Prolonged Exposure Therapy

Prolonged exposure (PE) therapy is a type of therapy that seeks to address the symptoms of post-traumatic stress disorder (PTSD) over a period of time. 

In examining prolonged exposure therapy, PTSD, and how the former can treat the latter, you can determine whether this course of treatment is a therapeutic intervention that makes sense to be implemented with your clients.

Recollections of a traumatic event can pose severe limitations on a person’s life. People with PTSD may withdraw from social interactions and activities they once enjoyed in order to avoid triggers. 

Avoiding these memories or triggers is common among trauma survivors, and it may help them feel better temporarily.

However, according to practitioners of PE  this short-term relief doesn’t truly heal the person. What’s more, they theorize that further avoidance will worsen PTSD symptoms over time. 

Numerous controlled research studies support the effectiveness of PE for PTSD, showing that it can improve symptoms for individuals with various types of trauma. 

Therapists use prolonged exposure therapy for complex PTSD, they also use exposure therapy for social anxiety and exposure therapy for phobias. Those who receive PE may continue to experience its benefits after the therapy sessions have ended. 

This article discusses what PE entails, its four parts, the techniques used, and situations where PE is not preferred. 

What is prolonged exposure therapy and what does it do?

Prolonged exposure therapy is a type of cognitive behavioral therapy (CBT) designed to treat PTSD by exposing clients to traumatic memories and related triggers in a controlled environment. 

This exposure-based protocol was developed by University of Pennsylvania clinical psychology professor Edna Foa, PhD, and her research team, and it is used to help adults, children, and adolescents. 

While many individuals who struggle with PTSD receive counseling, they often don’t talk about the traumatic event. 

The opposite is true for clients in prolonged exposure therapy PTSD treatment, where the specific events responsible for causing the trauma are discussed openly with the client. 

While people would normally choose avoidance to protect themselves, prolonged exposure therapy helps them realize that gradually facing these feared thoughts, feelings, and situations allows them to process the trauma. 

In other words, they can regain control by confronting what happened—instead of being controlled by the trauma. When PE ends, clients can expect an improvement in their symptoms. In addition, they will also develop coping skills to manage distress in their daily lives. 

PE for PTSD is practiced in individual therapy  over the course of 8 to 15 weekly sessions. Each session is about 90 minutes long. 

The four parts of prolonged exposure therapy

Over the course of your client’s treatment, they can expect the following to take place:

1. Psychoeducation

During the initial phase of prolonged exposure therapy, PTSD clients should be  gaining an understanding of PTSD and how it shows up in their lives. 

As their therapist, you’ll want to explain the symptoms associated with PTSD, such as nightmares, flashbacks, distressing thoughts, and being easily startled. 

The goal here is to increase your client’s knowledge about the different aspects of prolonged exposure therapy, PTSD, and how PE can help your client. With psychoeducation, the client receives  prolonged exposure therapy training so they can feel empowered and equipped to participate in their treatment. 

2. Breathing retraining

It’s important for your client to feel relaxed before they start their exposure exercises. This is where breathing retraining comes in. 

Anxiety symptoms can arise due to trauma—and diaphragmatic, or deep breathing, can be a great way to calm your client’s nervous system. 

There are many breathing techniques you can introduce to clients. I enjoy teaching my younger clients deep breathing exercises, and I find them to be incredibly useful for adults with PTSD during PE. 

Here are three creative and easy-to-recall examples: 

• 4-7-8 Breathing: Breathe in for four counts, hold it for seven seconds, and then exhale slowly for eight seconds. 
• Bubble Breaths: Your client imagines themself blowing bubbles. As each bubble floats away, the client can feel their tension floating away as well. 
• Box Breathing: This involves taking deep breaths in a pattern that looks like the shape of a square or box. 

No matter which breathing exercise you use with clients, remind them to breathe deeply from their diaphragm rather than shallowly from the chest. 

If time permits, check out these guided meditations you can use with clients to practice deep breathing. 

3. Imaginal exposure

As the name suggests, imaginal exposure is when a client revisits their traumatic experience in detail in a therapeutic environment. They can describe the experience verbally or in writing, depending on their comfort level. 

Make sure to determine their ability to tolerate distress when determining the method of exposure. 

With your client’s consent, record their narrative so they can listen to it outside of their therapy sessions as part of homework assignments. 

Listening to their own narrative of the traumatic event gives your client the opportunity to make sense of their experience. As they listen to it repeatedly, they become less emotionally reactive and their symptoms may also reduce. 

If a client feels triggered while the audio plays, they can practice relaxation exercises. Aside from deep breathing, they can do progressive muscle relaxation (PMR) or place their hands on their chest to ground themselves in the present moment. 

4. In vivo exposure

Another means of confronting feared situations as a result of trauma is in vivo exposure. While imaginal exposure means recounting memories, in vivo exposure involves real-life activities.

For example, a client receiving exposure therapy for social anxiety may be asked to participate in a social gathering—a friend’s birthday or an office party and converse with others—as part of their homework. 

It’s not unusual for clients to feel scared or anxious during in vivo exposure, especially when they anticipate a negative outcome. This is why it’s important to let them know that they will be able to dictate the pace.

When you plan the in vivo exposure together, consider the following: 

• The specific exposure they’re willing to engage in
• How long the exposure lasts
• Coping strategies they can use at the moment

The key is to keep the in vivo exposure as manageable as possible. 

Prolonged exposure therapy PTSD techniques 

Trauma survivors may struggle with cognitive distortions or negative thought patterns that aren’t based in reality. 

For instance, someone with complex PTSD as a result of prolonged emotional abuse during childhood may deal with thoughts like:“I must have been a bad child because my parents treated me so badly,” “I’ll never be able to have healthy relationships as an adult because I’m already damaged goods,” or “I deserved to be abused because I wasn’t perfect.”

Cognitive restructuring is a helpful tool used in PE so clients learn to recognize these unhelpful thoughts and then elicit alternative, more realistic thoughts. 

Research shows that combining exposure therapy with cognitive restructuring is most effective in reducing PTSD symptoms.

In addition to breathing retraining and homework assignments between therapy sessions,  it’s also important to teach clients how to prevent a PTSD relapse. 

Relapse prevention techniques, in prolonged exposure therapy PTSD treatment, include paying attention to warning signs of relapse—such as feeling nervous, self-critical, and isolating oneself from social activities. 

We also need to make sure that our clients set short-term and long-term goals for themselves, and plan healthy habits in line with these goals. These habits may include following a consistent sleep routine, engaging in regular exercise, and eating nutritious foods. 

Contraindications for prolonged exposure therapy 

There are some instances where PE is not suitable for individuals. Those with a high suicide risk pose safety concerns, which makes them unsuitable for PE. In these situations, PE therapy may do more harm than good by exacerbating distress. 

Clients with co-occurring psychological conditions—meaning they don’t just have PTSD, but also other conditions like bipolar disorder, severe depression, and psychosis—may need other specialized treatment. 

Final thoughts 

At first, prolonged exposure therapy for PTSD may sound intimidating or even dangerous to clients, and these initial reactions are completely understandable. However, as studies have shown, controlled and gradual exposure helps address trauma long after therapy ends. 

Regardless of the type of trauma the client  experiences, the education and support therapists provide during PE is crucial to building long-term coping skills and effectively mitigating their clients’ PTSD symptoms.

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