Q&A

Prolonged Exposure Therapy for PTSD: Common Questions Answered

Barbara Rothbaum on Prolonged Exposure Therapy for PTSD, including avoidance, dissociation, shame, dropout, and the use of exposure-based approaches across complex trauma presentations.

Prolonged Exposure Therapy is one of the most researched treatments for PTSD and remains a central approach within trauma-focused cognitive behavioral therapy. Originally developed by Barbara Rothbaum, Edna Foa, and colleagues, PE has been studied across a wide range of trauma presentations and clinical settings.

Clinicians have practical questions about how exposure-based work is applied in therapy. Questions often arise around avoidance, dissociation, shame, dropout, emotional engagement, and how PE compares with approaches such as Cognitive Processing Therapy and EMDR.

In this Q&A, Barbara Rothbaum responds to common clinician questions about Prolonged Exposure Therapy for PTSD, including the core elements of treatment, common challenges in practice, and the use of PE across different trauma presentations.

What are the core elements of Prolonged Exposure?

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).

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

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.

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

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.

How does Prolonged Exposure Therapy compare with Cognitive Processing Therapy?

Overall, studies comparing PE and CPT find them equivalent.

Has Prolonged Exposure Therapy been shown to be more effective than EMDR or Internal Family Systems Therapy (IFS)?

PE has been shown to be as effective as EMDR, and in one study, patients who received PE continued to improve after treatment more so than patients who received EMDR. I am not aware of any studies comparing PE to IFS.

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

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.

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

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.

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

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.

What are the primary risks associated with Prolonged Exposure Therapy?

The primary risk associated with PE is early termination from treatment, as it is for any PTSD treatment. There is often an initial increase in distress temporarily as patients are approaching the trauma memory and reminders that usually decreases readily with continued exposure, and this is explained to patients as part of full informed consent.

What calming or grounding strategies do you recommend when clients become highly distressed during Prolonged Exposure Therapy?

In general we work on an exposure paradigm in that the best way to learn you can tolerate the memories and distress is by experiencing it in measured doses and staying with it until it decreases. We will make adjustments as necessary to achieve the right “dose” for a patient and this might include starting with their eyes open, talking in the past tense, etc - the opposite of what we do to increase engagement. With patients with borderline personality disorder, it might take them longer and more repetitions for their distress to decrease, and we point that out so that they know what to expect and don’t give up before they experience relief.

How effective is Prolonged Exposure Therapy for developmental or multiple-incident trauma?

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.

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

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

How does Prolonged Exposure Therapy approach complex childhood trauma or pre-verbal trauma experiences?

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. There does need to be a memory of the trauma that can be verbalized.

How effective is Prolonged Exposure Therapy when shame is central to the trauma response?

We have found that shame is very often involved in PTSD and that PE works very well for shame and moral injury. We address these issues in the processing after the imaginal exposure.

Can Prolonged Exposure Therapy be used when clients present with dissociative symptoms?

Yes. It is important to try to keep the patient emotionally engaged. We view dissociative symptoms as coping responses to feeling overwhelmed. When people learn they can handle the memories and the distress decreases, usually so do the dissociative symptoms.

Do you have any advice for helping clients with emotional numbness?

If they meet criteria for PTSD, then we recommend receiving an evidenced based treatment for PTSD such as prolonged exposure. One of my analogies is that when they kink the hose to avoid negative feelings, it kinks it for all feelings, so the best way is to deal with the traumatic memories and triggers and the feelings they bring up to unkink the hose and be able to experience all feelings again.

Does Prolonged Exposure Therapy require a PTSD diagnosis, or can it also help with depression, shame, anxiety, panic, and other trauma-related difficulties?

PE definitely helps with depression, anger, shame, chronic anxiety, panic, substance misuse, etc. PE is indicated if there is PTSD or significant PTSD symptoms such as in subsyndromal PTSD.

Do clients need to be able to verbalize or clearly remember their trauma in order to engage in Prolonged Exposure Therapy?

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.

What are your thoughts on the concept of repressed memories?

I think that people deal with memories when they are ready to deal with them. I am not a big fan of techniques or medications aiming to unlock repressed memories. We find that during concentrated attention on the trauma memory such as during prolonged exposure, many people remember more of the traumatic event.

Are there contraindications for Prolonged Exposure Therapy, such as suicidality, NSSI, benzodiazepine use, or psychosis?

There is a little bit of data that benzodiazepines interfere with exposure therapy. Suicidal behavior often decreases with successful treatment, but the patient must remain safe during treatment. There have been reports of the successful use of exposure therapy with patients with serious mental illness. In general, the therapist progresses slowly and carefully in treatment in an attempt to not overwhelm the patient.

Can Prolonged Exposure Therapy be used when a client remains at risk of domestic violence?

We always want to try to ensure our patients’ safety first if possible. However, some patients do not wish to leave their domestic partners. If you have explored the options and they do not wish to leave, I think it is better to treat the PTSD than not, all the while paying attention to safety. In these cases, PE is a good choice. Care must be taken to protect the patient, if, for example, a domestic partner is checking the patient ‘s phone or belongings.

Is substance use or dependence an exclusion criterion for Prolonged Exposure Therapy?

No. It used to be in the initial studies but no longer. In fact, there are several published studies successfully using PE with people with Co morbid SUD (substance use disorder). If the substance use is secondary to the PTSD, we now think it is Morse effective to treat them together. One such program is COPE.

How can Prolonged Exposure Therapy be adapted for clients with acquired brain injuries or cognitive difficulties?

PE has been used successfully with patients with traumatic brain injury (TBI) and dementia. We are delivering PE to veterans with TBI in our intensive outpatient program combined with cognitive rehabilitation and seeing great outcomes.

Has Prolonged Exposure Therapy been adapted for pediatric populations? What adaptations need to be made for children and adolescents? What is the level of parental involvement?

Esther Deblinger and Judith Cohen have developed a program for children and their non-offending parent that has received support.

Are there specific trauma populations with a particularly strong evidence base for Prolonged Exposure Therapy?

PE has been used successfully across trauma populations including rape survivors, veterans, natural disaster survivors, torture survivors, political prisoners, various civilian traumas, terrorism survivors and others and across cultures. The PE manual has been translated into about 10 languages.

How does Prolonged Exposure Therapy compare with somatic and body-oriented trauma therapies?

I am not aware of studies comparing PE to these other therapies. PTSD patients often present with somatic symptoms and dissociation and PE can help with these as well.

What percentage of people, once fully informed of the exposure therapy protocol, chose not to go ahead with therapy? How do the drop-out rates for exposure therapy compare to other approaches for treating PTSD?

The drop out rates for exposure therapy are comparable to dropout in every kind of treatment for PTSD. Dropout is a challenge across PTSD treatment.

Do legal or forensic issues need to be considered before proceeding with Prolonged Exposure Therapy?

If the patient wants treatment and wants to get better, there should be no problem delivering PE. If there is potential secondary gain, that does need to be dealt with. We often use more objective measures of PTSD and response to treatment such as psychophysiological responses in addition to patient self- report.