Prolonged exposure

1. Introduction

Version followed: Foa, Hembree, Rothbaum & Rauch (2019), Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide, 2nd ed. (Oxford, Treatments That Work), for adults. Where only 1st-edition (Foa, Hembree & Rothbaum, 2007) procedures could be checked (exact timings, the "SUDS down by half" rule), this is flagged. The adolescent version, PE-A (Foa, Chrestman & Gilboa-Schechtman, 2009), is noted where it differs.

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 trauma memory and of reminders, and by beliefs that the world is entirely dangerous and that the person is incompetent. Change comes from deliberately and repeatedly approaching the memory (imaginal exposure) and safe but avoided situations (in vivo exposure) while emotionally engaged. This lets corrective information in: reminders are not dangers, remembering is not re-experiencing, distress is tolerable and passes, and the person can cope. Talking through what the person has learned (processing) then helps them organise the memory and revise trauma-related beliefs. [source: APA PTSD guideline PE page; Foa & Rauch interview, CDP; Kognito PE training text]

In the 2nd edition the authors cut PE to three core components: education, in vivo exposure, and imaginal exposure with processing. Breathing retraining is still in the manual but is no longer a core technique. Processing gets more detail, and new sections cover complex trauma, guilt and moral injury. [source: Foa & Rauch interview, CDP]

2. Framework

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 separately for daily listening. [source: APA guideline PE page; CSP #591 trial protocol] Intensive and massed formats exist (e.g., daily sessions), but the 2nd-edition guide leaves them out. [source: Foa & Rauch interview] PE-A runs 8–15 sessions of 60–90 minutes, once or twice weekly, for ages 13–18. [source: Title IV-E Clearinghouse; Foundations guidebook]

Pre-treatment: assessment and preparation.

• 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. [source: CDP course outline (assessment, preparing for PE); index-trauma rule from the therapist guide [uncertain]]
• 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. [source: Kognito PE training, p. 3]
• PE-A adds an explicit pre-treatment preparation phase. [source: Title IV-E Clearinghouse]

Session 1: orientation.

• Goals: give an overview of treatment and the rationale, stressing that homework matters. Do a structured trauma interview. Teach breathing retraining.
• Homework: practise breathing daily, listen to the session recording, and reread the rationale handout. [source: CSP #591 protocol; CDP outline; OUP Session 1 abstract]

Session 2: education and in vivo set-up.

• Goals: discuss common reactions to trauma, introduce and calibrate SUDS, build the in vivo hierarchy, and assign the first in vivo exercises.
• Homework: in vivo exercises, the common-reactions handout, listening to the recording, and breathing practice. [source: CSP #591 protocol; CDP outline]

Session 3: start of imaginal exposure.

• Goals: give the rationale for imaginal exposure, then do the first full-narrative imaginal exposure. Ratings: SUDS every 5 minutes and vividness every 10 minutes (1st-edition procedure). Then process it, review in vivo homework and assign new items.
• 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. [uncertain: exact 2nd-edition figure not verified]
• Homework: listen to the imaginal recording daily, continue in vivo work, and keep up breathing practice. [source: CSP #591 protocol; Kognito p. 11; CDP outline]

Intermediate sessions (Session 4 up to Session 14).

• Agenda and timing:
  • Homework review: about 10 minutes
  • Agenda setting: 3 minutes or less
  • Imaginal exposure: about 40–45 minutes
  • Processing: 15–20 minutes
  • In vivo discussion: 10–15 minutes
  • Homework assignment: about 5 minutes
• From about Session 5 or 6, imaginal exposure moves from the whole narrative to hot spots. [source: Psychotherapy Academy PE course (Rothbaum); OUP intermediate-sessions abstract]

Final session.

• Content:
  • Imaginal exposure to the whole memory (about 20–30 minutes; 30 minutes in the VA protocol)
  • Processing focused on how the memory and the self have changed
  • Re-rating the in vivo hierarchy and comparing ratings with the start
  • Reviewing symptom-measure change, and which parts of treatment helped most and least
  • A plan for continued self-directed exposure
  • Preparation for temporary symptom flare-ups
• [source: CSP #591 protocol; Kognito p. 14]

Criteria for moving between phases.

