641214

research-article2016

CCSXXX10.1177/1534650116641214Clinical Case StudiesGurak et al.

Article

The Use of Both Prolonged

Exposure and Cognitive Processing
Therapy in the Treatment of
a Person With PTSD, Multiple
Traumas, Depression, and
Suicidality

Clinical Case Studies

2016, Vol. 15(4) 295312
The Author(s) 2016
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DOI: 10.1177/1534650116641214
ccs.sagepub.com

Kayla K. Gurak1, Blanche Freund1, and Gail Ironson1

Abstract
Despite a high prevalence of comorbid disorders such as major depressive disorder (MDD),
the empirical guidelines for how to manage co-occurring conditions in the treatment of
posttraumatic stress disorder (PTSD) are lacking. In the context of a complicated presentation
of PTSD, this case illustration demonstrates the application of an integrated treatment
approach with Amanda, a 28-year-old female with a history of multiple traumas, undiagnosed
PTSD for 10 years, and comorbid MDD. In addition, Amanda began having suicidal thoughts
mid-treatment. This case study demonstrates how the integration of coping skills training
and cognitive processing therapy, in conjunction with prolonged exposure, helped Amanda
successfully complete treatment and be able to discuss her traumatic events with minimal
distress. At discharge, Amanda no longer met criteria for PTSD, had experienced significant
improvements in depression and anxiety symptoms, and was no longer experiencing suicidal
thoughts. These improvements were maintained at both 3 and 6 months post treatment.
Keywords
prolonged exposure, cognitive processing therapy, trauma, comorbid depression, suicidal
ideations

1 Theoretical and Research Basis for Treatment

Posttraumatic stress disorder (PTSD) has an estimated lifetime prevalence of 6.8% to 8.7% in the
U.S. adult population and is characterized by several key symptoms including negative alterations in cognition or mood (e.g., feelings of detachment and/or inability to experience positive
emotion), and changes in arousal and reactivity (e.g., irritability, hypervigilance, exaggerated
startle response; American Psychiatric Association, 2013; Kessler, Berglund, Demler, Jin, &
Walters, 2005). There is also a high prevalence rate of comorbid psychiatric disorders associated

1University

of Miami, Coral Gables, FL, USA

Corresponding Author:
Kayla K. Gurak, Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd., Coral Gables,
FL 33146, USA.
Email: kayla.gurak@gmail.com

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Clinical Case Studies 15(4)

with PTSD (Gadermann, Alonso, Vilagut, Zaslavsky, & Kessler, 2012). Major depressive disorder (MDD) is one of the most common co-occurring disorders with approximately 30% to 52%
of individuals with PTSD also meeting criteria for MDD (Angelakis & Nixon, 2015; Rytwinski,
Scur, Feeny, & Youngstrom, 2013). When compared with individuals who have PTSD alone,
comorbid PTSD/MDD is associated with greater symptom severity, greater subjective distress
and impairment, greater dissociation, poorer social and occupational functioning, and poorer
prognosis and response to treatment (Bedard-Gilligan et al., 2015; Campbell et al., 2007;
Rytwinski et al., 2013). There is also a strong relationship between PTSD and an increased risk
for suicidal thoughts and behaviors (Campbell et al., 2007). Prior literature suggests that the presence of MDD not only contributes to a more complicated and severe PTSD presentation but also
compounds the risk of suicidality in individuals with PTSD (Oquendo et al., 2003; Tarrier &
Gregg, 2004). However, despite the high prevalence rates of both MDD and suicidality in PTSD
populations, the clinical guidelines on how to most effectively treat patients that present with
these issues are scarce.
Prolonged exposure (PE), cognitive processing therapy (CPT), stress inoculation training
(SIT), and eye-movement desensitization and reprocessing (EMDR) are considered the frontline
PTSD treatments by the U.S. Department of Veteran Affairs (VA)/Department of Defense
(Steenkamp & Litz, 2013). Although each has its own empirical support, PE is the most widely
researched, has demonstrated effectiveness regardless of the type of trauma, and was found to be
the only efficacious PTSD treatment by the Institute of Medicine (IOM; 2007; van Minnen,
Harned, Zoellner, & Mills, 2012). Thus, PE is considered the gold standard treatment for PTSD
(Rauch, Eftekhari, & Ruzek, 2012).
However, with regard to individuals who present to treatment with PTSD and comorbid concerns, there seems to be a reluctance to research and treat more complicated PTSD cases due to
the commonly held belief that treating PTSD in these patients will exacerbate co-occurring conditions (van Minnen et al., 2012; van Minnen, Zoellner, Harned, & Mills, 2015). Some clinicians
report believing that trauma treatments are contraindicated for patients with comorbid conditions
or that certain patients are too fragile for trauma-focused treatment (Hamblen, Schnurr,
Rosenberg, & Eftekhari, 2009; van Minnen et al., 2012). This is especially true with PE as it is
commonly believed to be a stressful and intense treatment that may not be well-tolerated by
individuals with more complicated PTSD presentations. However, a small yet growing body of
literature does not support this assertion (Hamblen et al., 2009). Instead, it suggests that comorbid conditions actually remain the same or concurrently improve during the treatment of PTSD
(van Minnen et al., 2015). For example, Hagenaars, van Minnen, and Hoogduin (2010) demonstrated that patients with severe depressive symptoms obtained similar benefit from exposure
treatments when compared with patients without these concerns. In addition, although clinicians
are advised not to begin treatment with patients who are acutely suicidal, preliminary findings
suggest that PE can be used safely and effectively with patients presenting with low-to-moderate
suicidality behaviors or concerns (Harned & Linehan, 2008; Steenkamp & Litz, 2013; van
Minnen et al., 2012; van Minnen et al., 2015). It is also important to note that the extant literature
demonstrates that PE does not exacerbate suicidality, and there are no documented completed
suicides during PE studies (van Minnen et al., 2015). Until recently, no trauma-focused treatments addressed suicidal/self-injuring behaviors in PTSD patients. However, Harned and colleagues created an integrated treatment modality comprised of exposure therapy and dialectical
behavior therapy to specifically address both symptoms of PTSD and suicidal/self-injurious
behaviors in women with borderline personality disorder (Harned, Korslund, Foa, & Linehan,
2012; Harned & Linehan, 2008). Women in their samples experienced significant improvements
in PTSD symptoms, suicidal behaviors and urges, dissociation, depression, anxiety, and traumarelated guilt and shame (Harned et al., 2012; Harned & Linehan, 2008).

