Question 1

Does the distinction between PTSD and Complex PTSD have consequences for Prolonged Exposures?

Barbara Rothbaum · Accepted Answer

In studies that have explored these distinctions, PE has been found effective regardless of childhood trauma and symptom presentation.

Question 2

My clients refuse to participate in exposure therapy because they are avoidant. How can I address this?

Barbara Rothbaum · Accepted Answer

Express confidence that exposure therapy will help them and that you know they can do it. The fact that they are avoidant is even more reason they need exposure therapy. If they weren’t avoidant and weren’t hesitant, they wouldn’t have PTSD. Praise their efforts every session and let them know you understand how hard this is for them and that it will be worth it. It also works pretty quickly in the scheme of things.

Question 3

How does Prolonged Exposure Therapy rate for single incident trauma versus developmental or multiple incident trauma?

Barbara Rothbaum · Accepted Answer

The majority of patients who present for treatment for PTSD have been multiply traumatized and PE works just as well as for single incident traumas.

Question 4

How do you recommend that therapists overcome their own discomfort to use exposure in trauma therapy?

Barbara Rothbaum · Accepted Answer

In training therapists new to PE, we talk a lot about the parallel processes. The therapist is anxious about starting exposure therapy just as their patient is anxious. Both of their anxieties should decrease once they start and with repeated exposure. Sometimes therapists new to PE are hesitant to help their patients continue exposure when the patient wants to avoid. We encourage the therapists to borrow our confidence and the strength of the evidence, and the patients have thanked them in the end.

Question 5

How does Prolonged Exposure Therapy compare with other forms of CBT?

Barbara Rothbaum · Accepted Answer

In comparative studies, PE works equally well as comparison trauma- focused therapies and tends to work better than non trauma focused therapies. It is actually difficult to find differences between active treatments.

Question 6

What are the main challenges that clinicians encounter when utilizing Prolonged Exposure Therapy?

Barbara Rothbaum · Accepted Answer

I think the greatest challenge is patient avoidance and early termination from treatment. Clinicians are often worried about over-engagement, which we rarely see, but are more often confronted with under engagement.

Question 7

How does Prolonged Exposure Therapy compare with Cognitive Processing Therapy?

Barbara Rothbaum · Accepted Answer

Overall, studies comparing PE and CPT find them equivalent.

Question 8

Do patients need to be able to verbalize and visualize their trauma in order to engage with Prolonged Exposure Therapy? What if they have an unclear memory of the trauma?

Barbara Rothbaum · Accepted Answer

Patients do need to have some memory of the traumatic event to engage in PE.  It does not have to be complete, for example, in the case of a motor vehicle crash in which they lost consciousness, it is possible to work with what they do remember. We don’t want to engage in PE if patients aren’t sure if something happened.

Question 9

In your experience, what are the main challenges in treating trauma survivors?

Barbara Rothbaum · Accepted Answer

The hardest part about treating trauma survivors is getting them through the door. PTSD is a disorder of avoidance, and it breaks my heart how many people are out there suffering and won’t go for treatment. Many survivors think, “You can’t change what happened, so how could this help?” because they don’t understand they are suffering from PTSD and we do have effective treatments. It can also be difficult sometimes to keep survivors in treatment due to this avoidance, and that’s why we like the intensive outpatient program so much in which people are treated daily for 2 weeks.

Question 10

What are the core elements of Prolonged Exposure?

Barbara Rothbaum · Accepted Answer

The core elements of PE are imaginal exposure to the traumatic event (revisiting and recounting the memory out loud and repeatedly, recording it for daily practice) and processing (discussion of the material that emerges during the imaginal exposure), and in vivo exposure (confronting safe reminders in real life).  We teach a brief breathing retraining to use when exposure isn’t appropriate (e.g., going to sleep).

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