• Session 2 → Session 3: the hierarchy has enough items (5–10 to start, ideally 10–15) and the patient understands SUDS. [source: Kognito p. 8]
• Full narrative → hot spots: the patient has disclosed all the details of the event, distress has dropped across most of the narrative, and the patient volunteers more detail. This is usually around Sessions 5–6. [source: Psychotherapy Academy; Kognito p. 13]
• Hot spot → next hot spot: when the current one is sufficiently processed. Its SUDS has fallen and it no longer carries strong guilt, shame or horror. [source: Kognito p. 13]
• Ending: patient and therapist agree on substantial symptom reduction and that the hierarchy is largely mastered. The VA trial set a 12-session default, ending at 10 for fast responders and extending for slow ones. A specific percentage symptom-reduction cut-off was used in some Penn trials but is not verified here. [uncertain] [source: CSP #591 protocol]

Measurement. Administer a self-report PTSD measure (e.g., PSS-SR, PCL-5) and a depression measure at baseline and regularly during treatment, often every other session, and feed the scores back to the patient. [source: CDP outline objective 11; the every-other-session frequency comes from the therapist guide [uncertain]]

3. Guiding principles

[source for this section unless tagged: Foa & Rauch interview; Kognito PE pp. 4–5, 7, 11–12; CDP outline; APA guideline page]

• Avoidance maintains PTSD; approach treats it. Every session plan should reduce avoidance of the memory or of reminders.
• Emotional engagement is needed. The fear structure must be activated for corrective information to get in. Aim for real feeling, neither numbed nor overwhelmed.
• Anxiety during treatment is useful, not dangerous. Don't rescue the patient from distress inside exposures. Step in only if distress becomes counterproductive or physically risky.
• Lowering SUDS is not the goal. SUDS tracks trends and engagement. Never imply that low ratings are the target (Kognito: "decreasing SUDS should never be a goal of treatment").
• "Every imaginal exposure is a success" (Foa, CDP interview). Normalise whatever happened, high or low distress, and look for what was learned.
• Process while the memory is hot. Do processing right after imaginal exposure, open-ended and starting from where the patient is. It is part of exposure, not separate cognitive therapy.
• Fear usually fades with exposure alone; processing targets guilt, shame and anger. Spend processing time on those emotions and on the beliefs behind them.
• Breathing is for daily life, not for exposures. Calming techniques used during exposure can work as safety behaviours and block disconfirmation.
• Drop safety behaviours. Exposures should be done without the protective habits that keep the patient believing "I only survived because…". [source: Psychotherapy Academy module title "Safety Behaviors and Session 3"; the detailed rule is synthesis [synthesis]]
• Homework is where most change happens. Treat it as central and review it first in every session.
• The patient sets the pace within the protocol. Exposure is graded and collaborative, but the therapist keeps encouraging the next step.
• Get buy-in through a convincing rationale. Ambivalence predicts dropout. Be honest that PE is hard and present it as short-term discomfort for long-term gain.
• Resolve your own reservations about PE first. Therapist doubts ("too harsh", "will make them worse") show up as soft rationales and collusion with avoidance.
• Follow the manual flexibly. The structure reflects learning processes common to all patients. Adapt examples, pacing and language to the person.
• Measure and feed back. Use standardised measures to guide decisions and to show the patient their progress.
• Real safety comes first. Exposure is only to objectively safe situations. Do not ask a patient to approach situations that are actually dangerous.

4. Intervention inventory

All example therapist language below is my own illustrative wording, not text from the manual. Handouts and forms named here (rationale handout, Common Reactions handout, SUDS logs, homework records) belong to the Oxford guide and workbook. They are described, not reproduced.

4.1 Pre-treatment assessment and index-trauma selection

• Purpose / when: Before Session 1. Confirms that PE fits and chooses which memory to target.
• Steps:
  1. Run a structured PTSD assessment, using an interview or validated self-report, and screen for comorbidity.
  2. Screen for contraindications: imminent suicide or homicide risk, ongoing serious self-injury, psychosis, current danger. Make a safety plan where needed.
  3. List the traumas. Pick the index trauma: the event behind the most frequent and distressing intrusions now. If unsure, ask which memory the patient avoids most and which nightmares are about.
  4. Check memory adequacy. Fragments are enough.
  5. Take baseline measures.
• Example language (illustrative): "Of everything that has happened to you, which memory pushes into your mind most often and upsets you most right now?"
• Watch for: Patients sometimes pick a "safer" memory. If intrusions centre on another event, discuss and agree on the target. Current danger (e.g., an abusive partner) means doing safety work first.
• [source: Kognito p. 3; CDP outline; index-trauma rule from the therapist guide [uncertain]]