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Several additional studies suggest that integrated treatment approaches, which include nonexposure-based therapy techniques, may be more tolerable to individuals with more complicated
PTSD presentations and may also be perceived as more acceptable by clinicians (Kehle-Forbes
et al., 2013). While some studies suggest that combined treatments do not enhance treatment
outcomes (e.g., Foa, Dancu, et al., 1999; Foa et al., 2005), there are no studies to date that show
iatrogenic effects due to the addition of other treatment techniques. In other words, the addition
of other treatment components does not lessen the efficacy of exposure-based treatments nor
does it have detrimental effects on the patient or patient outcomes (Kehle-Forbes et al., 2013). In
fact, several studies which utilized integrated treatments have demonstrated significant improvements in PTSD, depression and anxiety symptoms, and overall mental health functioning (e.g.,
Steenkamp et al., 2011; Strachan, Gros, Ruggiero, Lejuez, & Acierno, 2012). Interestingly, two
case studies utilized a combination of imaginal, in-vivo, and interoceptive exposure therapy
(Wald & Taylor, 2010) or a combination of PE, mindfulness, and emotion regulation skills (Frye
& Spates, 2012), and both individuals demonstrated significant improvements in PTSD, MDD,
anxiety sensitivity, and emotion regulation skills.
Furthermore, three studies suggest that, when compared with singular treatments alone, integrated approaches can lead to improved patient outcomes. In a randomized control trial (RCT)
conducted by Cloitre et al. (2010), women with childhood-abuse-related PTSD who received
skills training in affect and interpersonal regulation (STAIR) + exposure experienced greater
improvements in PTSD symptoms, emotion regulation, and interpersonal problems when compared with women in either of the two control conditions (supportive counseling + exposure or
STAIR only). In another RCT that compared eight individual sessions of (a) imaginal exposure
(IE), (b) in-vivo exposure (IVE), (c) IE + IVE, or (d) IE + IVE + cognitive restructuring (CR) in
a sample of nonmilitary trauma survivors, Bryant et al. (2008) found the largest effect sizes and
reductions in symptoms of PTSD and depression in those who received IE + IVE + CR, which
suggests that CR provided additive gains to exposure therapy. Cigrang et al. (2011) incorporated
elements of CPT into PE treatment and found significant improvements in PTSD, depression,
and global mental health functioning in active-duty military members. Taken together, results
from these three studies seem to support the idea of incorporating or augmenting the CR and
skills-training components of trauma-focused treatments.
Despite promising preliminary results from the aforementioned studies that utilized integrative approaches, there continues to be a lack of empirical guidelines for how to effectively treat
PTSD in the context of complicating factors. The current case demonstrates how we handled a
complicated clinical presentation (i.e., severe depression, multiple traumas), began treatment
with PE, managed suicidality concerns when they arose mid-treatment, and traversed between
two treatment modalities (PE and CPT). Results lend further support to the use of an integrated
approach, which appeared to be well-tolerated by the client and led to improvements in PTSD,
depression, anxiety, and suicidal ideations, which continued to improve 3 and 6 months post
treatment.

2 Case Introduction
Amanda* (name changed to ensure confidentiality), a self-referred, 28-year-old, married,
Caucasian female, presented with symptoms of anxiety and depression, which began 8 months
prior when she lost her job (of 6 months) as a receptionist at a chiropractic office. At the intake,
Amanda met criteria for MDD (recurrent episodes, current, severe with anxious features) and
PTSD due to a history of multiple traumas including rapes at ages 18 and 21 and threatened
physical abuse from her father from the ages of 10 to 13. Amandas father suffered from untreated
bipolar disorder and completed suicide when she was 13 years old.

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3 Presenting Complaints
Amanda reported that since losing her job 8 months prior to presenting to treatment, she had been
experiencing symptoms of depression including uncontrollable crying, very sad mood, lack of
motivation, anhedonia, insomnia, upset stomach, loss of appetite, and feeling as if she was in a
pit. The symptoms had reportedly worsened in the month prior to presenting to treatment.
Amanda also reported that approximately 1 month prior to initiating treatment, she began experiencing anxiety symptoms (with no known precipitants) of difficulty breathing, feeling flustered, being unable to relax, and being awoken in the middle of the night with a racing heart.
These problems were significantly interfering with Amandas daily life and social relationships.
Although unemployed, Amandas depression made it difficult for her to find the motivation to
search and apply for jobs. Amanda reported that she found it difficult to attempt to make friends,
so spent most of her time with her husband of 3 years.
Amanda hoped that, by processing her trauma history in a therapeutic setting, she would be
able to see how the traumatic events had influenced her behaviors and ways of thinking. Amandas
additional goals for treatment included improving her self-esteem, reducing her symptoms of
anxiety and depression, learning to love herself, and thinking in a more positive way.

4 History
Amanda reported being a bright and confident child until the age of 10 or 11. She indicated that
she was a daddys girl and that her father was her role model. She described her father as loving, fun, social, active, and attentive toward his family. However, Amanda explained that when
she was 10 or 11, her father gradually became short-tempered. He would often come home
enraged, hitting walls, throwing things, and threatening to hurt Amanda, her younger sister, and
their mother. Amanda denied being physically injured by her father but endorsed many close
calls. She recalled one instance in which he pinned her against a cabinet, attempted to punch her
in the face, but missed, and ended up punching the cabinet. Amanda stated that on occasion, her
mother would intervene to defend her children. She denied any instances in which her father
physically injured her sister or mother. Amanda reported living in fear and, as such, loved going
to school because she did not feel safe at home. While it is unclear whether Amandas father
struggled with substance abuse or alcoholism, Amanda reported that her father suffered from
untreated bipolar disorder. When Amanda was 13 years old, her father completed suicide by
poisoning himself. She did not witness the event or see her fathers dead body. Shortly after her
fathers suicide, Amanda was diagnosed with depression (age 14). At the time of intake, Amanda
continued to struggle with the memories of her father and had difficulty reconciling the memories
of him before and after his mental illness. She also endorsed feeling as if his suicide was a choice
to leave or abandon the family and she often wondered why he did not choose them. Amanda
reported feelings of guilt and wondering whether some of her actions (e.g., the way she had spoken to him) had influenced his suicide.
Amanda began dating at age 14. At age 16, she began a 2.5-year relationship she described as
tumultuous. At age 18, she reported that her boyfriend forcibly raped her. She reported that
despite telling him no, and kicking, scratching, and biting him, he continued. He later insisted
that he thought she was engaging in role-playing. She stated that she remained in the relationship
for an additional 6 months until, following an argument, he slapped her across the face with so
much force that she fell to the ground. Amanda reported that the boyfriend had hit her a few times
before (e.g., slapped her on the back with so much force that it bruised) but she did not break up
with him until the incident in which he slapped her across the face.
At age 21, Amanda reconnected with a male friend from high school who was like a brother
to her. On her 21st birthday, she went out with a group of friends and invited the male friend. As

