Prolonged Exposure Therapy: How it Works & What to Expect

What Is Prolonged Exposure Therapy?

Prolonged exposure therapy (PE) is a type of exposure therapy used to treat trauma-related conditions like PTSD. It involves gradually exposing individuals to triggers associated with the trauma while teaching them coping strategies to manage distress. Through repeated exposure, people learn that trauma memories and reminders are not dangerous and that distress fades on its own, a process rooted in emotional processing theory, the framework developed by Dr. Edna Foa and Michael Kozak in 1986. Prolonged exposure was developed by Dr. Foa and colleagues at the University of Pennsylvania and is one of the most researched PTSD treatments in the world.
Here is how prolonged exposure compares with the other leading trauma therapies:

What Can Prolonged Exposure Therapy Help With?

Prolonged exposure therapy aims to help individuals confront and process their PTSD symptoms, allowing them to reduce the impact of the trauma on their daily functioning. Research shows that PE can lead to a reduction in the severity of PTSD symptoms, such as intrusive thoughts, avoidance behaviors, and hyperarousal.² The therapy helps individuals confront their traumatic memories, gradually exposing them to trauma-related stimuli, which allows for habituation and cognitive restructuring.

Prolonged exposure therapy can help with the following symptoms:

• Intrusive thoughts or memories of the traumatic event
• Nightmares and flashbacks about the trauma
• Avoidance of situations or places that remind the individual of the trauma
• Hypervigilance or being constantly on guard
• Negative thoughts or beliefs about oneself or the world
• Difficulty sleeping or concentrating
• Feelings of detachment or emotional numbing

Is Prolonged Exposure Therapy Effective?

Prolonged exposure therapy is effective for most people who complete it: about 53% of those who start PE, and 68% of completers, no longer meet criteria for PTSD, according to the VA National Center for PTSD.⁴ Gains tend to last, with one long-term study finding 83% still free of the diagnosis 6 years later. Prolonged exposure is recommended in the 2025 American Psychological Association guideline and the 2023 VA/DoD guideline as a first-choice treatment for PTSD, and both guidelines recommend trauma-focused psychotherapy over medication. PE has been tested extensively with veterans and active-duty service members, and while it works in these groups, military-related PTSD can be harder to treat, which has driven new intensive formats delivered daily over 2 to 3 weeks.¹

What to Expect During Prolonged Exposure Therapy

Prolonged exposure therapy typically begins with a comprehensive assessment and a discussion of the individual’s treatment goals. In subsequent sessions, individuals are gradually exposed to traumatic memories and situations in a safe and controlled environment while learning coping skills to manage emotional reactions. Treatment ends with a review of progress and a discussion of strategies for maintaining progress in the future.

Here are some things to expect during the prolonged exposure therapy process: 

• Assessment: During the initial assessment stage of prolonged exposure therapy, the therapist will gather information about the individual’s trauma history, symptoms, and treatment goals. This helps to tailor the treatment plan to the specific needs of the individual.
• Psychoeducation: Psychoeducation is an essential part of the process, where the therapist educates the individual about PTSD, the impact of trauma on the brain and body, and the rationale for exposure therapy. This helps to normalize the individual’s experience and build their understanding of the treatment process.
• Imaginal exposure exercises: Imaginal exposure exercises involve revisiting and recounting the traumatic event in detail, either through verbal descriptions or writing. This allows individuals to confront and process their traumatic memories in a safe and controlled environment, gradually reducing the distress associated with them.
• In vivo exposure exercises: In vivo exposure exercises involve gradually facing feared situations or activities that individuals have been avoiding due to trauma-related fears. By gradually exposing themselves to these situations, individuals can learn that they are not as dangerous as perceived and gradually reduce avoidance behaviors.
• Homework assignments: Homework assignments play a crucial role in prolonged exposure therapy. They involve practicing skills learned in therapy outside of sessions, such as listening to audio recordings of the imaginal exposure sessions or engaging in real-life exposure tasks. These assignments help reinforce the learning and generalization of skills, facilitating progress in therapy.

Prolonged exposure therapy typically involves at least 8 to 15 weekly sessions with a licensed mental health professional. The exact process and order of these stages may vary slightly depending on the individual’s needs and the therapist’s approach. Sessions typically last 60 to 90 minutes, and research cited by the VA National Center for PTSD has found 60-minute sessions work about as well as 90-minute sessions.

Can Prolonged Exposure Therapy Be Done in 2 Weeks?

Yes. Prolonged exposure can be compressed into daily sessions over 2 to 3 weeks, a format called massed PE, and research shows it works about as well as weekly treatment. Massed formats were developed because dropping out is one of the biggest obstacles in trauma therapy, and finishing in weeks instead of months gives symptoms less time to interfere with treatment.

In a 2018 randomized trial of 370 active-duty service members led by Dr. Edna Foa, massed PE delivered over 2 weeks reduced PTSD symptoms about as effectively as 8 weeks of standard weekly PE. A follow-up randomized trial published in JAMA Network Open in 2023 by Dr. Alan Peterson and colleagues at the STRONG STAR Consortium in Texas compared 15 daily sessions of massed PE with a 3-week intensive outpatient version and found large symptom reductions in both groups, with most participants completing treatment. The VA National Center for PTSD now lists massed delivery, with 10 sessions over 2 weeks, among supported PE formats and notes low dropout rates.