4.2 Treatment overview and rationale (Session 1)

• Purpose / when: Session 1, revisited whenever motivation drops. Buy-in predicts retention.
• Steps:
  1. Describe the programme: number and length of sessions, recording, daily homework.
  2. Explain the two maintaining factors, in the patient's own examples:
     • Avoidance of memories and reminders, which brings short-term relief but stops recovery.
     • Unhelpful beliefs: the world is entirely dangerous; I am weak or incompetent.
  3. Name the three tools (education, in vivo exposure, imaginal exposure with processing) and link each to a maintaining factor.
  4. Be upfront that PE is hard and that distress may rise briefly. Present it as short-term cost for long-term gain.
  5. Make it concrete. Ask what the patient avoids. Have them weigh whether avoidance has shrunk or grown their life. Sketch the curve of anxiety rising and falling if they stay. Use an analogy, such as helping a child overcome a fear.
  6. Invite doubts and answer them. Give the rationale handout as homework.
• Example language (illustrative): "Pushing the memory away makes sense, and it gives you relief for a while. But it also means your mind never gets to finish processing what happened. In this treatment we'll do the opposite, in a planned and gradual way."
• Watch for: Polite agreement without real buy-in. Ask the patient to explain the rationale back to you. Unspoken fears ("I'll lose control", "I'll go crazy") need to be said out loud and answered.
• [source: Kognito p. 4; OUP Session 1 abstract; CDP outline objective 1; Foa & Rauch interview]

4.3 Trauma interview (Session 1)

• Purpose / when: Session 1. Collects the information you need to tailor the hierarchy and the imaginal work: the trauma itself, other traumas, current symptoms, social support, substance use, and beliefs about the trauma (e.g., self-blame).
• Steps:
  1. Explain that you will ask for a brief outline of the trauma now, not the full account. The full account comes in Session 3.
  2. Work through the structured interview in the guide: what happened, when, injuries, perceived life threat, others' reactions, previous traumas, health, alcohol and drug use, current functioning.
  3. Note avoided situations and self-blaming statements for later sessions.
• Example language (illustrative): "I'd like a short outline today, just the headlines. We'll go into the full detail later, when we have the tools in place."
• Watch for: The patient flooding into full detail too early. Gently contain it and say there will be time later. Note any alcohol or drug use that could interfere with exposure.
• [source: CSP #591 protocol ("standardized interview" in Session 1); content areas inferred from the 1st-edition guide [uncertain]]

4.4 Breathing retraining (Session 1)

• Purpose / when: Taught in Session 1 as a portable tool for everyday stress (work meetings, driving, childcare). It is not used during exposures.
• Steps:
  1. Explain that people often over-breathe when anxious and that slowing the out-breath reduces arousal.
  2. Coach a normal-sized breath in through the nose, then a slow exhale while silently saying a calming word (e.g., "calm"), then a pause of a few counts before the next breath.
  3. Practise for several minutes in session. Record it so the patient can practise at home.
  4. Assign daily practice.
  5. Say clearly that it is not for use during in vivo or imaginal exposures.
• Example language (illustrative): "Breathe in normally... now breathe out slowly and say 'calm' to yourself as you exhale... hold it a moment... and again."
• Watch for: Breathing used to escape exposure. Ask whether they used it during exercises; if so, explain why not and fade it out. Hyperventilation or dizziness means the breaths are too deep.
• [source: Kognito p. 5; Foa & Rauch interview; CSP #591 protocol. Exact counts are from the 1st-edition guide [uncertain]]

4.5 Psychoeducation: common reactions to trauma (Session 2)

• Purpose / when: Session 2. Normalises symptoms, builds a shared language and supports the rationale.
• Steps:
  1. Invite the patient to say which reactions they experience.
  2. Go through the usual reaction clusters, linking each to the patient's own examples:
     • fear and anxiety
     • re-experiencing (intrusions, nightmares, flashbacks)
     • hyperarousal
     • avoidance
     • anger and irritability
     • guilt and shame
     • grief and depression
     • negative self-image
     • changes in relationships and sexuality
     • increased alcohol or drug use
  3. Frame each reaction as understandable after trauma. Point out that many are kept going by avoidance.
  4. Assign the Common Reactions handout for rereading.
• Example language (illustrative): "Many people who've been through something like this notice they can't trust anyone. Does that fit for you? How does it show up?"
• Watch for: Relief at feeling understood is a good sign. Watch for reactions the patient won't talk about yet, especially shame, guilt and sexual difficulties, and for intense self-blame. Note these as targets for processing.
• [source: CSP #591 protocol; CDP outline ("Common reactions to trauma"); reaction list from the 1st-edition handout as I understand it [uncertain]]

4.6 SUDS: introduction and calibration (Session 2)

• Purpose / when: Session 2, before building the hierarchy. Gives a shared 0–100 distress scale for planning exercises and tracking engagement.
• Steps:
  1. Explain the 0–100 scale.
  2. Anchor 0 to the patient's most relaxed moment, 100 to their most distressed (the worst moment of the trauma is acceptable), and 50 to midway. Add 25 and 75 if useful. Prefer non-trauma anchors, because responses to trauma reminders will change.
  3. Practise by asking for a rating right now.
• Example language (illustrative): "Think of a time you felt completely at ease. That's 0. The most upset you've ever been is 100. Where are you right now?"
• Watch for: Ratings stuck at 0 or 100 for everything. Re-anchor. Never praise low numbers as if they were the goal.
• [source: Kognito p. 7]

