How Useful Is Prolonged Exposure Therapy As A Treatment For Post-Traumatic Stress Disorder?

Prolonged exposure therapy is — together with cognitive processing therapy, cognitive restructuring therapy, stress inoculation training, and EMDR — one of the treatment approaches most likely to really help someone suffering from PTSD reduce their symptoms and improve their life.

Like many other kinds of talk therapy, prolonged exposure therapy falls under the "cognitive behavioral therapy" umbrella. Prolonged exposure therapy is not a generic kind of therapy suitable for just about anyone, though, as it was designed specifically with the needs of PTSD sufferers in mind.

What's the idea behind prolonged exposure therapy? 

The foundations of cognitive behavioral therapy as a broader therapeutic school of thought lie in the concept that subconscious thought processes affect our behavior and emotions in often maladaptive ways, and that figuring out what underlying mental processes are getting in your way can help you process them and then cause you to achieve lasting change. Prolonged exposure therapy borrows heavily from these same ideas. 

Everyone diagnosed with post-traumatic stress disorder makes conscious or subconscious efforts to avoid reminders of the trauma they lived through by definition — the diagnostic and statistical manual of mental disorders (DSM-5) has made avoidance a symptom you must have to be considered to have PTSD. 

Different people with PTSD will avoid painful reminders in different ways, of course. You may steer clear of any places, people, circumstances, and even for instance smells that are triggering for you. These circumstances that exist outside your own body and mind are referred to as external reminders.

You may also do your best to stop and thoughts, feelings, or memories that bring you back to the time of your trauma. If you can't seem to send reminders packing through sheer willpower and they still plague you, you may also turn to harmful coping behaviors like substance abuse, workaholism, or reckless behavior. Trauma reminders that come frm inside your mind are internal reminders.

Trying to cut yourself off from the most distressing events in your past may seem to make sense to people with post-traumatic stress disorder — by avoiding reminders of the trauma, you can also avoid the immediate emotional pain that can quickly take over everything everything in your life, and stay more functional. 

The catch is that relying on avoidance doesn't work. 

That's where prolonged exposure therapy comes in. You may have heard of a similar therapy for people with specific phobias. Say a person is terrified of spiders — not just a little scared, but really terrified, to the point where it interferes with their quality of life. Gradual exposure can desensitize the spider-phobic person and get them used to being around spiders without facing total meltdown. It's unpleasant work, but it often does the trick.

In prolonged exposure therapy for PTSD, the "spider" is, instead, the traumatic events that gave you PTSD. 

How does prolonged exposure therapy for PTSD work? What can you expect?

Prolonged exposure therapy for PTSD is a gradual process that unfolds over the course of about eight to 15 sessions with a therapist, which also last longer than a typical therapy appointment — up to two hours. You can expect weekly sessions that will take around three months to finish. Because there's homework for you to do, you'll actively be working on healing between sessions, too. 

• At first, your therapist will explain how the prolonged exposure therapy works, and they'll want to know a little bit about your trauma, but nothing too heavy. They may also teach you breathing techniques during the first session. 
• Over the next sessions, you'll get "stuck in" and start to do some real work. You'll need to make an honest list of all the things you have been avoiding since and because of your traumatic experience(s) — these can be people, places, but also things on your head, like thoughts and memories. 
• "Imaginal exposure" involves talking about your trauma in depth. Here, you confront the fears inside your own mind. Since trauma-related memories are processed very differently than normal memories in the brain, this can help you integrate the trauma into your personal timeline a more chronological way. Though this is going to be painful work without a doubt, processing your memories can help reduce reexperiencing symptoms of PTSD like flashbacks and nightmares. You'll become desensitized to the reminders as you process the trauma. 
• "In vivo exposure" means exposure to the things outside your brain that you've been avoiding in real life. These can be places (for instance, visiting the site of the car accident you were in, or going to a crowded and noisy place), people, or other things out there in the world. As with people who are scared of spiders, the goal is to desensitize you until you can bear these situations without extreme distress, and eventually hopefully even without distress. Your therapist should not ask you to do things that aren't safe for you during your in vivo exposure, however — avoiding someone who inflicted trauma on you is only healthy. Some of these experiences will be assigned as homework, and you'll discuss them in the next session.

Note that there have been some studies to assess how effective prolonged exposure therapy for PTSD can be when the sessions are carried out in the form of teletherapy — so therapy sessions by phone or online. This will be useful information for anyone who cannot or doesn't want to attend therapy sessions in person, whether for instance due to the COVID-19 pandemic or because they are currently homebound due to social anxiety. Teletherapy exposure therapy sessions have been shown to work well in reducing PTSD symptoms, though it does seem like fewer people complete such courses of therapy. 

Nonetheless, it is something you could consider, also because telesessions can potentially give you access to therapists who specialize in your kind of trauma but live further away.

Is prolonged exposure therapy an effective choice for PTSD?

It is. Other kinds of talk therapy have also been shown to work very well in helping people reduce their PTSD symptoms or even find remission from post-traumatic stress disorder, so prolonged exposure therapy is certainly not your only choice, but it is one of the most successful therapeutic approaches for trauma survivors. This is especially true for PTSD sufferers who have strong avoidance symptoms. 

Research has shown that prolonged exposure therapy can help people who lived through all sorts of different types of trauma, as well as that it can help both people who developed PTSD after a recent trauma and those who have been living with PTSD for a long time. 

This is not going to be fun, is it?

No, we're afraid not. You're going to confront the very things you've been trying to outrun, sometimes for a very long time and sometimes in such a way that your whole life revolves around avoiding trauma reminders. It's very possible that each exposure therapy session will hit you like a ton of bricks, especially if denial and avoidance have basically made up your entire coping strategy. (I know — been there, done that.) If your PTSD symptoms initially get worse, rather than better, as you start therapy, that's not entirely unexpected. 

Most people who work on healing from their trauma through exposure therapy do start to feel better and "lighter" as they process the trauma, however, and the distress you may experience during the therapeutic course lifts. As it does, you will no longer carry the burden you did before therapy in the same way. You can expect your symptoms to get a lot better.

If therapy is emotionally difficult for you, also know that the therapist is there with you every step of the way — so be sure to communicate what you are feeling and how therapy is impacting your symptoms, so they can help you by teaching you coping mechanisms.