Massed PE is worth asking about if weekly therapy has felt too easy to put off, if you want relief before a major life event, or if you live far from a trauma specialist and can travel for a short intensive program. The content of treatment is the same: psychoeducation, breathing retraining, in vivo exposure, and imaginal exposure with processing. Only the calendar changes.

What Techniques Are Used in Prolonged Exposure Therapy?

Prolonged exposure therapy utilizes several key techniques to help individuals confront and process their trauma. These include imaginal exposure, in vivo exposure, breathing retraining, and processing of traumatic memories and emotions. These techniques are designed to help individuals overcome avoidance, reduce the impact of trauma-related symptoms, and ultimately improve their overall functioning and well-being.

Therapeutic techniques used in prolonged exposure therapy include:

Breathing Retraining

Breathing retraining is a slow-breathing skill taught at the start of prolonged exposure therapy. The therapist coaches the individual to slow each exhale and practice for a few minutes every day. This is used to give people a dependable way to calm the body’s stress response between sessions. The VA National Center for PTSD lists breathing retraining as one of the four core components of PE, alongside psychoeducation, in vivo exposure, and imaginal exposure.

Processing

Processing follows each imaginal exposure exercise. The therapist and individual talk through the thoughts and feelings the retelling brought up, drawing on cognitive restructuring to work on trauma-related beliefs such as “the world is completely unsafe” or “I am permanently damaged by my trauma.” This is used to promote healing by helping new, more accurate ways of seeing the trauma take hold after each retelling.

Hierarchies

Hierarchies involve creating a list of situations or activities related to the traumatic event that individuals have been avoiding due to fear and anxiety. These situations or activities are ranked in order of difficulty, with the least difficult at the bottom and the most difficult at the top. Individuals then work through the hierarchy gradually, starting with the least difficult item and working their way up to the most difficult.

Hierarchies are used to promote healing by helping individuals confront the feared situations and activities that they have been avoiding and reducing avoidance behaviors that can maintain symptoms of PTSD.

In Vivo Exposure

In vivo exposure involves gradually facing the real-life situations, places, or activities identified in the hierarchy, starting with easier items and moving up. This is used to promote healing by helping individuals learn through direct experience that these situations are not as dangerous as they feel and that anxiety falls on its own with repeated practice, which reduces the avoidance that keeps PTSD going.

Imaginal Exposure

Imaginal exposure involves revisiting and recounting the traumatic event in detail, either through verbal descriptions or in writing. This is used to promote healing by allowing individuals to confront and process their traumatic memories in a safe and controlled environment, gradually reducing the distress associated with them. Pairing imaginal exposure with in vivo exposure can be especially effective in reducing PTSD symptoms.

What Does Prolonged Exposure Therapy Look Like in Practice?

Prolonged exposure therapy has been successfully utilized in a variety of situations and for different types of trauma. Examples of its application include treating survivors of sexual assault, veterans with PTSD, individuals who have experienced natural disasters, and those who have undergone traumatic medical procedures.

Here are a few examples of what prolonged exposure therapy could look like:

Prolonged Exposure Therapy for a Veteran With PTSD

In this scenario, prolonged exposure therapy would involve a structured approach to help the veteran confront and process their traumatic combat experiences. This may include imaginal exposure, where the veteran would recount and vividly describe their traumatic memories in a safe and supportive environment. In vivo exposure exercises might involve gradually facing situations that trigger trauma-related fear or avoidance, such as visiting crowded places or engaging in activities related to combat scenarios.

The therapist would guide the veteran through breathing retraining techniques to manage anxiety symptoms and ensure regular practice outside of therapy sessions. Throughout the therapy process, the veteran would also be encouraged to engage in homework assignments, such as listening to audio recordings of their imaginal exposure to reinforce the learning and promote generalization of skills.

Prolonged Exposure Therapy for Sexual Assault Survivors

Prolonged Exposure Therapy for sexual assault survivors would start with a verbal recount of the traumatic experience. After that, the survivor would be encouraged to confront the situations that they have been avoiding since the trauma. Exposure therapy often starts with a brief exposure to the trauma memory in a session with a therapist. Over time, the level of exposure increases, allowing the survivor to gradually revisit the memory and feel more at ease in dealing with it. In vivo exposure therapy could involve confronting feared situations such as going to social gatherings, being alone with strangers, or wearing certain types of clothes.

This gradual confrontation of feared situations is complemented with breathing exercises and cognitive restructuring to alleviate anxiety symptoms and facilitate the patient’s gradual re-entry into normal daily life.

Prolonged Exposure Therapy After a Traumatic Birth

A frightening or life-threatening delivery is a recognized cause of PTSD, and prolonged exposure therapy can help when memories of the birth keep intruding. Treatment would start with imaginal exposure, where the mother recounts the delivery in detail and revisits the memories she has been pushing away. In vivo exposure would then involve gradually approaching situations she has avoided since the birth, such as driving past the hospital, attending medical checkups, or hearing other birth stories.