4.7 Building the in vivo hierarchy (Session 2)

• Purpose / when: Session 2, updated throughout treatment. Lists objectively safe situations the patient avoids or endures with distress.
• Steps:
  1. Ask what they have avoided since the trauma: places, people, activities, sounds, smells, crowds, dark, being alone, media. Include items that are endured but avoided in subtle ways.
  2. The therapist suggests further items drawn from the trauma interview and common-reactions discussion.
  3. Rate each item for SUDS.
  4. Break items into graded variants by context, such as seeing a picture, then visiting the place, then handling the object. Vary company (with or without a support person), time of day and duration.
  5. Aim for 10–15 items covering a wide SUDS range. 5–10 is enough to start.
  6. Check each item is objectively safe. If unsure, reality-test it with the patient.
  7. Add items that target the patient's beliefs (e.g., the world is dangerous, I can't cope), and items that restart enjoyable activities they have dropped.
• Example language (illustrative): "Let's list everything you've stopped doing or only do with gritted teeth since it happened, even small things like sitting with your back to the door."
• Watch for: Hierarchies made up only of easy items. Dangerous items (e.g., a known high-crime alley at night) must be excluded or adapted. Subtle avoidance that still needs adding.
• [source: Kognito p. 8; CSP #591 protocol; CDP outline objective 3; enjoyable activities from Wikipedia summary of PE]

4.8 In vivo exposure assignments and homework

• Purpose / when: Starts after Session 2 and continues to the end. Breaks avoidance, tests whether reminders are dangerous, and builds confidence.
• Steps:
  1. Give the in vivo rationale (see 4.2). Exposures break the avoidance cycle, show that feared situations are safe, show that anxiety falls without escape, and build confidence.
  2. Choose roughly two items per week. Start around SUDS 40, with items that are challenging but likely to succeed.
  3. Plan exactly what, where, when, with whom and for how long. Plan to stay about 30–45 minutes, or longer if needed.
  4. Instruct the patient to remain until distress has dropped noticeably. The 1st edition says about halfway. The 2nd edition puts more weight on staying long enough to learn the feared outcome did not happen. [uncertain: exact 2nd-edition stopping rule not verified]
  5. Instruct no safety behaviours: no escape, no breathing technique, no distraction, no checking.
  6. Log SUDS at the start, at the peak and at the end on the homework form.
  7. Repeat each item until it is reliably low, then move up the hierarchy.
  8. In vivo is normally done as homework. Therapist-accompanied exposure is an exception when needed.
• Example language (illustrative): "This week: the supermarket at a busy time, twice, staying at least 30 minutes, without your phone as a distraction. Notice what happens to your anxiety the longer you stay, and what actually happens around you."
• Watch for: Leaving at the peak, which teaches escape. Ask about it and rebuild the plan. Boredom during an exercise is a good sign. Progress shows as lower starting SUDS across repetitions and the patient adding items on their own.
• [source: Kognito pp. 6, 9; CSP #591 protocol; APA guideline page]

4.9 Imaginal exposure rationale (Session 3)

• Purpose / when: Start of Session 3, just before the first imaginal exposure. Repeat it briefly whenever the patient balks.
• Steps:
  1. Ask how they have handled the memory so far. Usually it's pushing it away, and it keeps coming back.
  2. Explain what repeatedly revisiting the memory does:
     • helps process and organise it
     • separates remembering from the event itself, so remembering is not being re-traumatised
     • lets distress fall with repetition
     • stops fear spreading from the trauma to safe situations
     • builds a sense of mastery
  3. Use an analogy, such as digesting a heavy meal or sorting a jumbled cupboard.
  4. Agree to proceed.
• Example language (illustrative): "The memory keeps intruding because it hasn't been fully digested. If we go through it together, deliberately and many times, it can become a painful memory from the past rather than something that feels like it's happening now."
• Watch for: Fear of losing control or going crazy. Say it out loud and answer it: the memory is not the event, and you will be right there.
• [source: Kognito p. 10; CDP outline]