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he was unable to drive home at the end of the night due to his inebriation, Amanda told him he
could stay at her house. Once home, the male friend suddenly kissed her. Amanda refused and
insisted she thought of him as a friend only. Amanda is unable to remember details following her
refusal and reports feeling as if she blacked out or went in shock. Her memory returned to a
moment when she realized he was raping her. He had her pinned to the bed so that she was unable
to move, and she recalled repeatedly saying no and stop. She reported being paralyzed with
fear and thinking, If he is capable of this, there is no telling what he could do. Amanda reported
being in shock and staring at the ceiling for the rest of the night, unable to move. She stated that
he left in the morning and she remained in shock for approximately 1 week. She reported the
incident to the police 1 week following the event and decided to press charges. However, a day
before the trial, the hearing was canceled and all charges were dropped. Amanda believes that he
knew someone in the system and paid them off. Following the cancelation of the trial, Amanda
attempted suicide. She reportedly overdosed on several medications that were in her home. She
stated that a friend happened to call her after she had taken the pills and because Amandas
speech was slurred, the friend called her family, who found her and called 911. Amanda reported
that she did not need to have her stomach pumped as she had vomited the medications prior to
the paramedics arriving. Amanda was under observation at the hospital for 1 week. Amanda
denied any other suicide attempts. At the intake, Amanda denied any current suicidal ideations,
thoughts, or plans. Although she reported that, at times, she felt like a burden to her loved ones,
she had made a promise to herself to never attempt suicide again.
At the intake, Amanda endorsed numerous PTSD symptoms and met Diagnostic and Statistical
Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association,
2000) criterion A through H. Although DSM-IV-TR was being used at the time of Amandas treatment, she would have met Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM5; American Psychiatric Association, 2013) criteria as she endorsed experiencing symptoms of
reexperiencing, arousal, avoidance, and persistent negative alterations in cognitions and mood.
She reported that she had experienced these symptoms since age 21 and that some of her symptoms even began at age 18 years. Amanda endorsed experiencing physiological symptoms when
something reminded her of the trauma(s), always feeling extra alert or hypervigilant, having an
exaggerated startle response, experiencing frequent nightmares, not being able to remember a
part of the trauma, feeling emotionally numb, experiencing persistent irritability, and holding
beliefs such as, the world is not a safe place and you can never fully trust people. She
endorsed being most distressed by the rape that occurred at age 21 stating that this incident
crushed my whole world. She reported that she was no longer sure who she could trust as the
perpetrator (a long-time friend) was someone that she thought she knew. She also endorsed having a lot of self-blame as she had put herself in that situation. Although it was difficult for
Amanda to trust men, she was able to put aside her fears for the relationship with her husband.
However, she reported that she felt vulnerable and uncomfortable during sexual intimacy.
Amanda reported seeing a series of psychologists on and off throughout the years, but denied
ever receiving trauma-focused treatment. Although Amanda had taken antidepressant medication
since she was diagnosed with depression at age 14 (Effexor, dosage unknown), at the time of
intake, she had not taken medication for about 5 years as she felt she no longer needed it.

5 Assessment
Amandas pretreatment intake evaluation included modules from the Structured Clinical
Interview for DSM-IV-TR Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 2002) and
the SCID for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American
Psychiatric Association, 1994) Axis II Personality Disorders (SCID-II; First, Gibbon, Spitzer,
Williams, & Benjamin, 1997), and several self-report measures including the Dissociative

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Experiences Scale (DES), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory
(BAI), and the PTSD Symptom Scale (please see detailed descriptions in the Self-Report
Measures section below). Clients are referred out for a higher level of care if they have active
suicidal ideations, severe borderline personality disorder, or DES scores of 30 or higher, suggestive of a dissociative disorder. At the time of intake, Amanda denied any current suicidal ideations, did not meet criteria for borderline personality disorder, and had a DES score of 14.
Although Amanda had a previous suicide attempt at age 21, her strong marriage and social support from her husband mitigated this risk and allowed her to be accepted for treatment.
Per the results of Amandas intake evaluation, she met diagnostic criteria for MDD with a current, severe episode as she endorsed numerous depressive symptoms (e.g., anhedonia, loss of
appetite) and had experienced these symptoms for 8 months prior to intake. Amanda met criteria
for the anxious distress specifier as she presented with difficulty breathing, racing heart, feeling
flustered, and inability to relax. She also met criteria for PTSD, as she had experienced numerous
symptoms for years (e.g., hypervigilance, nightmares).
Amandas progress throughout treatment was tracked utilizing the BDI-II, BAI, PTSD
Symptom Scale, and the Posttraumatic Cognitions Inventory (PTCI), approximately every other
week during treatment, at termination, and at 3- and 6-month follow-up post treatment. It should
be noted that the PTCI was added as an additional measure to track progress approximately midway through treatment (when CPT began). Please see Table 1 for total scores at each evaluation
time point. Furthermore, during the active PE sessions, Amandas subjective distress was measured by the Subjective Units of Distress Scale (SUDS; see below for description). Amandas
SUDS ratings throughout the active PE sessions are displayed in Figure 1.

