Question 1

How does prolonged exposure therapy compare to somatic psychotherapy and body-oriented therapies for trauma? Are the latter better approaches for when clients present with somatic symptoms, dissociation, pre-verbal trauma or difficulty recalling traumatic events?

Barbara Rothbaum · Accepted Answer

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.

Question 2

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).

Question 3

Is the presence of drug/alcohol use or dependence an exclusionary criteria for prolonged exposure?

Barbara Rothbaum · Accepted Answer

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.

Question 4

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

Barbara Rothbaum · Accepted Answer

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.

Question 5

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 6

If a client meets criteria for PTSD due to domestic violence and at this point continues to be exposed to the risk of violence, is it okay to address the PTSD symptoms with Prolonged Exposure?

Barbara Rothbaum · Accepted Answer

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.

Question 7

What are your thoughts on the concept of repressed memories?

Barbara Rothbaum · Accepted Answer

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.

Question 8

Regarding the inclusion criteria for Prolonged Exposure, does there need to be a PTSD diagnosis or can PE address other types of psychological reactions to trauma such as depression, anger, shame, chronic anxiety, panic etc?

Barbara Rothbaum · Accepted Answer

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.

Question 9

What are the primary risks associated with Prolonged Exposure Therapy?

Barbara Rothbaum · Accepted Answer

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.

Question 10

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?

Barbara Rothbaum · Accepted Answer

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

Question 11

How can Prolonged Exposure Therapy be tailored for clients with ABIs (which has impacted their cognitive function)?

Barbara Rothbaum · Accepted Answer

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.

Question 12

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 13

How does Prolonged Exposure Therapy compare with Cognitive Processing Therapy?

Barbara Rothbaum · Accepted Answer

Overall, studies comparing PE and CPT find them equivalent.

Question 14

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 15

Are there specific trauma populations that have a particularly strong evidence base for utilizing Prolonged Exposure Therapy for PTSD?

Barbara Rothbaum · Accepted Answer

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.

Question 16

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 17

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

Barbara Rothbaum · Accepted Answer

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.

Question 18

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

Barbara Rothbaum · Accepted Answer

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.

Question 19

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?

Barbara Rothbaum · Accepted Answer

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.

Question 20

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 21

Do legal/forensic issues need to be considered before proceeding with prolonged exposure therapy?

Barbara Rothbaum · Accepted Answer

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.

Question 22

Are there contraindications for Prolonged Exposure Therapy e.g., suicidal or NSSI behavior; medications such as benzodiazepines, current psychosis?

Barbara Rothbaum · Accepted Answer

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.

Question 23

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 24

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 25

In CBT, prolonged exposure is used for PTSD. From my experience, however, it works well for fear-based appraisals (e.g., RTA, assault, etc.), but it doesn't work for shame-based appraisals (e.g., childhood sexual abuse- CSA). What are your views on prolonged exposure when there's shame (as in CSA)?

Barbara Rothbaum · Accepted Answer

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.

Question 26

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 27

I work a lot with trauma, and I wonder what are your recommendations for the best calming strategies to use in the moment for clients who dysregulate while practicing EP?

Barbara Rothbaum · Accepted Answer

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.

Question 28

I'm a CPT therapist in SF, CA.  Many of my clients have experienced complex childhood trauma.  Does PET focus on index traumas or complexity?  What if the trauma was pre-verbal?

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

The Benefits of Prolonged Exposure Therapy