4.10 Imaginal exposure: full narrative (Session 3 to about Session 5)

• Purpose / when: Activates the trauma memory with emotional engagement, so it can be processed. Starts in Session 3.
• Steps:
  1. Start the recorder.
  2. Instruct the patient:
     • close their eyes
     • picture the event as vividly as possible
     • tell it aloud in the present tense ("I am walking…") as if it is happening now
     • start just before the event and go to the point where they felt safe again
     • include what they see, hear, smell, feel in their body, think and feel
     • keep going even when they want to stop
  3. Ask for SUDS about every 5 minutes, briefly, without breaking the flow, and keep a log. The 1st edition also rated vividness about every 10 minutes.
  4. When the narrative ends, have them go back to the start and retell it, repeating as many times as fit in the time. That is about 40–45 minutes in current training; 45–60 minutes in the 1st edition and VA protocol. [uncertain: exact 2nd-edition duration]
  5. In the first one or two sessions, keep questions to a minimum and give brief encouragement. The aim is simply to stay with it. In later sessions, probe gradually for omitted detail and for thoughts and feelings at the time.
  6. When finished, ask them to open their eyes and give a final SUDS. Move straight to processing (4.12). Don't use relaxation to calm them.
• Example language (illustrative): "Close your eyes and go back to the moment just before it began. Tell me in the present tense: where are you, what do you see?" ... "You're doing well; stay with it." ... "What's your SUDS?" ... "What are you feeling in your body right now?"
• Watch for: Skipped segments, a sudden rush or a flat tone. These often mark the hot spots. Progress shows as more detail volunteered, falling peak and end SUDS across sessions, and the narrative becoming more coherent.
• [source: CSP #591 protocol; Kognito p. 11; APA guideline page]

4.11 Modulating emotional engagement

• Purpose / when: During imaginal exposure, when the patient is under-engaged (detached, numb, intellectualising, low SUDS despite distressing content) or over-engaged (overwhelmed, dissociating, losing awareness of the room).
• Steps for under-engagement:
  1. Use eyes closed and present tense.
  2. Add brief probes about the senses, body sensations, thoughts and feelings.
  3. Ask them to slow down at key moments.
  4. Explore in processing what makes it hard to let feelings in.
• Steps for over-engagement: Move toward distance while keeping the exposure going.
  1. Eyes open.
  2. Past tense.
  3. More frequent, grounding therapist comments, such as "You are here with me; it's a memory."
  4. Touch the hand only if the patient agreed to this beforehand.
  5. If still overwhelmed, have them write the narrative instead of speaking it.
  6. Return to standard instructions as tolerance grows.
• Example language (illustrative): "Keep your eyes open and look at me. You're in my office, it's [day]. Tell it as something that happened back then: 'I was…'."
• Watch for: The goal is engaged but present. If the techniques interrupt a patient who is already engaged, drop them, because extra probes can distract.
• [source: Kognito p. 11 (eyes closed, present tense, interjected probes; probes may distract an engaged patient); CDP outline objective 6 ("manage emotional engagement"); the over-engagement steps are from the 1st-edition guide [uncertain]]

4.12 Processing the imaginal exposure

• Purpose / when: Immediately after every imaginal exposure, 15–20 minutes, while the memory is still activated. Helps the patient integrate new information, reach new insights about the trauma and themselves, and revise trauma-related beliefs (especially guilt, shame and anger).
• Steps:
  1. Start with open questions about how it was and what they noticed.
  2. Reflect what happened, normalising either outcome. If SUDS fell while detail increased, name it as progress. If SUDS stayed high, say that's common early on and ask what they think kept it high.
  3. Ask what they learned or noticed differently this time.
  4. Follow the patient toward the meanings that come up ("I should have fought back", "I'm weak", "It was my fault"). Use Socratic questioning to weigh these against the full context they've just relived: what they knew then, what options they really had, and the threat they faced.
  5. Draw connections to in vivo work and to the patient's beliefs about danger and competence.
  6. Don't turn processing into formal cognitive restructuring with worksheets. It stays fluid and grows out of the exposure.
• Example language (illustrative): "What was that like today?" ... "You told much more detail this time and your ratings came down. What do you make of that?" ... "You said you 'froze like a coward'. Seeing it again, what was actually happening in that moment? What else could you have done, realistically?"
• Watch for: Lecturing or debating. The patient should reach the conclusion themselves. Signs it's working: new perspectives are voiced spontaneously ("I did what I could to survive"), less self-blame, and the story is told as past.
• [source: Foa & Rauch interview; Kognito p. 12; CDP outline objectives 9–10]

4.13 Hot spots

• Purpose / when: From about Session 5 or 6, once the whole narrative has been disclosed and distress has fallen across most of it. Targets the moments that stay most distressing, which is more efficient than repeating the whole story.
• Steps:
  1. Using the SUDS log and the patient's report, identify the moments that stay most distressing now. Agree on them together.
  2. Order them from most distressing. Work on one at a time.
  3. For each, start the narrative just before the hot spot and stop just after it.
  4. Retell that segment repeatedly, as many times as possible in the exposure time, "in slow motion" and probing for every detail: sensations, thoughts, emotions, meanings.
  5. Process it afterwards as in 4.12, often focusing on the appraisal tied to that moment.
  6. Move to the next hot spot when the current one is sufficiently processed.
  7. Continue hot-spot work until the final session.
• Example language (illustrative): "Today we'll zoom in on the moment you heard the door. Start a few seconds before, go very slowly, and tell me everything: what you see, hear, think and feel, frame by frame."
• Watch for: A hot spot is often where guilt or shame is attached, not only fear. New details may emerge that change the meaning. Progress shows as falling SUDS on that segment and a shift in the patient's interpretation of it.
• [source: Kognito p. 13; Psychotherapy Academy; OUP intermediate-sessions abstract; CDP outline objective 8]

