexually abused, and others who suffered PTSD from the effects of terrorist bombings.

In 2006, she trained three counselors in the technique at the Philadelphia non-profit, Women Organized Against Rape, and designed a study to measure its effectiveness compared to regular counseling methods in the treatment of sexually abused teenagers.

Tyhira's dramatic recovery would become part of the findings, which were published late last year in the Journal of the American Medical Association.

The experience of 61 sexually abused teenage girls, showed that Foa's methods were two to three times more effective than standard counseling, not only soothing the troubled souls of those with PTSD, but eliminating their symptoms completely.

Furthermore, Foa found, the counselors who had master's degrees but no prior experience in prolonged exposure therapy, became perfectly competent in the technique after a few days of specialized training and ongoing supervision.

At the end of their treatment, 83 percent of the girls who received prolonged exposure no longer met the criteria for PTSD, compared to 54 percent of those who received standard therapy. In follow-up studies one year later, those numbers held steady.

Left to fester, memories of sexual abuse, like other forms of trauma, can infect the survivor's entire personality. Rather than gingerly exploring the edges and gradually deal with the source of the injury, prolonged therapy works by lancing the problem at its throbbing core.

In her work with teenagers, Foa said, she had to adjust her methods to fit their developmental stage.

"At 12 or 13, you don't expect them to sit for 90 minutes in a therapeutic session," she said. Older teens and adults are asked to close their eyes and reimagine the traumatic experience. For some younger adolescents, Foa said, "that would be difficult."

Instead, she will ask them to draw pictures or write down their thoughts.

Having proven that the therapy works in all age groups, Foa said, the challenge now is to train more therapists to use it.

"We know it can be done. We know the therapy works. We know that therapists in the community can do it as well as experts and get as good results. But how do we incorporate it into everyday practice? That," she said, "is an uphill battle."

Fears that the treatment will worsen or prolong PTSD symptoms have kept many mental health professionals from trying it.

Without disputing the effectiveness of prolonged exposure therapy in certain cases, several experts said that the technique is not right for everyone.

"If you're building a house and you need a hammer, not everything is a nail," said Marjorie Levitt, associate professor in counseling psychology at Temple University.

Some therapists, as well as their patients, do not have the kind of personality that allows them to confront such damaging thoughts head on, Levitt said.

But especially in the early stages of training, especially, Levitt said, few if any of her students would be ready to take on that kind of challenge.

Nevertheless, she added, "I have tremendous respect for its efficacy in a lot of situations...If I had a person say, 'I've been raped, I have PTSD and I can't sleep,' I'd say, 'Call Edna.'"

At Women Organized Against Rape, which partnered with Foa's group in the study, all therapists now receive training in prolonged exposure therapy, said Carole Johnson, the executive director.

Both the rape victim and counselor, however, must be willing and able to follow through, Johnson said.

As part of the therapy, patients must do homework. Tyhira had to practice sitting with her back to the door, for example, something that gradually grew easier. She also was asked to watch the tapes of herself recounting the rape. And to put on the clothes she wore the day she was assaulted.

"I got myself to smell them," she said, "But I was never able to actually put them on. I ended up throwing them away."

The therapy requires 90-minute sessions, one-third longer than the average with regular counseling.

"People must be willing to commit to the time. They have to do some homework and they have to relive the whole incident - not everyone can do that."

The counselor, she said, "has to be a person who really believes in the process," and has enough of a rapport with the patient to persuade them to follow through.

"Can't we start small?" Tyhira had asked her therapist, Sandy Capaldi during their seventh session. (She was the only one of the study participants who consented to be interviewed and let her videotape be viewed.)

"This is tough, I know," Capaldi said tenderly. "But you can do it. . . You have that strength inside of you."

Tyhira had been warned. She would have to reach into the darkest corners of her mind, retrieve the worst memories and recount the horrible details. Not just once, but over and over and over again, until they were beaten to a powerless pulp. In the end, she was promised, her courage would be rewarded. She would be able to get on with her life.

"I was ready," she said during a recent interview at home in Overbrook. "I was tired. I'd had enough."

With each retelling, she found herself discovering new fragments. The roughness of the man's hands. His laugh. The kisses that made her skin crawl. The press of her pillow over her face to muffle her screams. Her fear that if someone heard her, she might be in even more danger.

"How's your stress now?" Capaldi would ask periodically.

On a scale of one to ten, Tyhira would answer that it had risen to 6, fallen to 2, crept back to 5, slipped down to 1 and 1/2 and in the end, exhausted, she could no longer tell.

At the end of the third recounting, she remembered finding the courage to resist with more power than before and his grip on her arms pinning her down.

"It felt like someone was sticking a broomstick inside me," she said.

She also remembered thinking that if only she had used a louder voice or fought harder, she would have escaped.

"How could I let this happen?" she said. "I felt worse than the lowest creature on earth. . . and he's enjoying himself while I'm dying slowly under this little pillow."

Capaldi praised her courage and helped her think it through.

"This isn't the kind of thing it's a snap to get over...Seriously, what could you have done? Just because your voice is big and strong doesn't mean someone is going to listen. . . It didn't matter to him."

Then like a coach in the corner of a boxing ring, she sent her back to the mat to face the bare knuckles once more.

"Get right back in there. You're doing great," she said.

Tyhira closed her eyes again.

"So, he's taking my clothes off..."

Six years later, Tyhira, now 22, has graduated college. She hopes to become an event planner and is expecting her first child this fall.

Sitting with her back to the door no longer upsets her, she said. At times, however, she still has panic attacks and has to use the breathing and relaxation techniques she learned during therapy.

"It's as if there was a box sitting in the middle of the living room," she said. "I know I will never get rid of it completely. But I had to learn to file it away so I am not always tripping over it."


Women Organized Against Rape, 24-hour hotline, 215-985-3333.

The Center for the Treatment and Study of Anxiety at Penn, 215-746-3327.




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