Accelerated Resolution Therapy

Masters of Chaos, by MSG Christopher Thiel, courtesy of the Army Art Collection, US Army Center of Military History.

Accelerated resolution therapy (ART) is a relatively new therapy that includes many techniques for resolving the traumatic memories associated with posttraumatic stress disorder (PTSD). Preliminary evidence to date suggests that ART is highly effective, requires fewer sessions, and has a much greater completion rate than traditional PTSD therapies. A key difference between ART and other therapies for PTSD is that ART is an internal process that focuses on images rather than cognitions or feelings. This aspect is particularly important in a military population, since veterans are often not comfortable or legally permitted to share the details of their combat traumas due to their graphic intensity, potential association with war crimes, or inclusion of classified information. Herein, we provide a general description of the therapy, a summary of relevant clinical investigations, and present two cases that highlight the use of ART in resolving combat-related and early childhood traumas. The first case is of a fairly typical Iraq/Afghanistan veteran with complex PTSD related to multiple combat traumas and childhood abuse. The second case is of a different veteran’s first ART session, demonstrating ART’s unique ability to resolve long-standing, painful emotions such as shame and guilt very rapidly.

9.1 General Description

ART is an emerging, trauma-focused approach to addressing traumatic memories, as well as difficult and conflicted feelings that may be based on past experience. ART employs imagery, metaphors, and Gestalt techniques to help patients achieve reduction of their emotional symptoms and a self-directed resolution to their problems. Developed in 2008 by Laney Rosenzweig, it has primarily been studied at the University of South Florida for symptoms related to PTSD [1–3]. A summary of published literature on ART may be found later in this chapter.

ART is both therapist-directed and patient-driven. It consists of a basic protocol to address specific memories and events, as well as an advanced protocol to address more psychologically complex issues that arise within the context of the basic protocol. ART interventions are carefully scripted and designed to help the patient symbolically separate from a troubling past and advance toward a more positive future. While ART foundationally addresses traumatic memories, its design and structure permit its application in a number of other psychiatric syndromes and conditions, including generalized anxiety, depression, bereavement, and addictions.

9.2 Protocols

The basic ART protocol is designed to address singular traumatic experiences, as well as more basic fears and phobias, such as fear of public speaking and fear of flying. It combines imaginal exposure (IE) with smooth-pursuit eye movements to rapidly facilitate desensitization, imagery rescripting (IR), and stress inoculation [3]. Like more widely studied therapies for PTSD—including eye movement desensitization and reprocessing (EMDR), prolonged exposure (PE), and cognitive processing therapy (CPT)—ART relies on psychotherapy elements carrying an A-level recommendation in the 2010 Department of Defense and Veterans Affairs (DoD/VA) Clinical Practice Guidelines for PTSD [4]. The basic protocol is designed for discrete experiences and has the potential to resolve a traumatic event in a single session. Even particularly intense memories can be virtually disassembled and reorganized into a meaningful narrative in 1–5 sessions, with each session focusing on different scenes or concerns as they relate to the presenting problem.

The advanced protocol allows for a more detailed exploration of complex past events, unresolved developmental issues, and conflicted feelings, such as dreading the loss of a critically ill parent while simultaneously craving the relief one might expect at that parent’s passing. It incorporates the use of metaphors and Gestalt techniques into the basic protocol, allowing deeper exploration of past experiences in relation to current affective and cognitive states. Rosenzweig describes these advanced techniques as ways to engage a patient’s creative energies in more of a dreamlike state, where individuals are able to imagine and freely address thoughts, feelings, and sensations without the limitations of traditional talk therapies, and often in a less traumatic way [5].

9.3 Procedure

The ART protocol begins with exposure and desensitization. The patient is asked to identify the targeted memory and provide a score on a Subjective Unit of Distress (SUD) scale. Discussion of the trauma may be as detailed or as brief as necessary to establish rapport while generating a moderate degree of somatic distress. The patient is given permission to share as many or as few details as desired about the event, making ART particularly useful for memories involving classified, criminal, or intensely disturbing material. Focusing internally on the targeted event, the patient evokes the images, sensations, cognitions, and emotions he or she initially recalled from the event, or those that were generated by the exposure process. Once desensitized, the patient is able to explore the traumatic content more deeply, often yielding impressive new understandings and insights.

