Prolonged Exposure (PE)

Theory of change

Recovery appears when the person stops avoiding the traumatic memory and its safe reminders, relives them in a sustained way and integrates them with new information about danger, competence and the present.

Core ideas

1. PE is a trauma-focused protocol, not a generic exposure

   Prolonged Exposure is organised around the traumatic memory and the present cues that the person avoids because they activate post-traumatic distress. Its specificity lies in combining prolonged imaginal revisiting of the index memory, in vivo exposure to safe reminders, subsequent processing and between-session practice. This architecture differentiates it from exposure protocols for OCD, phobias or other anxiety problems, because the clinical target is not to prevent rituals but to process the traumatic memory and reduce the avoidance that maintains PTSD. Reference: Foa, Rothbaum, Riggs and Murdock (1991); Foa, Hembree, Rothbaum and Rauch (2019).

2. Avoidance maintains PTSD by preventing corrective information

   People with PTSD usually avoid memories, emotions, conversations, places, activities and bonds associated with the trauma because contact with them produces anguish. This avoidance reduces distress immediately, but prevents them from learning that the memory can be tolerated, that the danger is over and that many present reminders are not equivalent to the trauma. PE intervenes directly on this mechanism, making repeated approach replace avoidance as the route to recovery. Reference: Foa and Kozak (1986); Foa, Hembree, Rothbaum and Rauch (2019).

3. The traumatic memory must be activated in order to be modified

   Emotional Processing Theory holds that a fear structure can only change if it is sufficiently activated and if, during that activation, information incompatible with its pathological elements is incorporated. In PE, imaginal exposure gives access to the stimuli, responses and meanings of the traumatic memory, while the subsequent processing and the repetition of the experience foster new associations between the memory, present safety, emotional tolerance and competence. Reference: Foa and Kozak (1986); Foa, Hembree, Rothbaum and Rauch (2019).

4. Remembering the trauma is not the same as reliving it

   One of the central clinical updates in PE consists in the person being able to experience the difference between remembering a traumatic experience and currently being in the traumatic situation. Imaginal exposure activates intense sensations, images and emotions, but it takes place in a safe and repeatable context. Through that repetition, the memory can lose part of its quality of present threat and become integrated as a painful past event rather than a current danger. Reference: Foa, Rothbaum, Riggs and Murdock (1991); Foa, Hembree, Rothbaum and Rauch (2019).

5. In vivo exposure recovers life; it does not seek to repeat the trauma

   PE's in vivo exposure is aimed at safe or low-risk reminders that have come to be avoided through traumatic association, such as journeys, places, social activities, intimacy, driving, news or public spaces. Its aim is to broaden behavioural freedom and to update beliefs of generalised danger. The task is designed with a clear assessment of current safety, because PE does not propose exposing anyone to violence, abuse, perpetrators or objectively dangerous contexts. Reference: Foa, Hembree, Rothbaum and Rauch (2019).

6. Subsequent processing updates meanings of danger, guilt and competence

   After the imaginal exposure, PE uses a clinical conversation to explore the emotions, details, thoughts and learning that arose during the evocation. This processing helps to revisit post-traumatic meanings such as "it was my fault", "I am weak", "I cannot bear it" or "the whole world is dangerous", without necessarily adding a separate formal technique of cognitive restructuring. The cognitive updating takes place within emotional contact with the memory and the repeated experience of facing it. Reference: Foa, Hembree, Rothbaum and Rauch (2019); Foa and Rauch (2004).

7. Within-session habituation is not the only indicator of change

   The original model valued the decrease of distress during the exposure as an indicator of processing, but later research qualified this, showing that improvement does not depend exclusively on anxiety falling in each session. PE is oriented towards a broader set of indicators: sufficient emotional engagement, reduction of avoidance, progressive decrease of arousal between sessions, modification of traumatic cognitions and functional recovery. Reference: Foa and Kozak (1986); Foa, Hembree, Rothbaum and Rauch (2019).

