Prolonged Exposure

Modality Format

A PE treatment is typically delivered in 9 to 12 individual therapy sessions of 90 minutes' duration. The first two sessions focus on information gathering and providing psychoeducation on PTSD and other common reactions to traumatic events. If the client has experienced multiple traumatic events, the therapist helps the client identify the event that causes the most distress (referred to as the “index trauma”). [Page 466]Later sessions involve repeated imaginal exposure to the index trauma and homework assignments including in-vivo exposure to avoided trauma cues between sessions.

Core Therapeutic Procedures

Imaginal and in-vivo exposure, the two core procedures in PE, consist of confronting memories and real-life situations related to the traumatic event(s). During imaginal exposure, the client is asked to mentally revisit the traumatic event, describing in vivid and temporally ordered detail how the event unfolded. The client indicates how much anxiety he or she is feeling at the beginning, during, and after this procedure using the Subjective Units of Distress Scale (SUDS). Monitoring levels of anxiety from 0 to 100 with the SUDS allows client and therapist to track changes in anxiety over time, both during each session and throughout treatment. This process of retelling the trauma is repeated in subsequent sessions and coupled with cognitive restructuring and relaxation techniques. In addition, the client is asked to listen to his or her audiotaped trauma narrative at home.

During in-vivo exposure, the client repeatedly confronts potentially distressing but nonharmful real-life situations that trigger memories of the trauma. Before embarking on this process, therapist and client collaboratively establish a hierarchy of feared and avoided situations. The client is then assigned exercises involving exposure to specific items on the hierarchy, moving from the least anxiety-provoking to the most anxiety-producing situations in a systematic, step-by-step fashion.

Another technique used in PE is cognitive restructuring, a process in which the client learns to identify maladaptive, inflexible patterns of thinking that contribute to anxiety and perpetuate avoidant behaviors. The client also learns relaxation techniques (e.g., how to breathe normally) to manage anxiety in his or her daily life. PE may also incorporate behavioral activation techniques such as scheduling positive activities to reduce symptoms of emotional numbing, social withdrawal, and depressed mood.

Theoretical Basis

PE is based on a fear-conditioning model of PTSD that considers difficulties in unlearning fear responses to reminders of the trauma as pivotal to the development and maintenance of PTSD. Both healthy individuals and people who develop PTSD tend to experience vivid, intrusive memories as an initial response to a highly stressful event. In healthy individuals, however, the intensity and frequency of these emotionally charged memories gradually diminish over time. In contrast, individuals with PTSD continue to be haunted by memories of the traumatic event and often reexperience the event through intrusive and disturbing memories, flashbacks, and nightmares.

...