Prolonged exposure therapy for ptsd

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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:
  1. Associations among stimulus elements do not accurately represent the world,
  2. Physiological and escape / avoidance responses are evoked by harmless stimuli,
  3. Excessive and easily triggered response elements interfere with behavior, and
  4. 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.

Dead Link Removed:
  • 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.
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This is a horribly abusive treatment that actually CAUSES a far more damaging form of PTSD that appears with episodes of extreme panic often leading to the arrest and incarceration of it’s victim for dangerously psychotic reactions to it. This happened to me. After I was arrested, handcuffed and taken to psychiatric emergency facility my legitmate treatment began with a complete and accurate explanation of what was done to me and exactly why it caused the extremely damaging reaction I had to it.
Evidence is contrary to your personal experience Mark. Any therapy in the wrong hands can be dangerous. Therapy techniques are what they are, but they become effective or not dependent upon the therapist and the client. Not everyone is suited to a specific type of therapy, which is why any therapeutic approach has to be assessed prior to delivery on a person. Questions and small samplings will often tell a therapist whether a client is right for a specific therapy type.
I agree, Mark, Exposure therapy is a horrible treatment. There are much better and less painful treatments available now. Rapid Resolution therapy, Accelerated Resolution therapy, and EMDR are a few excellent treatments that give relief in 1 to 5 sessions. Will you have the memories still, of course but they wont be as disturbing, I can promise you that.
PE shows the best results, to date, for veterans.

The other forms of exposure, not trauma focused, but environmental, are needed in all trauma treatments, regardless what you choose or what works for you specifically. Anyone who says they aren’t using exposure already, is a liar. You wake up, that is exposure. Get out of bed, that is exposure. Anything you “do” is a form of exposure. Adding the word therapy simply infers where any doing action causes a negative, add the word therapy because you now want to change the negative to a neutral / positive action.

If getting out of bed for you is a negative, and you changed something so you feel better getting out of bed, then you just performed exposure therapy on yourself.

People should not confuse exposure with how it is delivered. Every single therapy type can hurt a person uniquely, when done wrong, forced, or knowledge is lacking.
I am affected by crowds of people and perform my music in front of crowds. Is this considered exposure therapy? In it’s way.
Yes, that is an exact example of exposure therapy. The very thing you fear, you also confront and face, which obviously consistently helps you keep it under control. The love, passion or desire of doing something has outweighed your fear of not doing it because of x.

Well done Engineer.
Hi, I have just started prolonged exposure therapy, i talked about one of my experiences last week, I have complex ptsd. I am struggling to listen to the recording& my flashbacks have changed & increased. I am determined to complete it but can you tell me when the symptoms will start to improve please?
Hi Julia. Once you start poking the trauma bear, it can take months to a year before you get a full grasp again on symptoms. Think of it as short term pain for long term gain. You can live with the ongoing symptoms OR you can get stuck into resolving your trauma, which does cause massive symptom spikes for months afterwards, but then dissipates to much lesser / removes intensity totally.

Well done on facing your trauma, and just stick with the symptom spikes as part and parcel of the process. Yes, it feels worse now, but in six months you will have a very different feel of things based on where you were / are now, to where you will be at in six or twelve months for intensity.
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