Self-Report Measures
The DES (Bernstein & Putnam, 1986) consists of 28 items measuring how often certain experiences occur (sample item: Some people have the experience of finding themselves in a place
and have no idea how they got there. Select a number to show what percentage of the time this
happens to you). Scores of 30 or higher are suggestive of a dissociative disorder or more severe
psychopathology, which require a higher level of care than a short course of trauma-focused
therapy at an outpatient clinic.
The BDI-II (Beck, Steer, & Brown, 1996) is a well-validated and widely used measure of
depressive symptomatology. It is comprised of 21 items, each scored 0 to 3, with higher total
scores indicating higher levels of depressive symptoms.
The BAI (Beck & Steer, 1993) is a widely used and well-validated measure of anxiety symptomatology. Calculated from its 21 items, higher total scores indicate greater severity of anxiety
symptoms (sample item: Unable to relaxnot at all, mildly, moderately, severely).
The PTSD Symptom Scale (Foa, Cashman, Jaycox, & Perry, 1997) is comprised of 17 items
with parallel DSM-IV diagnostic criteria for PTSD as well as the symptom clusters of reexperiencing, avoidance, and arousal (sample item: Being jumpy or easily startled). Scores range
from 0-51, with higher scores indicating more severe and more frequent PTSD symptoms.
The PTCI (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) consists of 33 statements in which clients rate agreement on a 7-point Likert-type scale (1 = totally disagree to 7 = totally agree).
Sample item: People cant be trusted. The scale yields a total score (the sum of the 33 items) as
well as 3 subscales scores: negative cognitions about self (21 items), negative cognitions about
the world (7 items), and self-blame statements (5 items). The 3 subscales are each summed and
divided by the number of items on the subscale. The PTCI has demonstrated excellent internal
reliability, good testretest reliability, and discrimination between individuals with no trauma,
trauma with PTSD, and trauma but no PTSD (Foa, Ehlers, et al., 1999).

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43
29
36

1st
evaluation

Prep phase

25

28

30

19

Active PE

40
36

Amanda
has suicidal
thoughts

25
28

12
26
26

14
22
19

16

Coping skills and

restabilization phase

21
16
22
129
3.29
4.57
3.60

18
22
9
12
103
2.91
3.86
1.80

20

CPT phase

17
12
14
72
1.95
2.43
2.0

23

Post-CPT
return to PE

22
14
14
69
1.90
2.29
2.00

27

Proposed
term

18
11
12
58
1.52
2.14
1.80

29

Termination

11
5
6
40
1
1.57
1.20

30

3 months
follow-up

5
3
2
43
1.19
1.57
1

31

6 months
follow-up

Note. PE = prolonged exposure; CPT = cognitive processing therapy; BDI-II = Beck Depression Inventory-II; BAI = Beck Anxiety Inventory; PTCI = Posttraumatic Cognitions Inventory; PTCI (Self) = negative
cognitions about self score on the PTCI; PTCI (World) = negative cognitions about world score on the PTCI; PTCI (Self-Blame) = Self-Blame subscale of the PTCI.

BDI-II
BAI
PTSD scale (total score)
PTCI (total score)
PTCI (Self)
PTCI (World)
PTCI (Self-Blame)

Session

Notable time points

Table 1. Progress During Treatment.

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Clinical Case Studies 15(4)

Figure 1. Active PE Sessions 1-9.

Note. PE = prolonged exposure; SUDS = Subjective Units of Distress Scale.

The SUDS rating scale (Wolpe, 1990) ranges from 0 (no distress) to 100 (highest degree of
distress imaginable). Clients are initially asked to come up with several personal anchor points
(e.g., A 25 for me feels like . . .) and refer back to this scale during exposure sessions. Amanda
was asked for her SUDS rating every 5 to 10 min during exposure sessions.

6 Case Conceptualization
Because PE has demonstrated effectiveness and efficacy across a variety of traumas, it was
deemed appropriate for all of Amandas traumatic events. PE is based on two primary strategies:
repeated and prolonged IE (reliving the trauma) and IVEs (Foa, Hembree, & Dancu, 2002).
Typically conducted for 30 to 60 min per therapy session, the objective of repeatedly telling ones
trauma narrative (in first person, present tense) is to improve ones ability to process the traumatic memory (Foa et al., 2002). As individuals with PTSD typically avoid situations that remind
them of the traumatic event, IVEs (usually assigned as homework) have clients confront and
remain in these situations until the anxiety subsides or decreases (Foa et al., 2002). Both IEs and
IVEs effectively decrease clients anxiety, distress, excessive fears, and avoidance behaviors
(Foa et al., 2002). Clients are also taught Breathing Retraining as a coping strategy to alleviate anxiety that may have been evoked by discussing the trauma (Foa et al., 2002, p. 19). Clients
are encouraged to practice the technique three times per day for 10 minutes each time (Foa et al.,
2002). Therapeutic discussions following exposure sessions allow for the identification and modification of any unhelpful beliefs clients may hold, as well as the facilitation of cognitive processing, which is considered a key component of PE (Foa et al., 2002; Foa & McLean, 2015).
Prior to beginning PE, Amandas initial treatment plan included preparatory sessions to implement cognitive-behavioral techniques and create a regimen to effectively manage her depression
(see Sessions 1-3 under section Course of Treatment). Amanda reported feeling most distressed
by the rape that occurred at age 21. Thus, PE sessions began by focusing on this event. We had
initially planned to have Amanda habituate to this event, select the second most distressing event,
habituate, and so on. However, after four active sessions of PE, Amanda began having suicidal
thoughts (see Session 8 below). Therefore, we decided to modify our initial treatment plan by
suspending PE and spend time (which turned out to be 2 months) in a restabilization/coping skills
phase. After Amanda stabilized, we eased back into trauma work by switching treatment

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modalities to CPT. Because CPT does not entail reliving the traumatic event and instead focuses
on the cognitions associated with the event, it was deemed to be a less intense and potentially
more tolerable treatment for Amanda. In CPT, clients are asked to write impact statements in
which they focus not on the details of the trauma but instead on why the event happened and how
the event has affected their views of themselves, others, and the world. The client and therapist
then work together to identify unhelpful and/or inaccurate beliefs (stuck points) and attempt to
modify these beliefs through therapeutic techniques such as Socratic questioning and finding
evidence for or against the statements (see Resick & Schnicke, 1993 or http://cpt.musc.edu for a
free CPT learning course). After six sessions of CPT and no additional suicidal ideations or distress, we returned to PE to ensure that Amandas distress associated with her traumatic memories
had been fully cleared out. Amanda required five additional sessions of PE before she was ready
for treatment termination.