8. Between-session assignments are part of the treatment, not a minor supplement

   Listening to the recording of the imaginal exposure and practising in vivo exposure between sessions multiply contact with the memory and its reminders, reduce avoidance and consolidate learning outside the consulting room. PE depends on this continuity because PTSD is not maintained in session alone but in the everyday life restricted by the trauma. Adherence to assignments allows the person to discover that they can sustain the process without depending exclusively on the therapist's presence. Reference: Foa, Rothbaum, Riggs and Murdock (1991); Foa, Hembree, Rothbaum and Rauch (2019).

9. PE works without adding multiple anxiety-management techniques

   The trials that compared PE with stress inoculation training, PE combined with stress inoculation or PE with cognitive restructuring did not show a consistent advantage in adding auxiliary components to the protocol. These results support a version focused on imaginal exposure, in vivo exposure, processing and repeated practice, avoiding overloading the treatment with skills that may take time and attention away from the trauma-focused work. Reference: Foa, Dancu, Hembree, Jaycox, Meadows and Street (1999); Foa, Hembree, Cahill, Rauch, Riggs, Feeny and Yadin (2005).

10. The alliance in PE sustains approach, not avoidance

    The therapeutic relationship in PE must be empathic, safe and active, but its function is not to prevent the person from making contact with the trauma; it is to accompany them stably enough for them to be able to do so. The therapist validates the suffering, explains the logic of the treatment, monitors risk and dissociation, adjusts the pace and maintains the trauma-focused direction. The alliance is expressed in sustaining difficult work with respect, not in withdrawing the exposure every time distress appears. Reference: Hembree, Rauch and Foa (2003); Foa, Hembree, Rothbaum and Rauch (2019).

Influences

• Behaviour therapy
• Emotional processing theory
• Peter Lang's bio-informational model of fear
• Classical and operant conditioning
• Research on avoidance and extinction
• Cognitive-behavioural psychology of trauma

Key references

• Foa, E. B., y Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.
• Foa, E. B., Steketee, G., y Rothbaum, B. O. (1989). Behavioral/cognitive conceptualization of post-traumatic stress disorder. Behavior Therapy, 20, 155–176.
• Foa, E. B., Rothbaum, B. O., Riggs, D. S., y Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, 715–723.
• Foa, E. B., Riggs, D. S., Dancu, C. V., y Rothbaum, B. O. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473.
• Foa, E. B., Riggs, D. S., Massie, E. D., y Yarczower, M. (1995). The impact of fear activation and anger on the efficacy of exposure treatment for posttraumatic stress disorder. Behavior Therapy, 26, 487–499.
• Foa, E. B., y Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. Guilford Press.
• Jaycox, L. H., Foa, E. B., y Morral, A. R. (1998). Influence of emotional engagement and habituation on exposure therapy for PTSD. Journal of Consulting and Clinical Psychology, 66, 185–192.
• Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., y Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67, 194–200.
• Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., y Orsillo, S. M. (1999). The Posttraumatic Cognitions Inventory (PTCI): Development and validation. Psychological Assessment, 11, 303–314.
• Hembree, E. A., Rauch, S. A. M., y Foa, E. B. (2003). Beyond the manual: The insider’s guide to prolonged exposure therapy for PTSD. Cognitive and Behavioral Practice, 10, 22–30.
• Foa, E. B., y Rauch, S. A. M. (2004). Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72, 879–884.
• Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A. M., Riggs, D. S., Feeny, N. C., y 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, 953–964.
• Foa, E. B., Huppert, J. D., y Cahill, S. P. (2006). Emotional processing theory: An update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment. Guilford Press.
• Foa, E. B., Hembree, E. A., Rothbaum, B. O., y 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., y Rauch, S. A. M. (2019). Reclaiming Your Life from a Traumatic Experience: Workbook for Prolonged Exposure Therapy. Oxford University Press.