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, individuals can reduce their fear and anxiety responses, leading to decreased sensitivity to traumatic memories or triggers, a process known as systematic desensitization.

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
• Night terrors 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 one of the most studied treatments for PTSD and has been shown to be an effective treatment for trauma-related symptoms. While it is generally effective for a majority of individuals with PTSD, effectiveness may vary depending on the individual’s specific symptoms and circumstances. Research has also shown that PE is particularly effective for veterans and military personnel.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.

Prolonged Exposure Therapy Techniques

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:

Positive Self-Statements

Positive self-statements involve encouraging individuals to challenge negative self-talk and replace it with positive, empowering thoughts. This is used to promote healing by helping individuals develop a more positive and realistic view of themselves and their experiences. Examples of positive self-statements include “I am safe” and “I can handle this.”

Cognitive Restructuring

Cognitive restructuring involves identifying and challenging negative or distorted thoughts and replacing them with more realistic and positive thoughts. This is used to promote healing by helping individuals develop healthier patterns of thinking that can reduce the impact of trauma-related thoughts and emotions. Examples of cognitive restructuring in PE may include identifying and challenging beliefs such as “the world is completely unsafe” or “I am permanently damaged by my trauma.”

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.

Exposure & Response Prevention

Exposure and response prevention involves gradually exposing individuals to the feared situations or activities identified in their hierarchy while preventing them from engaging in avoidance behaviors or safety behaviors. This is used to promote healing by helping individuals learn that the feared situation or activity is not as dangerous as they perceive and reducing the anxiety response to that situation or activity over time.

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.

Examples of Prolonged Exposure Therapy

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 for Postpartum Depression

For postpartum depression, prolonged exposure therapy could start by encouraging the mother to recall the traumatic events connected to her symptoms, like the process of giving birth or other significant stressors leading up to the onset of her depression. After verbally recounting the trauma, in vivo exposure therapy would involve increasing exposure to situations or activities that trigger depression symptoms at a level that is comfortable for the mother. This could include basic acts like taking care of the baby, leaving the house, or engaging in affectionate activities with the baby and/or significant others.

Through these steps, the mother would eventually learn how to better cope with the challenges that come with being a new mom. With time, the mother would be better equipped to handle the stress of motherhood with a newfound resolve, having an improved sense of mood and reduced feelings of sadness, anxiety, and grief.

Strengths of Prolonged Exposure Therapy

One of the strengths of prolonged exposure therapy is its adaptability to address 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.

Drawbacks of Prolonged Exposure Therapy

A considerable challenge of prolonged exposure therapy is that it requires the individual to revisit traumatic memories, which can be extremely distressing. It is not uncommon for patients to resist treatment, struggle with homework assignments, or withdraw from therapy.(F5) 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. However, individuals who struggle with significant comorbidities, such as major depression or substance abuse, may require additional therapeutic support or alternative therapeutic approaches.

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 to 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?