7 Course of Treatment and Assessment of Progress

Therapist
Amandas therapist was a masters-level, advanced graduate student clinician working toward a
doctoral degree in clinical psychology at the University of Miami (UM). The therapist had been
trained in both PE and CPT as a part of UMs Trauma Treatment Program (TTP) and had weekly
supervision meetings with Gail Ironson (MD, PhD) and Blanche Freund (PhD). Dr. Ironson and
Dr. Freund created UMs TTP more than 20 years ago and have since co-facilitated and cosupervised the program. Both have extensive experience in treating clients with trauma histories/
PTSD with empirically supported treatments including CPT, PE, and EMDR.

Course of Treatment
Over the course of approximately 1 year, Amanda received 29 sessions of individual psychotherapy (three preparatory sessions, four active sessions of PE, eight sessions of restabilization
and coping skills training, six CPT sessions, five additional sessions of active PE, and three termination/relapse prevention sessions).
Sessions 1-3 (preparatory sessions). In Session 1, a treatment plan for managing Amandas depression was created which included starting an exercise regimen, reconnecting with her faith (a
self-reported goal), and signing up for health insurance. As Amanda preferred to not restart antidepressant medication, it was recommended that she begin an exercise regimen, because research
has demonstrated that physical exercise can be as effective as antidepressant medications in
mild-to-moderate depression (e.g., Blumenthal et al., 2007). Her depression symptoms were also
closely monitored, and it was agreed that if her symptoms worsened during treatment, she would
schedule an appointment with her psychiatrist and begin taking antidepressant medication again.
At Session 2, Amanda reported that she had began exercising three to five times per week, was
sleeping well at night, had not been woken by her anxiety symptoms, and felt determined to get
better. During these three sessions, Amanda was provided with psychoeducation on behavioral
activation and the rationale for PE treatment, was introduced to the concept of a fear and avoidance hierarchy, created her own hierarchy jointly in-session with her therapist, and was taught the
SUDS scale. In addition to the Breathing Retraining that Amanda was taught as a part of the PE
protocol (Foa et al., 2002), she was also taught guided meditation and progressive muscle relaxation. Amanda was provided with feedback on her PTSD diagnosis. Before presenting to treatment, Amanda was unaware that she met criteria for PTSD and simply thought that the traumatic
events had changed her permanently. We discussed common reactions to trauma as well as

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common symptoms of PTSD. Amandas experiences were normalized, and she had an opportunity to identify which PTSD symptoms she had been experiencing for the last 10 years (e.g.,
distressing nightmares, avoidance of reminders and feared situations, hypervigilance, exaggerated startle response). For her first in-vivo homework assignment, she selected an item off of her
hierarchy: looking at photos online of purple futons (the same color and style of couch the rape
at age 21 had occurred on) while sitting on the futon in her home (SUDS rating = 45-50). Amanda
had successfully completed this assignment with an initial SUDS rating of 50, which peaked to
65 and then decreased to 10.
Session 4 (Active PE Session 1). Amanda reported that she had obtained a job working as a teachers assistant at a local elementary school. Although she was feeling overwhelmed by her new,
busy schedule, she was still able to successfully complete her in-vivo homework assignment of
viewing a movie clip of a rape scene on repeat (SUDS = 75) and continue her exercise regimen.
Amanda selected this IVE because she felt it would be challenging yet manageable. The majority
of this session was spent conducting Amandas first PE session focusing on the rape that occurred
at age 21. Over the course of an hour, Amanda reported an initial SUDS rating of 65 to 70, peaked
to between 90 and 100, and decreased to 75. She reported that the experience was intense and
exhausting. She also noted that during the exposure, she was playing with her hair and rubbing
her face, which may have been safety behaviors that prevented her from fully reliving the experience. Therefore, Amanda agreed to try to eliminate the behaviors in the following exposures.
Homework assignments were to listen to the audio recording of the PE session, complete one
IVE from her hierarchy, and continue practicing deep breathing.
Session 5 (Active PE Session 2). Amanda reported that she had wanted to cancel this session because
the first PE was very uncomfortable. However, she stated that avoiding the session would simply
prolong the process. Despite the intensity and exhaustion of the first PE, she was pleasantly surprised by how much she was able to emotionally process the event. This PE session, Amanda
reported an initial SUDS rating of 65 to 70, peaked to between 85 and 90, and decreased to 55.
Amanda reported that the session was not that bad today. She also reported challenging herself
to limit the less relevant and less distressing details from her narrative and focus on what she was
experiencing (i.e., seeing, hearing, feeling). Amanda successfully stayed in the moment, focused
on the most distressing portions of her narrative, and did not engage in safety behaviors, which
appeared to allow her to access her emotions more deeply in this session as compared with the first
active PE session. The remainder of the session was spent processing Amandas confusion with
regard to her bodys response to the rape (i.e., the natural lubrication response of her vagina).
Amanda reported feeling betrayed by her body and angry that she did not fight back. However,
Amanda was able to recognize that her reactions may have saved her life and prevented her from
getting seriously hurt. Homework assignments were the same as the week prior.
Session 6 (Active PE Session 3). Amanda reported depressed mood and feeling hopeless. Amanda
denied any suicidal ideations, plans, or intent, but reported feeling very anxious to inform her
therapist that she had not been engaging in exercise. Unbeknownst to her therapist, Amanda had
recently had minor dental surgery and was specifically instructed by her doctor to not engage in
any physical activity during the healing period. Thus, Amanda and her therapist worked on
reframing her negative cognitions and setting reasonable expectations and goals for herself. The
remainder of the session was spent conducting the third session of PE. Amanda reported an initial
SUDS rating of 70, peaked to between 85 and 90, and decreased to 50. Amanda reported feeling
very concerned about her therapists judgments toward her, so the remainder of the session was
spent discussing these concerns and working on reframing these unhelpful thoughts. Homework
assignments were the same as the week prior.

