I hear this question often, and it is important for providers working with trauma survivors to follow the lead of the client. If a trauma survivor is having the symptoms of PTSD, there is not imminent risk (due to imminent safety or suicide risk; severe alcohol or substance use that require detox or intervention for physical safety), and they are presenting for treatment then they are ready for trauma work. As providers, it is our job to help people approach instead of avoid the trauma memory or memories that are haunting them. One part of this is letting the client know that it is unlikely PTSD will at some point make it easy to approach- PTSD is a disorder of avoidance. By approaching instead of avoiding the memory, trauma survivors can take their lives back from PTSD.

Trauma survivors with PTSD often have a lot of stressors in their life. This is normal and it is one way a treatment provider can assist. As a provider, once PTSD has been identified and we are working on trauma focused treatment, if the crisis is not life threatening then maintaining that focus to work through the PTSD symptoms is the most effective way for me to help the survivor. When PTSD is reduced, the survivor has more emotional resources to address all the other things going on in their life. We can align with the survivor to continue to focus on PTSD. Of course, this is always a collaborative decision working with the survivor to decide if they want to continue treatment, take a break, or end- and part of what we discuss is the benefit of finishing treatment. We can save 5-10 minutes at the end of session to discuss other issues (such as divorce, recent job loss, etc.) while maintaining the rest of the session focused on PE.

If we are doing memory exposure and the client is dissociated from their trauma, some guidance is provided below. The in session guide for the provider is to consider "what is the survivor learning in session today?" At its core, we want the client to have successful experiences where they are approaching the trauma memory or memories, feeling the emotions connected and seeing that they can do this. Part of our job as a provider is to notice what supports a client may need and integrate them either on a temporary basis to start or for the longer term. If the dissociations are brief (less than a minute or two) and the client returns to the exposure exercise, then I would not intervene and would provide lots of encouragement for their success in approaching the trauma in the processing. The provider would be watching and predicting that the number and duration of these dissociative moments would reduce as the client continues in treatment. If the client is not returning to the exposure work after a few minutes, then grounding techniques can help. Grounding techniques can include statements from a provider (saying the client's name, reminding them this is a memory in the past and you are here in XXX safe in my office), brief contact with a strong sensory stimulus (such as touching a cold metal filing cabinet near the client, an ice cube, etc.), or engaging in a behavior that grounds (such as twisting a tissue, etc.). Prior to exposure, if I am aware a client has a tendency to dissociate, I may set up a plan together for how they might want me to "bring them back." If the dissociation occurs and we have not already planned, I will use these same techniques and then ensure we plan for future sessions together. Recent work has also shown that clients who dissociate respond well to prolonged exposure (Van MInnen et al., 2012) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3406222/

Any client with PTSD who is not at imminent risk and who is seeking treatment would be a good candidate for PE or CPT. Research does not support that there are predictors of who might respond better to PE or CPT. Clients with guilt, anger, and dissociation can do well in either PE or CPT. A recent study in the VA suggested that remission and early response are more likely in PE than in CPT, though both interventions showed large reductions in PTSD and depression (Schnurr et al., 2022) https://jamanetwork.com/journals/jamanetworkopen/articlepdf/2788220/schnurr_2022_oi_211046_1641920492.11468.pdf If a provider is able to do both treatments well, then a discussion with the client can be helpful to decide what to do. If the provider is only able to do one or the other treatment, then starting with that intervention, whether PE or CPT, is an excellent treatment course.

Good differential diagnosis is necessary and then treatment planning based on that differential diagnostic evaluation will guide care. Bullying can meet criteria for what our diagnostic codes call trauma, and for some people, those memories are giving rise to the symptoms of PTSD. For others, the reaction may become another disorder that would be better described as generalized anxiety disorder, depression, or even substance use disorder. If the bullying involved a risk of harm to self or others and a specific memory or memories of the bullying is haunting the bullying survivor, then PTSD treatment may be appropriate. If the client has depression, then an appropriate intervention for depression would be warranted.

Readers are referred to the manual (Foa et al., 2019) for guidance on how to use PE effectively with all types of client presentations. At its core, PE providers are working with clients to:

1. Approach their trauma memory or memories.
2. Feel the emotions connected with those memories until the emotions either reduce in intensity or until the client experiences that they can feel strong affect without permanent negative consequences.
3. Approach the trauma-related and avoided people, places, and situations to take their lives back from PTSD. For most clients, this means following the standard PE procedures. Providers who are able to be supportive, encouraging, present and collaborative as their clients approach the memories and feel strong affect will see their clients improve.

I believe this question is asking whether a video recording can be used for the practice between sessions instead of the audio recording. Ideally, the client is closing their eyes and engaging with the memory content when listening to the imaginal exposure between sessions. Watching a video for most clients would reduce the engagement with the memory and emotional content. However, if a client requires this for some reason (such as difficulty hearing) or if the client gets over engaged with eyes closed, a provider might make that modification to use video instead of audio recording. The goal is to have the client approaching the memory and feeling the emotions connected.

Emotional processing theory (EPT; i.e., Rauch & Foa, 2006) forms the rationale for PE. At its heart, EPT, as applied to PTSD, asserts that the symptoms of PTSD develop following trauma due to:

1. avoidance of the trauma memory and reminders, and
2. negative thoughts about the self and the world. The more that a trauma survivor avoids the trauma memory and reminders, the more quickly and severely the PTSD symptoms will grow. In addition, once avoidance starts, negative reinforcement can result in clients limiting engagement to more and more people, places, and activities. Basically, the “safe” spaces get smaller, and the “dangerous” spaces get larger. Only by approaching instead of avoiding can a client take their life back from PTSD and learn that those trauma-related and avoided memories and reminders are not as dangerous as they feel due to PTSD.

Thank you for this question. I would not describe prolonged exposure as slowing down the cognitive process. Instead, I would describe PE as opening a window on the trauma memory that allows change to occur. The change that occurs comes from the experience of revisiting the memory and feeling the associated affect as well as changes to how the client views the self and the world at the time of the trauma and now. PE involves a digging into the memory, staying with it, and coming out the other side with a different perspective on the trauma and the self. For clients, as they feel more able to handle negative affect at the time of the trauma and now, the more they feel able to do what they want in life and PTSD symptoms are reduced.

Guilt responds well to both PE and CPT, and I would recommend if the veteran has PTSD engaging in one of these highly effective treatments would be an excellent plan. If you are working in PE on guilt, treatment will include processing focused on the pieces of the memory related to the guilt. For instance, if this veteran feels guilty about an action taken during a combat situation, the imaginal exposure will include revisiting in detail the memory and feeling the feelings associated, discussing those feelings then and now in processing, and discussing any thoughts that may change as the memory exposure progresses. Processing in these cases is reflective and present focused, with lots of room for the client to explore the memory with the provider to allow them to put the behaviors at the time of the trauma and now in the context of the trauma. The manual for PE (Foa et al., 2019) has additional direction and suggestions for how to address guilt.