Exposure Therapy for Clients with PTSD
By Jennie Lannette Bedsworth, MSW, LCSW
The thought of purposefully exposing someone to memories of a past trauma can sound frightening to clients and even therapists at times. Sometimes clinicians fear that exposure can make a client’s trauma symptoms worse, or complicate other conditions (Van Minnen et al., 2012).
However, the most successful therapies for post-traumatic stress disorder (PTSD) include exposure techniques provided by qualified therapists. A variety of exposure therapies are generally quite effective and safe, even when complicated histories are involved (Larson et al., 2016).
Exposure techniques operate under the assumption that PTSD symptoms are kept alive because the person suffering from it is avoiding the thoughts and feelings that relate to his or her traumatic experience. This essentially causes the person to get emotionally stuck, and the individual never fully processes or moves beyond the trauma.
Instead of the trauma survivor making meaning of what happened and integrating it into their lives, as many trauma survivors do, the past trauma manifests as a combination of symptoms. This can include PTSD symptoms such as re-experiencing the trauma as flashbacks or nightmares, avoidance of feelings or dissociation, constantly being on edge, and negative feelings about oneself and life in general (National Institute of Mental Health, 2016).
Over time, those suffering from PTSD may begin to not only avoid the situations that remind them of past traumas, but also any situation where they feel out of control, such as in crowded restaurants or walking alone at night. The more a person avoids such prompting events, the more his or her brain begins to associate danger with a certain thought or situation, such as going to the mall.
These fears can sometimes spread to even more areas. In this way the fear perpetuates itself – sometimes referred to as generalization.
Exposure therapies are designed to help clients move out of avoidance and in to facing memories and feelings in order to begin to process and make meaning of them. This also allows more freedom in life, without fears of everyday events that didn’t bother the client prior to the traumatic event. PTSD therapies include varying degrees of intensity when it comes to exposing clients to trauma memories and related thoughts and feelings.
One of the most intense, widely used, and effective treatments is prolonged exposure therapy (PE), developed by Edna Foa. PE uses education about trauma, exposure techniques, and cognitive restructuring to treat PTSD and related disorders. Two types of exposure are used, including in-vivo and imaginal exposure.
In-vivo exposure is used in other anxiety-related therapies as well, and involves facing everyday fears in real-life situations, such as working up to walking around a crowded shopping mall, or gradually facing fears about people who look similar to a past abuser. Over time, the mind and body learn through positive experiences that these situations are not generally dangerous (Foa et al., 2007).
The second type, imaginal exposure, is completed in the PE sessions with the therapist—clients tell their trauma story repeatedly over several sessions and listen to a recording of their story in between sessions. Gradually, the client begins to habituate, or get used to, listening to the story or facing prompting situations without having a frightened response (Foa et al., 2007). PE is used throughout the U.S. and is offered by the Veteran’s Administration (VA).
Dialectical Behavioral Therapy with PE (Prolonged Exposure)
PE is now sometimes used as a protocol within dialectical behavioral therapy (called DBT PE), and has been shown to be successful with clients who suffer from borderline personality disorder, PTSD, and self-harm behavior. The protocol follows much of the basic prolonged exposure model, but includes additional elements along with typical DBT therapy methods. Therapists also focus more on DBT-style processing and validation techniques, similar to that in a basic DBT therapy session. So far, DBT PE has been shown to further reduce the likelihood of self-harm and suicidal behavior than DBT alone (Harned et al., 2014).
Trauma-Focused Cognitive Behavioral Therapy
Another evidence-based and commonly used PTSD therapy, used traditionally with children and adolescents, is trauma-focused cognitive behavioral therapy, or TF-CBT. This therapy has some overlap with PE, as it also includes education about trauma for the child and parents, relaxed breathing, and self-care, leading up to the exposure elements. This therapy spends time focusing on education, safety, and coping skills. It incorporates gentler “gradual exposure” that begins on the first day of therapy.
The in-session exposure portion of TF-CBT is designed to be more flexible than in many other therapies, and can range from the child writing a narrative of the trauma, to creating a poem or video about what occurred. These methods can also be combined, and are called “individualized expressive techniques.” These allow children and teens to more naturally express and process their traumatic stories (Cohen et al., 2006). Other examples include children or teens combining music, art, or pictures with written narratives about their lives and past trauma.
