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Prolonged Exposure Therapy

Reviewed by Psychology Today Staff

Prolonged exposure therapy is a form of psychotherapy for post-traumatic stress disorder or PTSD. After a traumatic event, some people experience unwanted thoughts, disturbing nightmares, feelings of hopelessness, depression, and hypervigilance. If you have these symptoms, you understandably want to avoid thoughts, feelings, and things that remind you of the trauma. The goal of prolonged exposure therapy is to gradually help you re-engage with life, especially with things you have been avoiding. By doing so, you will strengthen your ability to distinguish safety from danger and decrease your PTSD symptoms.

When It's Used

Prolonged exposure therapy is appropriate for anyone who has experienced or witnessed a traumatic event. Many people who experience a traumatic event do not develop PTSD, and prolonged exposure therapy is not necessary for those without such a diagnosis. Additionally, given that the completion of this therapy requires that you speak about the trauma and encounter trauma-related thoughts, feelings, and objects, you may experience moderate distress. This distress is often brief, and people typically feel significantly better because of treatment.

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What to Expect

PET is conducted by a single clinician through one-on-one therapy. Sessions typically last 90 minutes and occur once a week for approximately three months, though treatment can be shorter at two months or longer at 15 weeks. Prolonged exposure therapy treatment involves imaginal exposure, directly facing a fear, learning about PTSD, and retraining how you breathe.

Your therapist will guide you through the retelling of the traumatic experience(s) that cause you to seek therapy. You will explore your thoughts and feelings, which is called processing. This will help you decrease the unwanted traumatic reminders, as well as feel less distress when recalling the trauma. In these sessions, your therapist will first ask you to make a list of the things you have been avoiding–sounds and places, for example. You will create an “exposure hierarchy” by ranking these avoided things based on how much distress they cause you when you encounter them.

What is an example of a person needing exposure therapy?

One example might be: A mother is driving in a car with her daughter, the car collides with an oncoming vehicle. The daughter dies in the accident, but the mother survives. The mother avoids driving from then on. A prolonged exposure therapist guides the mother to approach the trauma of her memory.

What is breathing retraining?

Taking a deep, slow breath to calm oneself is age-old. The best way to breathe is through the belly, not the chest; chest breathing is shallow and not deep like belly breathing. Essentially, one must breathe in through the nose, hold the breath, and exhale slowly through the mouth.

How It Works

Prolonged exposure therapy is based on associative learning theory—when two things appear together the brain learns to connect or associate them. Ivan Pavlov created the most famous associative learning experiment by repeatedly ringing a bell before presenting his dogs with food. The dogs began to salivate at the sound of the bell, as they learned to associate the bell with food. To break this association, Pavlov then repeatedly rang the bell without giving the dogs any food; the dogs eventually stopped salivating when they heard the bell. This same process is behind PTSD. When trauma occurs, there are many things in the environment—smells, sights, sounds—that the brain associates with the trauma. When we encounter these things outside of the trauma, the brain expects danger, causing fear and anxiety.

What is SUDS rating in therapy?

The Subjective Units of Distress Scale, or SUDs, is a self-assessment rating scale that measures how intensely a person experiences distress, whether it is anxiety,  anger, or other discomfort. The evaluation runs from 0 to 100, with 100 being the highest level of distress.

What to Look for in a PET Therapist

Screen your potential therapist either in person or over video or phone. During this initial introduction, ask the therapist:

• How will they help with your particular concerns?
• Have they dealt with this type of problem before?
• What is their process?
• What is the treatment timeline?

Health providers can receive training and certification for prolonged exposure therapy. Some institutions, such as university clinics, provide intensive workshops or seminars, with therapists completing one-on-one consultation therapy cases. Note that not all types of therapy are covered by insurance, so call your carrier for information.

McLean, C. P., & Foa, E. B. (2011). Prolonged exposure therapy for post-traumatic stress disorder: A review of evidence and dissemination. Expert Review of Neurotherapeutics, 11(8), 1151-1163.
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.
For a comparison of PET to other research-supported treatments for PTSD, please see: Gallagher, M. W., Thompson-Hollands, J., Bourgeois, M. L., & Bentley, K. H. (2015). Cognitive behavioral treatments for adult posttraumatic stress disorder: Current status and future directions. Journal of Contemporary Psychotherapy, 45(4), 235-243.
Articles cited in summary paragraph (not listed above): Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A., Riggs, D. S., Feeny, N. C., & Yadin, E. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73(5), 953- 964.
Taylor, S., Thordarson, D. S., Maxfield, L., Fedoroff, I. C., Lovell, K., & Ogrodniczuk, J. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71(2), 330 - 338.