Prolonged Exposure Therapy

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Prolonged exposure therapy for post-traumatic stress disorder works by slowly exposing the patient to an event that caused trauma. People often want to avoid experiences that remind them of their trauma, but this tends to allow the feelings of fear to persist. Gradually confronting the trauma teaches the patient that they are not actually in danger when they experience situations and emotions that remind them of their trauma.

Two types of exposure may be used during the treatment of post-traumatic stress disorder, including the following. 

Imaginal exposure for post-traumatic stress disorder

Imaginal exposure therapy for PTSD occurs during the therapy session. The patient describes the traumatic event in detail using the present tense, and the therapist and patient talk about the emotions raised by the imaginal exposure to aid in emotional processing. As the patient describes the event, they are recorded so they can listen to it between sessions to help process how they felt. 

In-vivo exposure for post-traumatic stress disorder

In-vivo exposure treatments for PTSD occur outside of the scheduled therapy session. The patient and therapist work together to identify people, places, and activities related to the traumatic event and choose which ones the patient should confront. This is typically completed in a way that challenges the patient without overwhelming them, building up their tolerance to feared stimuli.

By repeatedly experiencing a traumatic memory, experts believe that patients can process what happened, differentiate the past from the present, and gain control over the memory that may have been negatively impacted by post-traumatic stress. If a patient has experienced multiple traumatic incidents, targeting the most distressing event first can have a ripple effect that improves how they react to other traumatic memories.

Prolonged exposure therapy for PTSD is typically provided during weekly sessions spanning three months, with 8 to 15 sessions in total. Sessions are usually 90 minutes but can last anywhere from 60-120 minutes. The course of treatment suggested by Edna Foa for post-traumatic stress disorder is detailed below. 

During the first session, the patient and clinician may work together to choose an index trauma to address during the treatment. If the patient has experienced multiple traumas, it is suggested to target the memory that can provide the most efficient results. The event should be a notable memory that the patient can recall and narrate. It should also be associated with the patient’s distress and avoidance.

In the second session, the patient learns about common reactions to trauma, so they can better understand their symptoms and their connection to PTSD. The therapist may also introduce in-vivo exposure so that the patient can begin listing situations they’ve been avoiding, then rank them by how distressed they would be to confront each. After the stimuli are ranked, in-vivo assignments are selected to be completed outside of therapy sessions, with a goal of remaining in each situation either 45-60 minutes or until anxiety has decreased by at least 50%.

During the third session, imaginal exposure is introduced, discussed, and begun. The therapist and patient may spend approximately 45 minutes participating in imaginal exposure, and then 15-20 minutes may be spent processing the patient’s experience and what they learned. The patient may also be encouraged to listen to a recording of their recounting daily to help decrease anxiety. 

The remaining sessions of prolonged exposure therapy are spent reviewing the patient’s in-vivo homework assignments for the week and then completing imaginal exposure. During the final session, the patient and clinician will discuss the progress made and what the patient learned throughout the treatment. They will also create a plan to help the patient maintain the progress they achieved to help avoid any form of regression. 

Prolonged exposure therapy is most commonly recommended for the treatment of posttraumatic stress disorder. It can be beneficial for people who experience traumatic events such as:

• Natural disasters
• Physical or sexual assault
• Motor vehicle accidents
• Deployment
• Serious illness
• Fire
• Death of a loved one

The treatment, based on principles of cognitive-behavioral therapy, can successfully treat patients who have experienced more than one type of trauma or have comorbid conditions such as depression, a traumatic brain injury, substance use disorder, or suicidal ideation. Although the focus of prolonged exposure isn’t decreasing symptoms of depression, the treatment has been shown to help with these symptoms alongside those of post-traumatic stress disorder (PTSD).

While the majority of research has focused on the role of prolonged exposure in treating adults with PTSD, studies have shown that the treatment is also effective in children and adolescents with the condition. However, providers may need to follow a modified approach known as Trauma Mastery Therapy, in clinical psychology, which follows a different treatment schedule and involves the participation of a child’s caregivers. Other methods that may be beneficial for people with post-traumatic stress disorder (PTSD) include eye movement desensitization and reprocessing therapy (EMDR) and trauma-focused cognitive-behavioral therapy. 

Prolonged exposure is designed to accomplish several therapeutic goals.

Correct exaggerated expectations of harm occurring

This is accomplished by activating the fear structure without the patient being in the trauma that created the fear. Patients learn to tolerate the feelings of distress caused by in-vivo and imaginal exposure without sensing that they’re losing control. 

Organize the narrative in memory

Repeatedly retelling the story of the traumatic event helps the patient create a clear mental picture of what happened so the event isn’t modified in their mind. This has been shown to improve symptoms of PTSD. 

Distinguish the memory of trauma vs. the actual experience

Repeatedly retelling the traumatic event also helps change the associations that have been created between the traumatic memory and the perception of being in danger. Initially, patients with PTSD may report that just thinking about the experience makes them perceive that they’re reliving it. Talking through the event in a safe environment, in the presence of a trusted therapist, can help them discriminate between the feeling of threat that accompanies their memories and an actual, physical threat in the present moment. 

Change negative thoughts based on the trauma

These thoughts, such as ‘I am too weak’ or ‘the world is a dangerous place,’ are considered to be at the center of the fear structure for PTSD. Imaginal exposure is designed to help patients differentiate between the traumatic event they experienced and stimuli that are connected to it, so they can declare the negative thoughts they have to be untrue.

Researchers compared the impact of prolonged exposure therapy and cognitive processing therapy in treating the symptoms of posttraumatic stress disorder. Around 915 veterans participated in the study, and while PTSD symptoms improved in both treatment groups, there was a greater reduction of symptoms in those who completed prolonged exposure. This conclusion is similar to other recent studies that have looked at the efficacy of PE in supporting veterans and military personnel. 

Exposure therapy has also been shown to improve symptoms of PTSD in children and adolescents. A meta-analysis of six trials found that the treatment improved symptoms of both PTSD and depression in young patients, similar to the improvements seen in adult patients. When treating young children, however, the authors asserted it may be more beneficial to address all childhood events that may contribute to PTSD, not just the index trauma.

One challenge of prolonged exposure therapy is that clinicians rely on patients to complete and report on their in-vivo exposure, and not all patients are willing or interested in doing so. Researchers are currently examining the use of medical technology in allowing therapists to virtually ‘accompany’ patients as they complete their in-vivo exposure. While the research is still ongoing, the goal is to help maximize the therapeutic value of in-vivo exposure to help improve symptoms of PTSD.