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Session 7 (Active PE Session 4). Although Amanda reported a recent increase in anxiety due to life
stressors (i.e., finances, trying to sign up for health insurance), she was able to successfully complete all of her homework assignments including a new IVE (going to a coffee shop with her
husband and sitting with her back to the door, SUDS = 65). She reported thinking that this exposure would be very challenging and found that it was not distressing at all. Thus, she planned
to challenge herself by going to the coffee shop alone for this weeks homework (SUDS = 80).
The remainder of the session was spent conducting the fourth PE in which Amanda reported an
initial SUDS rating of 75, peaked to 90, and decreased to 60. Amanda initially appeared to be
reciting her narrative in a mechanical, nonemotional manner and so was encouraged to access the
fear structure by tapping into her emotions and feelings. Amanda subsequently became more
engaged and active in the PE session. She reported that, although distressing, she was pleased
that she allowed herself to become more engaged in the emotional processing of the event.
Homework assignments were the same as the week prior.
Session 8 (Amanda has suicidal thoughts). Amanda arrived to session visibly upset and distressed.
She reported severe symptoms of depression and anxiety as well as suicidal thoughts with no
known precipitants. Amanda denied experiencing any triggering or distressing events that could
have influenced the increase in symptoms and onset of suicidal thoughts. Amanda reported that
the evening prior to this session, as well as the morning before the session, she had the thought
of throwing herself off of the balcony (she and her husband lived in a high-rise building), as well
as taking whatever pills she could find in the home. As previously mentioned, Amanda had
attempted suicide at age 21 by ingesting a variety of pills. As Amanda had easy access to the
balcony as well as medications within the home, both thoughts were concerning. Amanda had her
husband drive her to the session but had simply told him that she was not feeling well. Amanda
signed a release of information for her therapist to speak with her husband and he was brought
into the session. With the support of her therapist, Amanda shared her suicidal thoughts with her
husband. Together, Amanda, her husband, and Amandas therapist created a safety plan, which
included her husband collecting all medications within the home and storing them in a safe place,
assisting Amanda in continuing to engage in behavioral activation (e.g., getting up and showering, going outside for walks), and making sure she was meeting her caloric needs (Amanda
reported a loss of appetite and was eating only once per day). Amanda and her husband were also
provided with emergency numbers, and a plan was created in case Amanda experienced additional suicidal ideations or urges to act upon her thoughts. Amanda also agreed to schedule an
appointment with her psychiatrist to restart her antidepressant medication.
Sessions 9-15 (restabilization and coping skills training phase). Amanda had seen her psychiatrist and
began taking Effexor-XR 75 mg daily. For the majority of these sessions, Amanda and her therapist worked on stress and anxiety management and psychoeducation of coping skills and strategies. Typically, when she was feeling depressed, anxious, or distressed, Amanda would freeze
and remain on the couch where she would ruminate for hours. Amanda was encouraged to create
and keep a Calm Down Kit of adaptive and pleasant activities or items (e.g., crosswords,
DVDs of her favorite sitcom) near the couch so that she could easily access and counteract the
tendency to freeze up. Additional coping skills included relaxation techniques (e.g., deep breathing and progressive muscle relaxation), speaking with supportive family members, behavioral
activation techniques such as going for a walk or bicycle ride, identifying her current stressors,
creating manageable to-do lists with reasonable deadlines, organizing her weekly responsibilities through use of a daily planner, and learning how to systematically challenge her unhelpful
thoughts such as I am useless, I am stupid, and I am not good enough. Amanda did very
well with these sessions and did not experience any additional suicidal ideations or increases in
depressive symptomatology. However, around Session 14, due to an issue with her health

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insurance, Amanda had run out of her antidepressant medication and was without it for about 1
week. Thus, we agreed to wait to resume the trauma work once Amanda had been taking her
medication consistently again for 2 additional weeks.
Sessions 16-19 (introduction to CPT, CPT Impact Statements 1-3 [Set A]). Starting at Session 16,
Amanda had been back on her antidepressant medication for 2.5 weeks, had not experienced any
suicidal thoughts for several months, and had resumed exercising regularly for about 1 month.
Amanda reported an improvement in her depression, anxiety, and PTSD symptoms and attributed
the positive changes to psychopharmacotherapy, psychotherapy, her newly acquired coping
skills, engaging in exercise, socializing more often, and the social support from her husband. As
an example, Amanda reported that on days she felt a bit down, she did not ruminate on depressive thoughts but instead got up and completed several chores or went for a walk or a bicycle ride,
which improved her mood. Amanda was introduced to CPT and was provided with a rationale for
this treatment modality. We decided to begin this phase of treatment by addressing Amandas
relationship with her father because she had reported that this was the least distressing of her
traumatic events. In addition, Amandas relationship with her father seemed to have laid the
foundation for several of her core beliefs (e.g., You can never truly know someone; Men
should not be trusted).
Amanda wrote three impact statements about her relationship with her father. She and her
therapist discussed the stuck points within the statements (e.g., Is this why he [my father] hated
me so much? and The man whom was meant to love me most in this world was ashamed to call
me his daughter), challenged her unhelpful/inaccurate beliefs, collected evidence for her fathers
behavior, and engaged in Socratic questioning. In addition, Amanda had written in her second
impact statement that her father never told me he loved me, never complimented me . . . never
embraced me . . . . Together, Amanda and her therapist challenged the idea that she had never
experienced her fathers love and support and had been defining their entire relationship by the
short period of time (the 3 years) that her father had been suffering from untreated bipolar disorder. Amanda was also able to identify contrary evidence for her negative core beliefs (e.g., I am
unlovable.) as her father was very loving toward her until he became sick, and even during the
years of her fathers emotional and threatened physical abuse, she was consistently loved, supported, and cared for by the other adults in her life, such as her mother and grandmother. After
three impact statements and challenging all remaining stuck points, Amanda felt ready to move
on to another trauma.
Sessions 20-21 (CPT Impact Statement 1-2 [Set B]). Amanda now felt ready to address the rape that
occurred at age 21. Amanda was still struggling with thoughts such as, I am a weak and vulnerable female and there is nothing I can do to defend myself and You never know what someone
is capable of. Within just two sessions, Amanda was able to reframe these thoughts and began
to view herself as a strong female equipped with multiple ways she can defend herself (e.g., using
her loud and powerful voice, using her creative and intelligent mind). After two impact statements and no remaining stuck points, Amanda was asked whether she wanted to address the rape
that occurred at age 18. Amanda did not feel the need to address this rape in treatment as she
reported that it felt different from the rape that occurred at age 21. Amanda explained that at
age 18, she fought back (kicked, scratched, bit) and yelled NO! whereas at age 21, she felt she
laid there and let it happen. Amanda also had guilt and shame cognitions associated with the
second rape because she believed she brought it upon herself by inviting her friend to stay with
her. Thus, as Amanda had successfully completed five impact statements (three about her father,
two about the rape at age 21), and tolerated CPT with no increases in symptomatology or suicidal
thoughts, we decided to return to PE to ensure that Amanda was no longer distressed by the
memories of the rape that occurred at age 21.