Cognitive Processing Therapy
Cognitive processing therapy (CPT) is another evidence-based therapy used by the VA and others to treat PTSD. It also includes educational and cognitive components and in some cases an exposure element. It was initially created to treat rape victims (Resick & Schnicke, 1992).
CPT specifically educates clients about the thoughts and feelings that are related to their PTSD symptoms. The processing helps the client understand how his or her thoughts and beliefs were changed because of the development of PTSD.
In one type of CPT, the client is asked to write and review a written narrative of his or her traumatic experience – this is the exposure element. Another format is also sometimes offered that does not include the direct exposure but focuses on the cognitive elements.
Eye Movement Desensitization and Reprocessing - EMDR
Perhaps one of the most well-known and popular trauma treatments is eye movement and desensitization and reprocessing, known as EMDR. This therapy also includes an exposure element, in the sense that at times clients are asked to focus on a target image, such as a moment or the entire experience of a traumatic event while participating in a type of processing which involves eye movement similar to what’s experienced in REM sleep (Posmntier et al., 2010).
Just as with more direct exposure therapy, the client becomes desensitized to the memory. There is some disagreement about why EMDR is effective—some believe it is the exposure and processing itself rather than the eye movement (Sharpless & Barber, 2011). Nonetheless, it is one of the most researched, evidence based and available treatments for PTSD.
While there are many studies that compare the benefits of one trauma treatment to another, the common theme among the most effective at helping clients overcome PTSD includes exposure elements. While this can seem frightening at first, the hard work put in by trauma therapists and clients is worthwhile in the end.
—Jennie Bedsworth, MSW, LCSW, is a therapist based in Mid-Missouri who writes about trauma and other mental health topics.
Exposure Therapy Resources for Clinicians
If you’d like to learn more about providing a specific type of exposure therapy, visit these resources related to the various treatment types discussed in this article. (You can also contact Jennie for support or a second opinion. Call 573/291-7315.)
*A web-based learning course for TF-CBT: https://tfcbt.musc.edu/f
*Social Work Today’s article Trauma-Focused Cognitive-Behavioral Therapy—Hope for Abused Children: http://www.socialworktoday.com/archive/051412p22.shtml
*A web-based learning course for CPT: https://cpt.musc.edu/
*VA’s National Center for PTSD, Professional Site: http://www.ptsd.va.gov/professional/index.asp
*APA’s information sheet on exposure therapy: http://www.apa.org/research/action/exposure.aspx
*Penn Behavioral Health’s article about PE: https://www.med.upenn.edu/ctsa/workshops_pet.html
*University of Washington’s page on DBT PE: http://depts.washington.edu/dbtpe/what-is-dbt-pe/
*EMDR Institute: http://www.emdr.com/what-is-emdr/
Cohen, J.A., Mannarino, A.P., & Deblinger, E. (2006). Treating Trauma and Traumatic Grief in Children and Adolescents. New York: The Guilford Press.
Foa E. B, Hembree E. A, Rothbaum B. O. (2007) Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. New York, NY: Oxford University Press.
Harned MS, Korslund KE, Linehan MM. (2014) A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour research and therapy, 55, 7-17.
Larsen, S. E., Stirman, S. W., Smith, B. N., & Resick, P. A. (2016). Symptom exacerbations in trauma-focused treatments: Associations with treatment outcome and non-completion. Behaviour Research and Therapy, 77, 68-77.
National Institute of Mental Health (2016, February) Post Traumatic Stress Disorder. Retrieved from http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
Posmntier, B., Dovydaitis, T., & Lipman K. (2010). Sexual Violence: Psychiatric Healing With Eye Movement Reprocessing and Desensitization.Health Care for Women International, 31(8), 755–768.
Resick PA, Schnicke MK. CPT for sexual assault victims. Journal of Consulting and Clinical Psychology. 1992.
Sharpless, B. A., & Barber, J. P. (2011). A Clinician’s Guide to PTSD Treatments for Returning Veterans. Professional Psychology, Research and Practice, 42(1), 8–15.
Van Minnen, A., Harned, M. S., Zoellner, L., & Mills, K. (2012). Examining potential contraindications for prolonged exposure therapy for PTSD. European Journal of Psychotraumatology.