Prolonged Exposure Therapy

Presentation

Prolonged Exposure (PE) therapy is a treatment protocol for post-traumatic stress disorder (PTSD) developed by Edna B. Foa, psychology professor at the University of Pennsylvania. It is one of the most studied and validated psychotherapies for PTSD, recommended as first-line treatment by the APA, VA/DoD and WHO.

Based on Foa and Kozak's emotional processing theory (1986), this approach rests on the principle that avoidance — behavioral and cognitive — maintains PTSD symptoms by preventing the patient from emotionally reprocessing the traumatic memory and learning that associated stimuli are no longer dangerous.

Founder: Edna B. Foa (born 1937), psychology professor, University of Pennsylvania

Core Principles

Emotional Processing Theory proposes that PTSD results from a pathological fear structure — a memory network containing erroneous associations between trauma and ordinary stimuli, negative self and world evaluations, and conditioned fear responses.

Repeated exposure to traumatic memory (imaginal exposure) and safe but avoided situations (in vivo exposure) enables: 1) habituation — fear response naturally decreases with repetition; 2) corrective learning — the patient learns the memory itself is not dangerous; 3) fear structure modification — pathological associations are replaced by more realistic ones.

Main Indications

• Post-traumatic stress disorder (primary indication)
• Chronic and treatment-resistant PTSD
• Sexual assault-related PTSD
• Combat PTSD (veterans)
• Accident or disaster-related PTSD
• Multiple traumas

Session Overview

The standard protocol comprises 8 to 15 sessions of 90 minutes. Sessions 1-2 cover psychoeducation, trauma information gathering, breathing retraining and in vivo exposure hierarchy construction.

From session 3, each session includes: 1) Review of between-session in vivo exposure; 2) Imaginal exposure — the patient narrates the traumatic memory in present tense, eyes closed, repeatedly (30-45 minutes); 3) Post-processing — discussion of emerging emotions and insights; 4) Prescription of in vivo exposures and daily listening to the imaginal exposure audio recording.

Variations and Sub-techniques

• Standard prolonged exposure (Foa protocol, 8-15 sessions)
• Brief prolonged exposure (5-day intensive protocol)
• Prolonged exposure for adolescents (PE-A)
• Group prolonged exposure
• Virtual reality exposure therapy (VRET)
• CPT — Cognitive Processing Therapy (complementary approach)

Contraindications

• Imminent and unstable suicidal risk
• Active untreated psychosis
• Severe active self-harm requiring prior stabilization
• Active unstabilized substance abuse
• Severe structural dissociation
• Cognitive inability to follow structured protocol