What Is Exposure Therapy For PTSD?

Post-traumatic stress disorder can cause a list of severe symptoms that can make it difficult to move through daily life. Multiple therapeutic modalities have been developed to address symptoms of this condition and help individuals recover from the impacts of traumatic events, including an approach called exposure therapy. Understanding exposure therapy may help you make an informed decision on whether this modality may be helpful for you. 

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What is exposure therapy for PTSD? 

Exposure therapy is a therapeutic approach often used to treat post-traumatic stress disorder (PTSD). PTSD is a condition that can cause individuals to experience persistent and severe symptoms after experiencing or witnessing a traumatic event. For those without PTSD, challenging symptoms after a traumatic event may subside on their own within weeks or months of the trauma. However, for those with PTSD, symptoms often last for years, particularly if left untreated. 

There are several treatments available for PTSD. However, exposure therapy is one of the most effective methods to date. One 2023 clinical trial found that out of 234 military personnel and veterans, 61% succeeded in reducing symptoms, and 74% reported continued symptom reduction one month after treatment onset. More than 50% achieved diagnostic remission at six months. 

Types of exposure therapy 

Different types of exposure and response prevention (ERP) therapy techniques can be used to treat various disorders. The different methods can be used in conjunction for maximum effectiveness. Types of exposure therapy include the following. 

In vivo exposure

In vivo exposure involves exposing individuals to real-life, anxiety-provoking situations, objects, people, and other triggers. For example, if an individual fears heights, the process may consist of gradually exposing themselves to high places. 

In vivo exposure occurs in an individual’s everyday life, sometimes outside of sessions when engaging in therapy in-office is impossible. As such, the therapist may ask the client to complete assignments between sessions by keeping a log containing the details of what they experienced and to rate their level of discomfort at different points during the exposure.

Introspective exposure

The introspective exposure technique involves exposing individuals to physical symptoms or sensations associated with somatic anxiety. By experiencing and learning to tolerate these sensations, individuals may learn to manage the distress more effectively. For example, an individual with anxiety about hyperventilation may practice breathing techniques that simulate hyperventilation until they can control their breathing. 

Virtual reality exposure for stress disorder treatment

In VR exposure therapy, clients use virtual reality technology to simulate realistic, immersive environments that cause fear and anxiety. This technique allows individuals to confront their fears in a controlled and safe setting. An example of VR exposure may include using a driving simulator to help an individual who fears driving become accustomed to being behind the driver’s seat— slowly and gradually working their way up to driving.

Imaginal exposure

Imaginal exposure involves guiding an individual through visualizations in which they vividly imagine the feared memory or situation in detail. An example of imaginal exposure would be to ask an individual with a fear of snakes to view pictures and describe past exposures to snakes in as much detail as possible. Often, imaginal exposure occurs in a treatment setting. However, with time and support, the individual may be able to encounter snakes in real life without anxiety.

Prolonged exposure therapy for PTSD

Prolonged exposure therapy involves repeatedly revisiting and processing trauma-related memories or triggers. It is often used to help individuals with PTSD who have experienced or witnessed a severely traumatic event. 

PTSD prolonged exposure therapy contains four components. First, the therapist may educate the individual about the forthcoming treatment and what to expect. Then, they will work on breathing relaxation exercises. Afterward, the patient will be exposed to the trigger(s) related to the individual’s traumatic experience. Finally, the client and therapist can work together through guided visualizations or repeated recounting of the traumatic incident. 

How exposure therapy and prolonged exposure therapy work

Exposure therapy consists of several stages that may help individuals gradually reduce their anxiety to confront and overcome their traumatic memories or fears. The process may differ between individuals based on their personal needs. Treatment often consists of 12 weekly individual sessions lasting roughly 50 to 60 minutes.

Exposure therapy often begins with a preliminary assessment in which the mental health professional learns about the client’s specific fears, triggers, and symptoms. This stage may help the therapist develop a personalized treatment plan and identify the most appropriate type of exposure therapy for the individual. Beyond the initial assessment, there are several potential steps, including the following. 

Prolonged exposure is one specific form of exposure therapy that focuses on revisiting traumatic memories for extended periods, helping individuals process their emotions and gradually decrease their distress.

Psychoeducation

Psychoeducation is a part of the exposure therapy process in which the patient (and family members, when appropriate) learn how it works, what to expect, and how to get the most out of it. 

Establishing safety and coping strategies

Before beginning exposure, the therapist works with the individual to develop coping strategies and relaxation techniques to manage the anxiety and stress the client may encounter during the exposure sessions. This stage aims to ensure the individual is safe and supported throughout therapy.

Creating an exposure hierarchy for cognitive behavioral therapy

During this phase, the client and therapist work together to develop a present-tense hierarchy of feared stimuli such as situations, objects, or memories. The therapist can ask the individual to rank their level of anxiety associated with them from least to highest. This process can serve as a structured, systematic guide from which to work. 

Exposure exercises

The individual begins confronting their fears or traumatic memories, starting with the least traumatic and continuing to the most challenging ones. During this phase, the therapist guides the individual through the exposure exercises, providing support as needed. 

