Prolonged exposure therapy (PE) is a theoretically-based and highly efficacious treatment for chronic post-traumatic stress disorder (PTSD) and related depression, anxiety, and anger. Based on basic behavioral principles, it is empirically validated, with more than 20 years of research supporting its use. Prolonged exposure is a flexible therapy that can be modified to fit the needs of individual clients. It is specifically designed to help clients psychologically process traumatic events and reduce trauma-induced psychological disturbances. Prolonged exposure produces clinically significant improvement in about 80% of patients with chronic PTSD.The PE therapy was found to be superior to supportive therapy in sexually abused women with PTSD in a randomized controlled trial. Prolonged exposure therapy was also found to decrease PTSD and depressive symptoms in female methadone-using child sexual abuse survivors.
Prolonged exposure therapy was developed by Edna B Foa, PhD, Director of the Center for the Treatment and Study of Anxiety. Practitioners throughout the United States and many other countries currently use prolonged exposure to successfully treat survivors of varied traumas including rape, assault, child abuse, combat, motor vehicle accidents and disasters. Prolonged exposure has been beneficial for those suffering from co-occurring PTSD and substance abuse when combined with substance abuse treatment.
Over years of testing and development, prolonged exposure has evolved into an adaptable program of intervention to address the needs of varied trauma survivors. In addition to reducing symptoms of PTSD, prolonged exposure instills confidence and a sense of mastery, improves various aspects of daily functioning, increases client’s ability to cope with courage rather than fearfulness when facing stress, and improves their ability to discriminate safe and unsafe situations.
In 2001, Prolonged Exposure for PTSD received an Exemplary Substance Abuse Prevention Program Award from the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA). Prolonged exposure was selected by SAMHSA and the Center for Substance Abuse Prevention as a Model Program for national dissemination.
PTSD is characterized by the re-experiencing of the traumatic event through intrusive and upsetting memories, nightmares, flashbacks, and strong emotional and physiological reactions triggered by reminders of the trauma. Most individuals with PTSD try to ward off the intrusive symptoms and avoid the trauma-reminders, even when those reminders are not inherently dangerous. To address the traumatic memories and triggers that are reminders of the trauma, the core components of exposure programs for the disorder are:
- Imaginal exposure,Imaginal exposure can help a person directly confront feared thoughts and memories. Imaginal exposure may also be used when it is not possible or safe for a person to directly confront a feared situation. For example, it would not be safe to have a combat veteran with PTSD directly confront a combat situation again.Therefore, he may be asked to imagine a feared combat situation that he experienced.
- Interoceptive Exposure was originally designed to treat panic disorder. However, there is evidence that it may be successful in the treatment of PTSD as well. It is designed to help people directly confront feared bodily symptoms often associated with anxiety, such as an increased heart rate and shortness of breath. The therapist may assist this by having a person (in a controlled and safe manner) hyperventilate for a brief period of time, exercise, breath through a straw or hold his breath.
- Prolonged Exposure therapy is a combination of the above three methods. It has been found to be very effective for PTSD sufferers and involves an average of 8 to 15 sessions for about 90 minutes per session. Prolonged exposure therapy consists of education about trauma and what you will be doing, learning how to control your breathing (interoceptive exposure), practicing in the real world (in vivo exposure) and talking about your trauma (imaginal exposure) revisiting the traumatic memory, repeated recounting it aloud, and processing the revisiting experience.
- In vivo exposure, refers to the direct confrontation of feared objects, activities or situations by a person under the guidance of a therapist. For example, a woman with PTSD who fears the location where she was assaulted may be assisted by her therapist in going to that location and directly confronting those fears (as long as it is safe to do so). Likewise, a person with social anxiety disorder who fears public speaking may be instructed to directly confront those fears by giving a speech.
The goal of this treatment is to promote processing of the trauma memory and to reduce distress and avoidance evoked by the trauma reminders. Additionally, individuals with emotional numbing and depression are encouraged to engage in enjoyable activities, even if these activities do not cause fear or anxiety but have dropped out the person’s life due to loss of interest.
The imaginal exposure typically occurs during the therapy session and consists of retelling the trauma to the therapist. For the in vivo exposure, the clinician works with the client to establish a fear and avoidance hierarchy and typically assigns exposures to these list items as homework progressively. Both components work by facilitating emotional processing so that the problematic traumatic memories and avoidances habituate (desensitize).
Exposure therapy is considered a behavioral treatment for PTSD. This is because exposure therapy targets learned behaviors that people engage in (most often the avoidance) in response to situations or thoughts and memories that are viewed as frightening or anxiety-provoking.
For example, a rape survivor may begin to avoid relationships or going out on dates for fear that she will be attacked again.
It is important to recognize that this learned avoidance serves a purpose. When a person experiences a traumatic event, he may begin to act in ways to avoid threatening situations with the goal of trying to prevent that traumatic experience from happening again.
In many ways, this avoidance is a safety-seeking or protective response. However, as this avoidance behavior becomes more extreme, a person’s quality of life may lessen. He may lose touch with family or experience difficulties at work or in relationships.
In addition, avoidance can make PTSD symptoms stick around longer or even intensify. That is, because a person is avoiding certain situations, thoughts, or emotions, he doesn’t have the opportunity to learn that these situations may not be quite as threatening as they seem.
In addition, by avoiding thoughts, memories, and emotions, a person doesn’t let himself fully process those experiences.
The goal of exposure therapy then is to help reduce a person’s fear and anxiety, with the ultimate goal of eliminating avoidance behavior and increasing quality of life. This is done by actively confronting the things that a person fears.
By confronting feared situations, thoughts, and emotions, a person can learn that anxiety and fear will lessen on its own.
So, how does a person actively confront feared situations, thoughts, and emotions during exposure therapy? A number of methods may be used by a therapist.