4.14 Daily listening to the imaginal recording

• Purpose / when: Homework from Session 3 onward. Extends imaginal exposure between sessions.
• Steps:
  1. Record only the imaginal exposure portion separately.
  2. Assign daily listening at a set time and in a private place, with eyes closed and engaging as in session. Not just before sleep.
  3. Log SUDS at the start, peak and end.
  4. Separately, assign one listen to the full session recording each week.
  5. Ensure the recording is stored securely.
• Example language (illustrative): "Listen once a day, like an appointment, when you have 45 minutes alone. Picture it as you did here, and jot your ratings on the form."
• Watch for: Listening while busy with other things (a form of avoidance), skipped days, and higher-than-expected distress at home. Review the log at the start of every session.
• [source: CSP #591 protocol; APA guideline page; the not-before-sleep and secure-storage advice is my own [synthesis]]

4.15 Homework review and in vivo processing (every session)

• Purpose / when: Opens every session from Session 2. Reinforces adherence and draws out learning.
• Steps:
  1. Review each form: what was done, SUDS pattern, and what happened.
  2. Praise effort specifically.
  3. Ask what they learned and whether the feared outcome happened.
  4. Problem-solve what didn't get done (see Section 5).
  5. Use the results to choose and adjust next week's items.
• Example language (illustrative): "You stayed in the café for 40 minutes and your rating went from 70 to 35. What did you expect to happen, and what actually happened?"
• Watch for: Glossing over missed homework. Patterns of starting high and leaving early. Learning that's coming through, e.g., "Nothing bad happened, and I coped."
• [source: Psychotherapy Academy session timings; CDP outline objectives 7 and 9; the review questions are my own [synthesis]]

4.16 Identifying and dropping safety behaviours

• Purpose / when: From Session 2 onward, when planning and reviewing exposures. Stops protective habits from preventing new learning.
• Steps:
  1. Ask how the patient gets through difficult situations: sitting near exits, scanning, carrying objects, having a companion, being on the phone, drinking, using breathing.
  2. Explain that these keep alive the belief that safety depended on them.
  3. Add versions of hierarchy items without the safety behaviour. Fade the behaviours gradually.
• Example language (illustrative): "If you always sit facing the door, your brain credits the seat for keeping you safe. Let's see what you learn when you sit with your back to it."
• Watch for: Swapping one safety behaviour for another. Hidden mental safety behaviours such as counting or mental reassurance.
• [source: Psychotherapy Academy module "Safety Behaviors and Session 3"; Foa & Rauch interview (breathing as a safety behaviour). Details are my own [synthesis]]

4.17 Re-engaging enjoyable activities

• Purpose / when: For patients with prominent numbing, loss of interest or depression. Added to the in vivo plan.
• Steps:
  1. List activities enjoyed before the trauma and dropped since.
  2. Add them to the hierarchy or weekly plan even if they don't trigger fear.
  3. Schedule and review them like other in vivo items.
• Example language (illustrative): "Let's also put back one thing you used to enjoy, like the Sunday football, even if it doesn't scare you. We're rebuilding your life, not only reducing fear."
• Watch for: Anhedonia makes these feel pointless at first. Schedule them anyway and track mood.
• [source: Wikipedia summary of PE components; scheduling details are my own [synthesis]]

4.18 Final session: whole-memory retelling, review and relapse prevention

• Purpose / when: Last session. Consolidates gains and plans independent practice.
• Steps:
  1. Run a shorter imaginal exposure to the whole memory, start to finish, about 20–30 minutes. If time allows, twice.
  2. Process with questions about how the memory now feels compared with the start.
  3. The patient re-rates every hierarchy item. Compare with original ratings. Discuss items that improved and why. Plan continued practice for items that didn't.
  4. Review measure scores across treatment.
  5. Ask what helped most and least.
  6. Review the skills learned.
  7. Prepare for temporary flare-ups, often triggered by stressful life events or anniversaries. Plan to respond with exposure, not avoidance.
  8. Mark the ending.
• Example language (illustrative): "When you first rated the crowded train it was 90; today you've said 25. What made the difference?" ... "If symptoms come back for a while after something stressful, what will you do?"
• Watch for: Remaining high-SUDS items. Plan targeted self-exposure and consider booster sessions if gains are incomplete. [synthesis]
• [source: Kognito p. 14; CSP #591 protocol]

