Prolonged exposure

Domain II · Behavioural & cognitive · Edna Foa, Hembree, Rothbaum · 2007 · University of Pennsylvania

What it is

Prolonged exposure (PE) is a manualised, individual cognitive-behavioural treatment for PTSD, developed by Edna Foa and colleagues at the University of Pennsylvania (Center for the Treatment and Study of Anxiety, CTSA). It rests on emotional processing theory. PTSD is kept going by avoidance of the…

Format

• Format. Individual sessions, usually weekly (twice weekly is also used). Each session lasts about 90 minutes. Treatment usually runs 8–15 sessions, and the original trials used 9–12. Whole sessions are audio-recorded so the patient can listen again, and the imaginal exposure portion is recorded…
• Goals: confirm a PTSD diagnosis, pick the index trauma (the memory causing the most current distress and re-experiencing), screen for contraindications, and take baseline measures.]

Who practises it, and how they are trained or regulated

• Contraindications: imminent suicidal or homicidal risk, ongoing serious self-injury, current psychosis, or current high risk of assault (e.g., living with an abusive partner). Stabilise these first. The patient needs only enough memory of the trauma to tell a narrative, even a fragmentary one. Comorbid depression, anxiety, substance use, personality disorder, guilt, shame and anger are not exclusions.
• Goals: give an overview of treatment and the rationale, stressing that homework matters. Do a structured trauma interview. Teach breathing retraining.
• Duration of the first exposure: about 45–60 minutes in the 1st edition and the VA trial protocol. Current Penn-lineage training timings give about 40–45 minutes.

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Is there physical contact? Was it explained beforehand, and do you feel free to say no or stop at any point?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• Anhedonia makes these feel pointless at first. Schedule them anyway and track mood.]
• Ongoing danger at home or school, which needs safety work first. Caregivers who encourage avoidance.
• Ratings stuck at 0 or 100 for everything. Re-anchor. Never praise low numbers as if they were the goal.
• Remaining high-SUDS items. Plan targeted self-exposure and consider booster sessions if gains are incomplete.
• Swapping one safety behaviour for another. Hidden mental safety behaviours such as counting or mental reassurance.]

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.