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Session 22 (Active PE Session 5). Amanda reported some anticipatory anxiety at this session. During PE, she reported an initial SUDS rating of 35, peaked to 65, and decreased to 50. Amanda and
her therapist spent the remainder of the session discussing potential reasons as to why she did not
habituate. Amanda admitted to trying to white knuckle it through this session to prove that she
was no longer distressed by the rape. However, she reported that it was more uncomfortable than
she thought it would be and was surprised at the emotions that still surfaced for her. She reported
feeling disappointed and frustrated that she was not yet done with treatment. Amanda was praised
for her honesty but was also reminded of her progress since her last PE in which her peak SUDS
rating was 100. Thus, over the course of treatment, she had already experienced a 50% reduction
in SUDS ratings. Amanda denied feeling distressed at the end of the session and ended with a
SUDS rating of 35.
Session 23 (Active PE Session 6). Amanda denied experiencing distress or suicidal thoughts following the prior weeks session. At this PE session, Amanda reported an initial SUDS rating of
30, peaked to 55, and then decreased to 35. She reported that during the last three times of telling
her narrative, she felt bored. This was viewed as a breakthrough, because up until this point,
Amanda had always felt physiologically activated and distressed when telling her trauma narrative. Amanda felt happy that her hard work was starting to pay off. Amanda denied feeling distressed at the end of the session.
Session 24 (Active PE Session 7). Amanda denied experiencing distress or suicidal thoughts following the prior weeks session. She reported feeling ready for this session and said, Lets do
this! She reported an initial SUDs rating of 20, peaked to 40, and decreased to 20. It was noted
that approximately halfway through the PE session, Amanda had postured her hand in a way that
was suggestive of covering or protecting her vaginal area. Amanda was asked to remove her hand
during the PE session and then she and her therapist discussed afterward. Amanda agreed that
this was a safety behavior as she still felt uncomfortable discussing how her vagina became naturally lubricated during the rape. Although Amanda reported initially having the thought, My
body betrayed me, she was able to cognitively restructure without prompting or assistance to,
Its a natural reaction and my body was trying to protect me from getting hurt. Amanda denied
feeling distressed at the end of the session.
Session 25 (Active PE Session 8). Amanda arrived and stated that she already felt bored prior to
starting the PE. She reported an initial SUDS rating of 20, peaked to 30, and decreased to 20.
Amanda struggled to stay awake during this PE session but denied that it was a safety behavior
or way to dissociate. At the end of the session, Amanda declared, That was SO boring! Once
again, Amanda denied feeling distressed at the end of the session.
Session 26: (Active PE Session 9). Amanda reported an initial SUDS rating of 0, peaked to 20, and
ended at 0 to 5. Amanda once again struggled to stay awake and reported feeling tired and relaxed
while telling her trauma narrative. Amanda and her therapist agreed this was a sign of true progress, because Amanda had never imagined that it could be possible to feel relaxed while discussing the rape. She reported that it is now just a memory of something that happened to her but she
no longer felt the physiological activation, emotional reactivity, guilt, and shame that she used to
feel. Amanda and her therapist agreed that she was ready to terminate treatment.
Sessions 27-29 (termination sessions). Session 27 was initially going to be Amandas last session.
However, when she arrived, she reported that she had gotten into an argument with her husband and
had had a suicidal thought that morning. Specifically, she thought, He has had enough of me. I
should just end it all. I should just jump off of the balcony. However, she reported that she was able

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to immediately reframe the thought to, This is ridiculous. It was a silly argument in which he overreacted and me killing myself would definitely be an overreaction. At work, Amanda had tried to
tell a coworker about the argument, but as the coworker was reportedly dismissive of her, this triggered thoughts of I am inadequate and worthless. Amanda was having a difficult time reframing
her unhelpful thoughts and then disclosed that last week, her psychiatrist had decreased her antidepressant medication dosage by half (now on Effexor-XR 35mg) to see whether it would help with
side effects (Amanda had been experiencing some lightheadedness). However, as Amanda did not
inform her therapist of this change beforehand and she had experienced a suicidal thought that
morning, termination was delayed until Amanda was once again stabilized on her previous dose of
Effexor-XR 75 mg. Amandas therapist facilitated a conversation between Amanda and her husband regarding the argument that took place that morning. They both agreed it was a silly argument
and Amanda felt relieved to learn that her husband did not feel that she was a disappointment.
Once again, a safety plan was created in case Amanda experienced suicidal thoughts again. Amanda
contacted her psychiatrist, informed him of what had occurred on the half dosage, and Amandas
original dosage was reinstated. Session 28 was a couples session that Amanda had requested.
Amandas therapist met with Amanda and her husband and discussed common symptoms of PTSD
and depression, adaptive coping skills, how he can be most helpful when Amanda is struggling with
increased symptoms, and how to deal with conflict most effectively. They were provided with several handouts to take home and Amanda and her husband reported enjoying and learning a lot during the session. Session 29 was Amandas termination session in which Amanda and her therapist
reviewed all of the adaptive coping strategies and skills she learned in therapy, as well as her progress. A relapse prevention plan was also created.

Assessment of Progress
Amanda successfully completed treatment and is able to tell her trauma narratives with minimal
distress. She cognitively restructured self-blaming and guilty thoughts related to the traumas and
now holds healthy and realistic views of what occurred. At the time of discharge, Amanda no
longer met criteria for PTSD, had significantly lower depression and anxiety symptoms, and was
no longer experiencing suicidal thoughts. Although Amanda continued to have minimal depression symptoms, she was able to successfully challenge her unhelpful thoughts and had a relapse
prevention plan and excellent coping skills in place. She reported feeling better equipped to manage her depression and acknowledged that she will have good and bad days. Amanda continued
to see her psychiatrist and take antidepressant medication. Amanda remained employed at the
elementary school and reported feeling as if she had her life back.

