Prolonged Exposure Therapy for PTSD: Common Questions Answered

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).

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.

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.

Overall, studies comparing PE and CPT find them equivalent.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.