Prolonged Exposure: The Only Way Out is Through

McCallum Place Clinical Director discusses the importance of Prolonged Exposure Therapy in the treatment of PTSD


Three treatments currently exist for Post-Traumatic Stress Disorder (PTSD) that involve trauma reprocessing and which carry the designation of “strong” research support from the American Psychological Association:  Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR).  All three treatments incorporate exposure to the memory of the trauma, a testament to the role of avoidance in the etiology of PTSD.

Trauma is a relatively common life experience, with approximately 50% of women and 60% of men experiencing what the DSM-4 defined as a “criterion A” traumatic event.  However, 7-8% of the population develops PTSD.  Therefore, PTSD cannot be the inevitable or even likely outcome of trauma.  Risk factors for the development of chronic PTSD include:  repeated traumas, “severe” trauma, interpersonal traumas, and avoidant coping strategies.  The importance of “severe” or repeated traumas seems obvious; I suspect the importance of interpersonal traumas is that they risk undermining one’s ability to trust other people and encountering other people is a common event!  The role of avoidance, however, may be less intuitive.

Individuals struggling with PTSD often attempt to cope with the trauma by trying not to think about it, discuss it, or encounter stimuli that are reminiscent of the trauma.  What we attempt to aggressively avoid tends to intrude into our consciousness in unexpected and unpleasant ways.  Avoidance and escape from distressing memories promotes and maintains PTSD over time.  The avoidant behaviors are strengthened over time because they rapidly relieve anxiety, albeit temporarily, via negative reinforcement.  Avoidance also allows fears to generalize (i.e. expand over time), while preventing fear extinction and memory processing.  Metaphorically, PTSD memories are like papers strewn across a desk, versus sorted and filed neatly in a cabinet.  Such insufficient processing contributes to the memories’ intrusion in the form of re-experiencing symptoms, which patients experience as occurring in real-time, versus as a distant memory.  PE, CPT, and EMDR emphasize exposure therapy because it is the antidote to avoidance.

Clinicians may feel uncomfortable treating PTSD via exposure.  A common fear is that of ‘retraumatizing’ the patient.  Memories, however, are not dangerous; PTSD patients regularly come into contact with the memories in the form of nightmares and flashbacks.  However, such brief exposure, often followed by escape, worsens anxiety instead of promoting desensitization.  Most patients can tolerate exposure work, as the therapists teaches and models that intense emotions are not unending or harmful.  Most patients who participated in the seminal PE studies did not experience an exacerbation of their symptoms.  For those who did, exacerbation was temporary and did not affect the final response to the treatment.  PE can also be used with patients who have complex problems and comorbidities.  PE asserts that exposure is the most compassionate treatment for PTSD, representing the quickest path to achieve desensitization and symptom reduction.  Although, much like in physical therapy to rehabilitate an injured joint, the discomfort of facing distressing memories and triggering situations must be endured in exchange for progress.

In graduate school, I sensed that the prevailing recommendation at the time was to delay the treatment of PTSD until after a patient had completed treatment in higher levels of care, or at least until the eating disorder or comparable symptoms had remitted.  I suspect the approach reflected a fear of exacerbating self-destructive coping behaviors.  But, what if maladaptive behaviors like self-injury, substance abuse, and/or eating disorder behaviors represent the patient’s effort to cope with PTSD symptoms?  How would such behaviors remit without resolving the PTSD symptoms fueling them?  In recent years, the work of Melanie Harned has addressed this dilemma by providing protocols for the integration of exposures therapies into existing treatments for other disorders, like Dialectical Behavior Therapy.  In short, PTSD patients with multiple problems and/or self-destructive behaviors are asked to demonstrate that they can abstain from such behaviors for a period of time before PE begins.  In the event self-destructive behaviors return and risk nullifying the benefits of exposure work, PE is paused.  Self-destructive behaviors can function as escape behaviors, blocking desensitization and reducing the potential benefit of the exposure work.  After pausing PE, therapy would focus on increasing the patient’s distress tolerance, with the goal of returning to PE as quickly as safely possible.

PE comprises a variety of components.  As daily homework assignments, patients face avoided people/places/situations/things/sensory cues which are not dangerous, but which elicit memories of the trauma.  In session, patients discuss the trauma narrative, working up to the ability to tell the complete story, with full sensory detail, in the present tense, and with their eyes closed.  These imaginal exposures lower anxiety associated with the memory via habituation, promote distinction between the specific trauma and similar stimuli, and reprocess the memory so that it can be experienced as a past event, versus a present experience.  Later in-session exposures focus on ‘hot spots’ – the most anxiety-provoking aspects of the trauma narrative – versus the entire memory.  Imaginal exposures end with a breathing exercise to assist the patient in calming and transitioning.  The final segment of the session is devoted to addressing beliefs related to the trauma, often involving themes of safety, trust, guilt, and self-blame.

Therapists at McCallum Place are currently learning about PE in their weekly group supervision meetings.  We strive to provide the highest quality treatment by synthesizing our individual clinical judgment, our patient’s preferences for treatment, and the guidance of empirically support treatments.  While the therapeutic relationship may be the most powerful agent of change, specific disorders often also require specific techniques for the best and fastest results.  Treatments like PE can not only resolve PTSD, but also reduce the reliance on eating disorder behaviors in patients for whom there is a functional relationship between the two disorders.



About John Rapp, LCSW, Therapist

John Rapp earned a bachelor of science degree in microbiology and immunology from the University of Wisconsin-Madison and an MSW from Washington University in St. Louis.  He is a licensed clinical social worker in the state of Missouri.  John started his career at McCallum Place and has returned as clinical director after four years as an outpatient therapist.   John is a psychodynamic therapist, aiming to help patients bring uncomfortable feelings and patterns into awareness, so they can better understand their own minds and more freely make desired changes.  He also has significant experience providing cognitive-behavior therapy, dialectical behavior therapy, and exposure therapy.  He specializes in helping patients become more emotionally and interpersonally regulated, so that they can relinquish the need for ineffective or self-destructive coping.

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