Prolonged Exposure Therapy (PE) was developed by Edna B. Foa, who is the Director of the Center for the Treatment and Study of Anxiety. PE is simply referred to as “Exposure Therapy,” and to date is the most highly efficacious treatment for the treatment of Posttraumatic Stress Disorder (PTSD). PE is encompassed as one part of the more robust treatment for PTSD, being Cognitive Behavioral Therapy (CBT) model. Exposure therapy is an emotional processing behavioral therapy, and primarily targets fear conditioning. What most don’t realize is that we perform exposure therapy daily, doing nothing other than going about our lives. This is how we function in life, until something goes wrong, like severe trauma, which impedes our basic functioning abilities.
There are many who have adapted exposure therapy to suit themselves and their practice, however; this page focuses with the primary developer, Edna B.Foa, because this has shown to be the fundamental source demonstrating the best overall result, specifically for those with PTSD. The first reference is the substance to this article, with further references merely highlighting any specific points. There are studies for and against everything nowadays, though any of empirical nature, demonstrate PE as the best for longevity.
How Does Prolonged Exposure Therapy Work?
The simplicity of exposure therapy is that it invokes a two fold effect. Most therapy is undertaken in a therapists office. Lots of talk, without any real doing, such as Eye Movement Desensitization and Reprocessing (EMDR) and Trauma Focused – Cognitive Behavioral Therapy (TF-CBT). Exposure therapy takes a different approach, by swapping the primary therapeutic role to doing, which invokes an emotional response that can then be talked about. How can you talk about something in therapy that you don’t really fully understand to begin with? You can’t, which is why most cognitive therapies by themselves lack effective long term results due to little acknowledgement and reinforcement within the brain; with severe and complex sufferers, they quickly revert to existing negative behaviors because rationale has not been accepted through reinforcement within their brain through the act of doing.
PE however, if used correctly, completely changes that outcome by mixing together practical aspects to intentionally provoke an emotional reaction that can then be cognitively processed and further lessened through a combination approach. It all comes back to belief systems and associated fear.
PE is a desensitization therapy that removes irrational fear conditioning from the brain. Because you’re now scared of men, as a man raped you, PE pieces together rational vs. irrational fears, by combining the practical aspects and reinforcing that practice with the theoretical emotional reinforcement, ie. go talk with random men within controlled environments, say hello to them in the shops, etc, then reinforce the result to yourself vs. what you perceived would happen. If you drowned at the beach, got rescued and were resuscitated, you may now fear the ocean, so PE would begin you at walking along the beach, then walking on the beach in the water, and progressively edging you back into the ocean, demonstrating and reinforcing the aspects specific to that one event vs. how long have you been swimming in the ocean when nothing bad has happened! Rational vs. irrational logic due to a new fear response. Some aspects must be tackled in theory, but the majority is doing the actual task yourself.
A fear structure becomes pathological when:
- Associations among stimulus elements do not accurately represent the world,
- Physiological and escape / avoidance responses are evoked by harmless stimuli,
- Excessive and easily triggered response elements interfere with behavior, and
- Harmless stimulus and response elements are erroneously associated with a threat meaning.
To put it simply, basic life functioning causes extreme anxiety to you because you fear it, which is irrational fear, not rational fear. Rational fear is something that has valid threat or danger associated to it, ie. jumping from an airplane, walking through a known bad neighborhood late at night, or down a dark alley in a crime district that you know is used by gangs. Rational vs. irrational fear!
Bad things still happen to people when they rationally should not, which is where acknowledging that being in the wrong place at the wrong time exists, and there is nothing you can do about that in life, and must accept this as part of life. What you control vs. what you do not control.
Types of Exposure Therapy
There are various methods in which exposure therapy can be applied, both within a theoretical context and practical context, some of which are:
- Imaginary – You remember your trauma within your mind, noting emotions and reactions as they arise.
- Talking – This is exposure therapy, the physical act of saying your trauma, even followed by repetitive listening to it after the fact.
- Writing – You write about your trauma on paper or computer then read it over and over.
- Practical (In Vivo) – You physically do something you fear, starting progressively and building up to the actual event.
There are many types of exposure therapy, which you can really come back to using the five senses. As stated initially, exposure therapy is really everything we do, prolonged exposure then re-exposes the brain constantly to desensitize an irrational fear, which is how humans go about life day to day.
Prolonged Exposure Structure
PE is structured in a similar manner using a basic 8 – 12 session format. Like most trauma therapies, this format is also completely useless for the majority of PTSD sufferers who happen to endure life long PTSD symptoms. The significant difference with PE to other therapies is the session length, being PE should be 90 minute session lengths.
- Session 1 – Program overview, trauma interview and breathing retraining.
- Session 2 – PTSD education and rationale of exposure, SUDS briefing, construct In Vivo hierarchy and assign homework.
- Session 3 to 11 – Conduct and process imaginary exposure, assign homework.
- Session 12 – Assess before and after results, finalize therapy and discuss relapse.
Severity dictates length of overall therapy, not a theoretical structure recommendation.
Whilst PE is deemed to be the most efficacious treatment for PTSD longevity, it is more apt to state that PE, when combined with a cognitive processing treatment such as CTT, EMDR and stress inoculation training, obtains significantly better results than by using any one method by itself.
PTSD treatment is best treated using the right combination of treatments, as all four tier 1 treatment options bring unique aspects to the sufferer that no one by itself cater. When combined, suddenly longevity of results is obtained, and continues to improve with time.