Initial exposure begins with the patient visualizing the targeted event (referred to in ART as a scene) while simultaneously being guided by the therapist in sets of eye movements. The exposure and desensitization process typically lasts between 5 and 20 min. During this period, any distressing images, sensations, thoughts, or emotions are targeted with the protocol to reduce their intensity. Simple and less complex experiences may resolve quickly, while memories that are rooted in earlier experiences may require additional interventions to resolve.

One such intervention is known as the scene match. Scene match addresses an earlier event that evokes thoughts, feelings, sensations, or images that are similar or somehow related to the targeted event. Any distressing component of the earlier event that is evident during IE is addressed using the ART protocol until the individual can recall the details of the event without experiencing distress. The IE and resolution of the patient’s distress as related to the earlier scene is key to moving forward in the protocol.

The next procedural segment is called the Director’s Intervention. The Director’s Intervention accomplishes the critical process of rescripting the traumatic event. The procedure is directed by the therapist, but the new scene is self-selected by the patient, creating a very personalized resolution of the event. Rosenzweig calls this process “Voluntary Image Replacement,” which refers to the imagining of a preferred, alternative version of the event in place of the original event [5]. This rescripting exercise allows patients to imagine themselves in a way that emphasizes a sense of mastery within or over the event. In other words, patients are able to metaphorically express their true wishes by visualizing a preferred scenario in place of the original targeted memory.

The subsequent procedural segment begins after the Director’s Intervention, when the patient has finalized his or her preferred version of the targeted memory and is able to imagine the event differently while recalling the original narrative without distress. The images are changed while the actual memory of the event is retained in a narrative form. This segment starts with a test exposure to the original event (scene). Any remaining images, sensations, cognitions, or emotions are addressed until they are fully resolved, including scene matches to past or related events. The patient then processes future triggering events in a similar fashion. The emotions, sensations, images, and cognitions that arise when the patient visualizes future triggers are addressed using the same ART tools, permitting the patient to visualize positive but realistic outcomes.

The closing segment of a typical session includes a series of metaphorical interventions intended to help the patient completely resolve any lingering distress. The symbolic imagery evoked during this segment permits patients to visualize themselves taking charge of the past and consciously disposing of negative life experiences. The process helps generalize the resolution achieved during the session to previously untargeted stressors and traumatic memories. The patient often elects to bring significant individuals from their past or present life to a future in which they envision themselves no longer burdened by their present problem. This segment also provides a final opportunity for the therapist to identify lingering issues or alternatively for the patient to solidify a newfound sense of mastery over past traumas.

9.4 Description Summary

Through the use of IE and IR, ART targets the original memory in its entirety and promotes resolution of the associated sensations, cognitions, images, and feelings within a singular period of reactivation. However, ART goes beyond basic exposure therapies by attaching more positive, empowering, self-directed images, sensations, feelings, and cognitions to the event within the reconsolidation window, which bench research suggests may contribute to lasting change [6, 7]. The event’s original content and narrative remains intact, but without the affective valence previously assigned to it, and often with more detail than the patient was initially able to recall.

9.5 Current Evidence Base for ART

9.5.1 Funding History

As of this publication, there have been seven funded research efforts related to ART. Of these, two have been federally funded and the remaining five studies are from a range of funding sources. Three of the funded studies are completed and four are in progress, but manuscripts and scientific presentations are being developed across all studies. Solicitation for additional funded research is ongoing and includes federal, nonfederal, and foundation sources. Table 9.1 below summarizes the funded ART research studies including purpose, sponsor, and a brief description.