4.19 PE-A (adolescent) adaptations

• Purpose / when: Ages 13–18.
• Structure: Four phases:
  1. Pre-treatment preparation
  2. Psychoeducation and treatment planning
  3. Exposures (in vivo, imaginal with listening homework)
  4. Relapse prevention and ending
• Format: Delivered flexibly at the adolescent's pace, with greater family involvement.
• Steps: Follow the adult components above within those phases. Use developmentally adapted examples and the teen workbook. Involve caregivers in psychoeducation and in supporting homework. [uncertain: module-level detail and caregiver session content]
• Example language (illustrative): "This is like a game plan: you choose with me which things to practise, and we build up step by step."
• Watch for: Ongoing danger at home or school, which needs safety work first. Caregivers who encourage avoidance.
• [source: Title IV-E Clearinghouse; Foundations guidebook]

5. Handling problems

Items tagged [source] are grounded in the cited sources. Items tagged [synthesis] are my own clinical guidance, consistent with PE principles but not verified in the manual.

• Temporary symptom increase (often around Sessions 3–5, when imaginal exposure starts).
  • Predict it in Session 1 and again in Session 3. Present it as a sign of engagement, not damage.
  • Keep the plan; don't pause exposure.
  • The increase is usually modest and short-lived, and it doesn't predict worse outcome or dropout.
  • [source: Kognito p. 4; job notes on known risks]
  • Also check sleep, substance use and risk at that point. [synthesis]
• Homework non-adherence.
  • Review homework first every session, so it signals that homework is central.
  • Find the specific obstacle: practical (time, privacy, where to keep the recording) or avoidance ("I didn't feel ready").
  • Plan practical fixes: fixed time slots, phone reminders, a smaller item.
  • For avoidance, return to the rationale. Do part of the homework in session. Reduce the step size but not the expectation.
  • [source: CDP outline objective 7 for the centrality of homework; the specific strategies are my own [synthesis]]
• Avoidance of the imaginal exposure itself (cancellations, small talk, "can we skip it today").
  • Name the pattern without blame.
  • Ask them to restate the rationale. Reconnect to their goals.
  • Start the exposure early in the session, before avoidance builds.
  • Agree a minimum (e.g., one full retelling) rather than skipping. [synthesis]
• Under-engagement / emotional numbing / flat SUDS. Use eyes closed, present tense and sensory probes (4.11). Explore fears about feeling, such as "if I start crying I won't stop". Remember that 2nd-edition processing treats low-distress exposures as useful too. [source: Kognito p. 11; Foa & Rauch interview]
• Over-engagement / overwhelm. Use eyes open, past tense, more frequent grounding comments and a written narrative (4.11). Keep going at reduced intensity; don't stop. Don't use breathing or relaxation to end distress, because finishing distressed is acceptable. [source: Kognito p. 12; over-engagement techniques [uncertain], see 4.11]
• Dissociation during exposure.
  1. Ground: eyes open, the patient says where they are and the date, feels the chair, holds a textured object.
  2. Then resume the narrative from just before the point where they dissociated, with more frequent check-ins.
  3. Track the triggers in processing.
  • In severe cases, combined DBT plus PE protocols exist for co-occurring BPD and self-harm.
  • [synthesis; DBT-PE noted in the Wikipedia summary]
• Patient is stuck (no change in symptoms or SUDS by about Session 6–8).
  • Check fidelity: Are recordings being heard daily? Is in vivo done long enough without safety behaviours? Is the hierarchy too easy? Is engagement adequate?
  • Check whether the index trauma is still the right target.
  • Check whether the distress is now mainly guilt, shame or anger, and if so focus processing there.
  • Check whether hot spots have been identified.
  • Seek PE consultation.
  • [synthesis, informed by the CDP outline objectives 11–12 on using measures to refine treatment]
• Guilt, shame and moral injury dominate.
  • Use hot spots on the moments the guilt attaches to.
  • In processing, use Socratic questioning about foreseeability, the options really available, intent and responsibility shared with others.
  • The 2nd-edition guide has new sections on guilt and moral injury. [source: Foa & Rauch interview; specific content of those sections [uncertain]]
• Anger rather than fear. Process the meanings behind the anger (betrayal, injustice) in processing. Keep exposure going. Add in vivo items that the anger is used to avoid (e.g., being near people who resemble the perpetrator). [synthesis]
• Multiple traumas.
  • Target the index trauma first. Gains often generalise.
  • If another memory remains distressing near the end, it can become a second imaginal target if sessions allow.
  • [source for index-first: CDP outline "assessment"; generalisation and second target [uncertain] / [synthesis]]
• Memory gaps or a fragmented memory. A partial memory is enough. Narrate what is remembered, including the gaps ("then it goes blank"). Don't push to fill gaps with guessed content. [source: Kognito p. 3 for memory adequacy; the guidance on gaps is my own [synthesis]]
• Emerging suicidality or self-harm.
  • Run standard risk assessment: ideation, intent, plan, history, protective factors.
  • Update the safety plan collaboratively, including lethal-means counselling (safe storage or temporary removal of firearms and stockpiled medications).
  • If risk becomes imminent, pause exposure and stabilise. Resume when risk is managed.
  • Ongoing serious self-injury or imminent risk are contraindications to starting PE. [source: Kognito p. 3; the rest follows current standard risk-management practice [synthesis]]
• Substance use.
  • Substance use is not an exclusion.
  • Agree no alcohol or drugs before or during exposures, or before listening to recordings, because substances dampen engagement and learning.
  • Monitor use if it increases during the temporary symptom rise.
  • Consider integrated programmes (e.g., COPE) for substance use disorder. [uncertain: COPE]
  • [source: Kognito p. 3 on comorbidity; Wikipedia summary; the rest is my own [synthesis]]
• Ongoing real danger (e.g., an abusive partner, a hazardous workplace). Do safety planning first. Keep in vivo items strictly to objectively safe situations. Defer PE if the patient is currently at high risk of assault. [source: Kognito p. 3; principle of objective safety]
• Alliance ruptures (e.g., "You're making me relive this; you don't care").
  • Acknowledge the difficulty and validate the feeling.
  • Own any missteps, such as pushing too fast or a hurried rationale.
  • Re-explain why the exposure matters. Renegotiate pace collaboratively (e.g., a smaller in vivo step, eyes-open imaginal) without dropping exposure.
  • Ask for feedback at the end of sessions.
  • [synthesis; the Kognito material stresses alliance and buy-in]
• Therapist's own reluctance (fear of harming, colluding with "not today").
  • Resolve reservations before starting: the risks of PE are temporary and modest.
  • Use consultation.
  • Notice when you are the one changing the subject during exposure.
  • [source: Kognito p. 4]
• Early dropout risk. Dropout clusters early, around the start of imaginal work.
  • Build buy-in deliberately.
  • Predict the temporary rise.
  • Contact patients promptly after a missed session.
  • Consider twice-weekly sessions around Sessions 3–5 to carry them through. [synthesis; the dropout figures in the job notes are 10–38% across trials]
• Telehealth delivery. Agree on privacy, an emergency plan and the patient's location. Make sure the patient can record the session. Check the camera shows enough to observe engagement. [synthesis]
• Training and fidelity. Certification as a PE therapist, through the CTSA programme, requires an intensive workshop (about 4 days) plus at least two consulted cases. Ongoing consultation is the main safeguard against drift. [source: Title IV-E Clearinghouse]

