BrainLine
Find more treatment options

In this section

Disclaimer: This article is for informational purposes only. Please speak with a medical professional before seeking treatment.

What can prolonged exposure therapy help with?

PTSD, acute stress disorder, as well as specific fears and phobias.

What is prolonged exposure therapy?

Prolonged exposure therapy (PE) is a form of psychotherapy that can help you confront your PTSD triggers and gradually reduce or overcome your fear. Specifically, it’s a trauma-focused cognitive behavioral psychotherapy. You’ll learn how to deal with trauma-related memories, feelings, and situations in healthy ways that help reduce avoidance of past trauma. The goal is to help you understand that trauma-related memories are not dangerous and do not need to be avoided. The therapist will ensure the therapy session is a safe space to confront your fears directly.

What is prolonged exposure therapy like?

Prolonged exposure therapy typically involves about 8 - 15 individual sessions with a trained therapist. According to Dr. Edward Chandler Wright of the Warrior Care Network:

Prolonged exposure involves reducing your avoidance of the traumatic memory and intentionally facing it and talking it through on a regular and repeated basis. That can be challenging, but it’s also a really effective and powerful way of reducing the disgust that the memory brings up. It’s also giving a person a chance to look at the trauma from different angles and think of it in new ways that they might not have considered … and to see if there might be a more balanced or helpful outlook you can take.

You might be asked to imagine your trauma or to write about it. Imagined exposure may be used as a first step towards exposure in real life, known as “in vivo exposure.” Or imagined exposure might be used instead of in vivo exposure, especially for people in extreme distress. Imagined exposure is also helpful in situations that are difficult to recreate in therapy, like a battlefield.

Here’s Dr. Wright again:

[Part of this therapy] is called ‘in vivo exposure.’ This involves facing physical reminders of the trauma — like pictures, movies, certain sounds or smells — as we experience situations that aren’t dangerous but feel threatening because of the trauma. For most veterans, this includes crowded, busy public places. By confronting these things, the patient finds out firsthand that nothing bad happens, they can handle the distress it brings up, and it actually gets easier with repeated practice. ... There are ways of going about trauma-focused therapy that can help a person ease into it. For example, with in vivo exposure, where we ask people to go out into crowded places, we start at a level that’s just one step outside of their comfort zone. So, we’re not asking them to go to a football game on day one, or to go straight to a mosh pit. We might have them just sit with their back to the front door of their own home. Or go to a coffee shop when it’s not too crowded and work on not watching the door to see every person who comes in. There’s always a manageable level we can start a person off with to at least get them moving in the right direction. And as they do that and see that they’re able to handle it and actually like moving forward and making progress, that progress can give them encouragement to keep at it.

As with other forms of cognitive behavioral therapy [link], you’ll also be provided with information about how fear is a physiological response to danger, about how your body reacts to fear, and about common reactions to trauma. You’ll be taught to reframe negative thoughts. And you’ll also learn coping skills like relaxation skills training and positive self talk.

What do people with PTSD say about undergoing prolonged exposure therapy?

It was explained that the treatment is more effective if I relived the trauma that I experienced. I didn’t believe that because … I said, ‘How would reliving what put me into this shell going to help me? Why should I keep reliving the trauma that I experienced?’ … Being as I wanted closure, I was willing to try it. So I tried it. There was no time set. I could have quit any time. I said, ‘It’s not going to work.’ But it worked, and it helped me. Now I have some closure.

— Arthur Jefferson, SSgt (Ret), U.S. Army

 

I repeated myself about a million times about what I did into a tape recorder where I would be honest with myself and I would listen back to it and realize that there wasn't anything I could do. My stories were consistent in my choices. My choices were consistent because of what happened. I didn't feel that me doing it by myself and not seeking treatment was gonna be beneficial. So going to [PE] was actually an advance forward. It was a step. It was a progression in the direction that I wanted to move.

— John Angell Jr., U.S. Marine Corps

 

With prolonged exposure and reliving the instance over and over and over again, the memory doesn’t fade. The intensity behind it does. And by reliving some of the scariest moments of my life when I was in Iraq, you learn that it’s there, but the intensity of the memory goes away.

— Veteran

 

 

Prolonged exposure was the best. The toughest but the best. I felt like this thing was chasing me and it was a big, ugly monster after me and then I turned around and it was really just a mouse, you know, once I faced it and confronted it.

4 Veterans speak about PE

Why does prolonged exposure therapy work?

When you experience a traumatic event, often a natural response called avoidance develops. Avoidance is when you avoid people, places, situations, or triggers that remind you of the traumatic experience. This is a natural response to trauma, because the brain wants to avoid experiencing the pain, fear, and other negative emotions and bodily sensations that are associated with the traumatic event. However, sometimes generalization occurs. Generalization is the process of associating things that are normally harmless with the traumatic event. A common example of generalization is when someone experiences trauma in a combat environment, but that trauma generalizes to normal events like a car backfiring, fireworks, or loud sounds or noises.