Table 9.1

Summary of the funded ART research studies

Title	Sponsor	Status	Population	Brief description
Accelerated resolution therapy (ART) for rapid resolution of symptoms of psychological trauma	Substance Abuse and Mental Health Services Administration	Completed	Adults (mostly civilians) with symptoms of PTSD (n = 80)	Prospective cohort study to evaluate efficacy and safety of ART as a brief treatment modality for symptoms of PTSD
ART for psychological trauma	Telemedicine & Advanced Technology Research Center (TATRC)	Completed	US Service members and veterans with symptoms of PTSD (n = 57)	Randomized controlled trial of ART versus an attention control (AC) regimen for treatment of symptoms of PTSD and related comorbidities, with 3-month follow-up evaluation
Psychophysiological assessment of PTSD before and after treatment with ART	Charles Stark Draper Laboratory	Completed	Adults (principally civilians) with diagnosed PTSD (n = 13)	Pilot investigation that applied psychophysiological assessment before and after treatment with ART to a selected sample of civilians and veterans with PTSD
Pilot study of delivery of ART by Scottish registered nurses in mental health for treatment of military psychological trauma	University of South Florida and University of Stirling	Ongoing	Veterans of the British Armed Forces with symptoms of PTSD (n = 24)	Prospective pilot study to evaluate efficacy and safety of ART as a brief treatment modality for symptoms of PTSD among British veterans
Use of ART for women veterans experiencing posttraumatic stress disorder (PTSD) secondary to military sexual trauma (MST)	University of South Florida	Ongoing	Female veterans with MST and symptoms of PTSD (n = 10)	Pilot study to evaluate efficacy and safety of ART as a brief treatment modality for PTSD secondary to MST
ART for PTSD and sleep dysfunction	American Psychiatric Nurses Association	Ongoing	Veterans with symptoms of PTSD and sleep dysfunction (n = 15)	Pilot study to examine efficacy of ART for treatment of symptoms of comorbid PTSD and sleep disturbance
Prospective cohort study of ART for treatment of military psychological trauma	Chris T. Sullivan Foundation	Ongoing	Service members and veterans with symptoms of PTSD (n = 200)	Prospective cohort study (n = 200) to evaluate efficacy and cost-effectiveness of ART for treatment of symptoms of PTSD, with oversampling of MST and refractory PTSD

9.5.2 Completed Study Results

For the three completed studies of ART, two have resulted in a total of five peer-reviewed publications to date (four data based and one case report). In the first prospective cohort study to evaluate the efficacy and safety of ART as a brief treatment modality for symptoms of PTSD, a total of 80 adults aged 21–60 years with symptoms of PTSD (mostly civilians) were enrolled, of whom, 66 (82.5 %) completed treatment and 54 of 66 (81.8 %) provided 2-month follow-up data [1]. ART was delivered in a median of three treatment sessions. Mean scores pre- and post-ART and at 2-month follow-up were: PTSD checklist-civilian version (PCL-C): 54.5 ± 12.2 versus 31.2 ± 11.4 versus 30.0 ± 12.4, Brief Symptom Inventory: 30.8 ± 14.6 versus 10.1 ± 10.8 versus 10.1 ± 12.1, Center for Epidemiologic Studies Depression Scale (CES-D): 29.5 ± 10.9 versus 11.8 ± 11.1 versus 13.5 ± 12.1, Trauma-Related Growth Inventory-Distress scale: 18.9 ± 4.1 versus 7.4 ± 5.9 versus 8.2 ± 5.9 (p < 0.0001 for all pre-ART versus post-ART and 2-month comparisons). No serious adverse events were reported. While this study did not include a control group, it provided empirical evidence of ART as a potential brief treatment modality for symptoms of PTSD and related comorbidities.

In a subgroup analysis of the above study, which consisted of 28 adults with high levels of comorbid symptoms of PTSD and major depressive disorder, subjects underwent a mean of 3.7 ART treatment sessions (range 1–5) [8]. For the 17-item PCL-C (PTSD checklist), the pre-ART mean score (standard deviation) was 62.5 (8.8) with mean changes of − 29.6 (12.5), − 30.1 (13.1), and − 31.4 (14.04) at post-ART, 2-month, and 4-month follow-up, respectively (p ≤ 0.0001 for comparisons to pre-ART score). Compared to pre-ART status, this corresponded to standardized effect sizes of 2.37, 2.30, and 3.01, respectively. For the 20-item CES-D measure of depressive symptoms, the pre-ART mean was 35.1 (8.8) with mean changes of − 20.6 (11.0), − 18.1 (11.5), and − 15.6 (14.4) at post-ART, 2-month, and 4-month follow-up, respectively (p < 0.0001 compared to pre-ART score). This corresponded to standardized effect sizes of 1.88, 1.58, and 1.09, respectively. Strong correlations were observed at 2-month and 4-month follow-up for posttreatment changes in PTSD and depression symptom scores (r = 0.79, r = 0.76, respectively, p ≤ 0.0002).

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