Through these steps, the mother learns that the memories of the birth are painful but not dangerous, and the distress they carry fades with repeated visits. Over time, she can care for her baby and return to daily life with fewer intrusive memories, less anxiety, and less need to avoid reminders of the delivery.

What Are the Benefits of Prolonged Exposure Therapy?

Prolonged exposure therapy’s biggest strength is its evidence base: it carries the strongest recommendation in every major PTSD treatment guideline, including the APA, VA/DoD, and international guidelines. It is also flexible enough to fit different experiences of trauma. Therapists can modify the therapy based on the individual’s unique trauma history, symptoms, and readiness for exposure.¹ By providing a structured but flexible approach, PE allows individuals to confront and process their trauma in a safe and supportive environment. This personalized approach increases the likelihood of positive outcomes in the treatment of PTSD.

What Are the Risks & Drawbacks of Prolonged Exposure Therapy?

The main drawback of prolonged exposure therapy is that it is demanding: sessions revisit painful memories on purpose, and the distress can rise before it falls. It is not uncommon for patients to resist treatment, struggle with homework assignments, or withdraw from therapy.¹ It is important for the therapist to provide support throughout the therapy process, modify the therapy based on the individual’s needs and readiness for exposure, and address any safety concerns.

Another challenge in prolonged exposure therapy is the commitment required for the therapy to be effective. The therapy involves a substantial time commitment, as it typically requires weekly sessions lasting 60-90 minutes each for several months.³ Additionally, both in-session and between-session homework assignments are necessary to desensitize the trauma response and reduce anxiety. It is crucial that individuals are willing to engage in the work required for the therapy to be successful.

Is Prolonged Exposure Therapy the Right Choice for You?

When considering prolonged exposure therapy, it is important to consult with a mental health professional to determine if it is the right choice for your individual needs. Factors to consider may include the type and severity of the trauma, the individual’s personal strengths and coping skills, and any comorbid diagnoses.

Individuals with a history of severe trauma, such as combat or sexual assault, may benefit from prolonged exposure therapy. Additionally, individuals with PTSD who are motivated to engage in exposure-based therapies and are willing to engage in homework activities between sessions may be a good fit for this treatment. Individuals with significant comorbidities, such as severe depression or a substance use disorder, may need added support alongside PE rather than being ruled out; research supports delivering PE together with substance use treatment through combined protocols such as COPE.

What Is the Cost of Prolonged Exposure Therapy?

The cost of prolonged exposure therapy can vary depending on several factors, such as the location, therapist’s qualifications, and duration of treatment. Generally, therapy sessions can range from $100 to $250 per session. It is advisable to check with individual therapists or treatment centers to obtain specific pricing information. Some therapists may offer sliding scale fees based on income or have options for reduced-cost treatment.

Does Insurance Cover Prolonged Exposure Therapy?

Insurance coverage for prolonged exposure therapy can vary depending on the specific insurance plan. Many insurance plans provide coverage for mental health treatment, including therapies like PE, but it is essential to check with the insurance provider to determine the extent of coverage. Prior authorization may be required, and they may have specific criteria for coverage, such as a formal PTSD diagnosis and the recommendation of a healthcare professional. Contact the insurance company directly or consult with a mental health provider who can assist in navigating insurance coverage.

How Do You Find a Prolonged Exposure Therapist?

Individuals seeking a prolonged exposure therapist can start by checking with their health insurance provider for in-network providers or seeking referrals from a primary care physician or mental health professional. An online therapist directory or an online therapy platform can also help to find therapists with expertise in PTSD treatment, including prolonged exposure therapy. A directory allows individuals to filter by treatment modality, location, and insurance plans. They can also offer reviews and ratings from previous clients to assist in decision-making.

When choosing a prolonged exposure therapist, it is important to look for the following qualities:

• Specialization and experience in treating PTSD and utilizing prolonged exposure therapy specifically.
• Proper licensure and credentials as a mental health professional.
• Good rapport and a trusting therapeutic relationship.
• Willingness to collaborate and involve the client in the treatment process.
• Flexibility in adapting the therapy to individual needs and preferences.

Here are some key questions to ask a potential prolonged exposure therapist:

1. How long have you been practicing prolonged exposure therapy?
2. What is your experience in treating PTSD specifically?
3. Can you explain your approach to prolonged exposure therapy and how it can be effective?
4. How do you handle any difficulties or challenges that may arise during treatment?
5. Can you provide success stories or examples of previous clients who have benefited from prolonged exposure therapy?
6. What is your availability for regular therapy sessions? Do you have any cancellation policies?
7. Are you in-network with my insurance, or do you accept other forms of payment or offer sliding scale fees?
8. How often do you typically meet with clients for prolonged exposure therapy, and for how long?
9. Do you collaborate with other healthcare providers if additional support is needed?
10. What is your approach to handling the emotional difficulties and potential triggers that may arise during therapy?