Sources

Sources:

• Prolonged exposure therapy — Wikipedia
• APA Clinical Practice Guideline for PTSD: Prolonged Exposure
• Staff Perspective: Drs. Edna Foa and Sheila Rauch on the new PE manual (Center for Deployment Psychology)
• CDP PE course outline, June 2024
• CSP #591 trial protocol, Comparative Effectiveness Research in Veterans With PTSD (NCT01928732)
• OUP: PE Therapist Guide 2nd ed., Session 1 (abstract)
• OUP: PE Therapist Guide 2nd ed., Intermediate Sessions (abstract)
• Psychotherapy Academy: PE for PTSD intermediate sessions (Rothbaum)
• van Minnen & Foa (2006), duration of imaginal exposure (Penn CTSA PDF)
• Kognito Interactive PE training text, pages 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 [uncertain: the programme title is not shown on these pages; the content appears to follow the 1st-edition manual]
• Title IV-E Prevention Services Clearinghouse: PE for Adolescents
• Foundations guidebook: PE-A

Further reading (not drawn on): books and papers cited

• Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. A. M. (2019). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide (2nd ed.). Oxford University Press.
• Rothbaum, B. O., Foa, E. B., Hembree, E. A., & Rauch, S. A. M. (2019). Reclaiming Your Life from a Traumatic Experience: Workbook (2nd ed.). Oxford University Press.
• Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged Exposure Therapy for PTSD: Therapist Guide. Oxford University Press.
• Foa, E. B., Chrestman, K. R., & Gilboa-Schechtman, E. (2009). Prolonged Exposure Therapy for Adolescents with PTSD: Therapist Guide. Oxford University Press.
• Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin.
• Hembree, E. A., Rauch, S. A. M., & Foa, E. B. (2003). Beyond the manual: The insider's guide to prolonged exposure therapy for PTSD. Cognitive and Behavioral Practice.