Processing and debriefing

After each session, the therapist and patient discuss any thoughts, emotions, and reactions that arose during their time together. This discussion may help the individual process and learn from the experience to prepare for future encounters. 

Generalization and maintenance

As the individual progresses through exposure therapy, the therapist may aim to offer them the tools necessary to independently navigate and prepare for situations that could otherwise cause them stress and discomfort in the real world. The therapist helps the individual maintain their progress and continue to strengthen their coping skills outside of therapy. 

Evaluation and follow-up

Throughout the process of exposure therapy, the therapist works with the patient to practice applying skills and coping strategies to manage challenges as they arise during the day and prevent future relapse.

Understanding post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (or PTSD) can be distressing for individuals living with it and their loved ones. This condition develops in individuals who have experienced or witnessed a life-threatening or traumatic event, such as combat, abuse, natural disasters, or other violent or traumatic conditions. In the US, an estimated 3.5% of adults and 8% of individuals aged 13 to 18 experience PTSD at some point in their lifetime. 

Symptoms

People with PTSD often experience intense, unpleasant thoughts and feelings associated with their experience that can last well after the traumatic event has ended. There are four categories in which PTSD falls based on symptom type, but people can experience more than one concurrently.

Symptoms of PTSD include:

• PTSD can cause intrusive memories marked by recurrent, distressing memories of the event, nightmares, or flashbacks.
• Avoidance of people, places, activities, or situations that remind the individual of the traumatic event can also occur. 
• Negative changes in thinking and mood, such as difficulty remembering certain aspects of the traumatic event or a diminished ability to take pleasure in things the individual once enjoyed. They may develop feelings of detachment or estrangement from others. Some people with changes in mood resulting from PTSD might blame themselves for the event.
• Changes in reactivity and arousal, such as angry outbursts or being easily startled, are common symptoms of PTSD. People with PTSD may have difficulty sleeping or have a sense of being continuously tense or “on edge.”

Cognitive behavioral exposure therapy for other mental health conditions

Beyond PTSD, exposure therapy can be used to help people with various mental illnesses, anxiety disorders, and phobias, including but not limited to: 

• Specific phobias: Some people with specific phobias, such as heights, flying, enclosed spaces, spiders, and others, may find exposure therapy helpful.
• Social anxiety disorder: Some people experience considerable fear of social situations in which they might fear being embarrassed or judged by others, such as in situations of public speaking. 
• Panic disorder: This condition causes intense episodes of psychological and physical distress based on a fear of having multiple panic attacks. Symptoms of panic attacks include but aren’t limited to shortness of breath, heart palpitations, and sweating. 
• Obsessive-compulsive disorder (OCD): OCD is a condition characterized by intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions). For example, people with OCD may become preoccupied with the perceived threat of sickness, leading them to wash their hands excessively. Some OCD thoughts and behaviors can create significant problems in an individual’s life at work, school, home, and relationships.
• Generalized anxiety disorder (GAD): People with GAD may experience excessive worry, anxiety, and fear. These symptoms are persistent and often emerge without a specific cause or reason.  

Challenges and benefits of exposure therapy for PTSD

Exposure therapy is one of the most effective forms of treatment for adults with PTSD. However, some individuals are reluctant to participate. Emotional distress associated with revisiting traumatic memories may cause treatment resistance and difficulty with treatment plan adherence. 

However, some find that exposure therapy reduces symptoms like intrusive memories, avoidance behaviors, and heightened arousal. Additionally, individuals may experience a sense of empowerment when confronting and processing traumatic memories in a safe and controlled environment that they may carry into their daily lives. 

Exposure therapy is flexible, allowing therapists to tailor a treatment program to the individual’s needs and experiences. For example, they may recommend medications or pair exposure therapy with other treatments, such as cognitive-behavioral therapy (CBT). This personalized treatment approach may result in long-term positive outcomes. 

Online therapy for PTSD treatment and support

Exposure therapy is a clinically proven method for treating conditions like PTSD— helping individuals process and potentially overcome traumatic responses. By confronting traumatic memories and experiences in a safe, supportive environment, individuals may regain a sense of control and empowerment. 

For some people, PTSD can be highly destructive and have far-reaching impacts on work, relationships, and other areas of life. As such, engaging in therapy can have benefits. However, some may find that traditional, in-person therapy isn’t a fit. They may face difficulty with limited options for scheduling and selecting the right therapist. They may have challenges commuting to and from in-person appointments or encountering strangers in an office setting. 

Although it might not be a fit for everyone, research suggests that online therapy is an effective alternative to conventional in-office treatment for some people with PTSD. Virtual therapy often eliminates the need to visit an office, potentially resulting in greater scheduling flexibility and less potential anxiety associated with in-person therapy. 

Online therapy platforms like BetterHelp also offer access to a broader selection of mental health professionals who treat PTSD. This access can give individuals control over which therapist they match with and greater flexibility for changing therapists if they aren’t a match. Additionally, online therapy may be more affordable than traditional treatment without insurance coverage.