PE works because the therapist helps you identify those times when avoidance and generalization have happened. By confronting this fear in the safe environment of a controlled session, you can learn to reduce your fear and anxiety surrounding a specific memory or experience, gradually eliminating avoidance behavior and increasing quality of life. This usually occurs by gradually introducing objects, ideas, or situations that could be related to the avoidance or generalization behavior.

Since anxiety is physiological, its treatment also requires learning strategies to help cope with the distress in the moments where you are confronted with triggers. The idea is that through exposure, you can safely re-experience the scary emotions repeatedly until the reminders (or triggers) no longer elicit such a strong physiological response. This habituation response then allows you to process the painful emotions so you can recognize that they aren’t dangerous.

What do experts say about prolonged exposure therapy?

In PE we help the person confront the memory of the traumatic event and the reminders of the traumatic event, but in a therapeutic manner so that something changes. A lot of our folks will say doc, what are you talking about? I think about the trauma a hundred times a day. How is this different? What is different is the way we do it. The way they do it, they might think about it and then they avoid it. They shut it down. And we’re going to have them go through it in their mind’s eye, describe the traumatic event out loud. And we do it over and over and over and we tape record it and get them to listen to it at home. And then we do what we call process it. So we talk about some of the stuff that comes up. Talk about the guilt that maybe they didn’t do enough. Talk about the fear or other things that are holding them back.

— Dr. Barbara Rothbaum, Emory University, Warrior Care Network

SIt’s not necessarily the kind of treatment where you’re going to feel better that same day because you talked something through. I think of it more as tough exercise where you’re going to work really hard and you might feel sore or exhausted afterwards, but that hard work leads to a longer-term improvement that accumulates over time. And we know that the things we ask of them in exposure therapy may be in direct contradiction to what’s most comfortable for them or what they think is keeping themselves safe. Because with prolonged exposure, we’re trying to actively target that avoidance. Avoidance is a very understandable coping strategy that people have developed and that’s helping them manage their symptoms, but it’s really preventing them from recovering in the longer-term.

— Dr. Edward Chandler Wright, Massachusetts General Hospital, Warrior Care Network

What makes for quality treatment with prolonged exposure therapy?

You’ll need a licensed therapist with specialized training in prolonged exposure therapy from an established program. These programs typically include extensive education, hands on training and/or intensive workshops in how to perform PE as well as significant experience with cases under supervision before a practitioner becomes independent.

How strong is the evidence for prolonged exposure therapy?

According to the National Centers for PTSD, “Prolonged Exposure [PE] is one of the most frequently studied treatments for PTSD. Based on the large number of studies showing it is effective, [PE] has the strongest recommendation as a treatment for PTSD in every clinical practice guideline.”

The American Psychological Association “strongly recommends” PE as an effective treatment for adults with PTSD. That rating is based on four factors: strength of evidence, balance of benefits versus harms and burdens, patient values and preferences, and applicability.

Many scientific studies have been done to determine whether PE is a safe and effective treatment for PTSD. For instance, a study in 2010 in Clinical Psychology Review found that among 675 people, the average person who completed PE fared far better than a person who hadn’t completed this therapy. These people also showed large reductions in symptom severity, and these reductions lasted over time. In 2020, Clinical Psychology & Psychotherapy published a meta-analysis of 18 studies covering 1397 people with PTSD. It found that PE helps lower severity of PTSD symptoms and that these changes lasted over time. It also found that PE was more effective when combined with medication.

With prolonged exposure and reliving the experience over and over and over again, the memory doesn’t fade.  The intensity behind it does. And by reliving some of the scariest moments of my life when I was in Iraq, you learn that it’s there, but the intensity of the memory goes away.

Veteran Andrew Reeves

Where can I go to get prolonged exposure therapy? (limited list)

Please note: Some practitioners may not do PE outside of an inpatient or intensive outpatient program (IOP) setting like the Wounded Warrior Project® Warrior Care Network due to liability or potential for initial negative outcomes.

References

Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical psychology review, 30(6), 635-641.

Zhou, Y., Sun, L., Wang, Y., Wu, L., Sun, Z., Zhang, F., & Liu, W. (2020). Developments of prolonged exposure in treatment effect of post‐traumatic stress disorder and controlling dropout rate: A meta‐analytic review. Clinical Psychology & Psychotherapy, 27(4), 449–462.

Disclaimer: This article is for informational purposes only. Please speak with a medical professional before seeking treatment.

 

Reviewed by Amy Shapiro-Rosenbaum, PhD, Cooper Hodges, PhD, Lyndsay Tkach, MA, CBIS, and Michelle Neary, March 2021.

The BrainLine Treatment Hub was created in consultation with TBI and PTSD experts.