8 Complicating Factors
Amanda began having suicidal thoughts while undergoing PE. These thoughts were particularly
concerning and needed to be addressed before continuing trauma-focused therapy. As Amanda
presented to treatment with few adaptive coping skills, 2 months of treatment time were required
to teach her several coping strategies and ensure that she was stabilized. After restablization and
coping skills training, we felt that resuming trauma-focused treatment with CPT would be a more
tolerable treatment modality before returning to PE.
It was also important for Amandas husband to be aware of Amandas suicidal thoughts during
treatment and fortunately, Amanda agreed and signed a release of information that allowed her
therapist to speak with him and bring him into session. However, Amandas therapist still needed
to handle this situation in a delicate manner that felt supportive to Amanda.
In addition, Amanda presented to treatment with severe levels of depression which required careful monitoring throughout treatment. Although Amanda did not begin therapy on antidepressant

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medication, she was agreeable to meeting with her psychiatrist to restart Effexor-XR (75 mg) when
she experienced increased depressive symptomatology and suicidal thoughts mid-treatment. Despite
two unanticipated instances in which she was not taking her medication consistently (e.g., an insurance issue, and her psychiatrist halving the dosage), Amanda was very medication-compliant
throughout treatment.

9 Access and Barriers to Care

Fortunately, Amanda did not experience any barriers to care. She was financially stable and could
afford treatment, she owned a car and could drive herself to therapy sessions, she was motivated
for treatment, and had a very loving husband who was both financially and emotionally supportive of her decision to pursue treatment. In addition, although some clinics do not treat patients
with past suicide attempts, Amandas past suicide attempt was mitigated and she was accepted
for treatment due to the abovementioned strengths.

10 Follow-Up
Follow-up assessments were conducted 3 and 6 months post treatment. At both time points,
Amanda reported that things had been going very well in all domains of her life including work,
social relationships, her marriage, and spirituality. She denied experiencing any relapses or suicidal thoughts. Since terminating treatment, her symptoms decreased to a minimal level (see
Table 1). She reported that she has been more physically active, no longer naps after work, and
is attending church and bible study regularly. Amanda has remained employed at the local elementary school and also reported instances in which she was challenged with novel tasks and
rose to the occasion. She reported taking initiative at work, being proactive, continuing to engage
in helpful thinking, and using CR and other coping skills when needed. In the near future, Amanda
would like to go back to school to pursue a degree in Education.

11 Treatment Implications of the Case

Amanda presented to treatment with several traumatic events and had been living with undiagnosed PTSD for 10 years, as well as comorbid MDD. Amandas case became more complicated
when she began having suicidal thoughts after the fourth active session of PE. Because there are
few empirical guidelines on how to handle complicated presentations of PTSD, particularly if
suicidal concerns arise mid-treatment, Amandas case may serve as an example of how flexibility
and willingness to switch treatment focus and modality may be extremely beneficial to the client.
A handful of studies have utilized integrated treatment approaches in which exposure therapy is
combined with other non-exposure techniques such as CR. In line with results from these prior
studies, Amanda experienced significant decreases in PTSD, depression, and anxiety symptoms.
Furthermore, these studies suggest that an integrated approach may be better tolerated and viewed
as more acceptable by clients and clinicians alike. Amandas treatment case lends further support
to this view because despite severe levels of depression and suicidal thoughts, Amanda remained
in treatment and continued to be compliant with the treatment plan. Amanda presented to treatment with fear and avoidance behaviors as well as many maladaptive beliefs about herself (e.g.,
guilt and self-blame), others (e.g., You can never fully trust anyone.) and the world (e.g., The
world is a dangerous place.). Amanda appeared to benefit from both trauma-focused treatment
modalities in that she was able to confront feared situations and trauma-related memories through
PE, experience habituation, and challenge her unhelpful/inaccurate beliefs through CPT.
As Amandas case is simply one example of integrating PE, CPT, and coping skills training, it
is unclear if a different sequence of events would have affected outcomes. For example, although

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there is no way to determine which clients may experience suicidal thoughts and when, perhaps
coping skills training prior to beginning trauma-focused treatment would decrease the possibility
of suicidal thoughts. It is also possible that clients who first receive several sessions of CPT may
then feel better prepared for PE. Despite Amandas promising results as well as results from other
studies that have utilized integrative approaches, additional research must be conducted before
making definitive conclusions about the effectiveness of these treatments. Future research should
also attempt to identify the active ingredients in integrative treatments. However, this may prove
difficult as trauma-focused treatments can share common components. For example, cognitive
processing and relaxation training play important roles in PE.

12 Recommendations to Clinicians and Students

Although it is common for clinicians to be reluctant to take on more complicated cases of PTSD,
Amandas case illustrates that even if a case is complicated and suicidality concerns arise midtreatment, trauma-focused treatment can be modified and can successfully proceed. Therefore, it
is important that as a field, we continue to explore how to most effectively address these concerns
and create empirically supported guidelines for clinicians on the frontline.
Amandas case also illustrates that flexible approaches to treatment that incorporate other
treatment modalities can be well-tolerated and beneficial to the clients progress in treatment.
Therefore, it is recommended that clinicians and students seek out training in several treatment
modalities so they can integrate other techniques or change treatment modalities if necessary.
Most importantly, although Amanda experienced some difficult moments in treatment in which
she did not want to continue, and had increases in symptomatology and suicidal thoughts, she
ultimately experienced significant improvements in PTSD, depression, and anxiety symptoms
and successfully completed treatment. Amanda serves as a great reminder that although trauma
treatments such as PE can be intense, they are effective.
Acknowledgments
A special thanks to our client who gave us permission to write about her case. We also thank the other TTP
therapists, Emily Georgia and Devika Jutagir, for their helpful suggestions on this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies
Kayla K. Gurak, MS, is currently a fifth-year clinical psychology doctoral student with clinical and
research interests in severe, chronic, and disabling psychiatric disorders. Her research focuses on identifying factors that may help improve course of illness for patients.
Blanche Freund, PhD, is a lecturer and adjunct faculty in the Department of Psychology. She has conducted clinical research and therapy with trauma survivors since 1987. She has been the codirector of UMs
Trauma Treatment Program since 1995 and conducts training and supervision in Prolonged Exposure.
Gail Ironson, MD, PhD, is a professor of psychology and psychiatry and a board-certified psychiatrist. She has
over 200 publications in the field of behavioral medicine applied to HIV/AIDS, cancer, cardiovascular disease,
and the biological effects of trauma. She has directed the UM Trauma Treatment Program for more than 20 years.

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