Prolonged Exposure Therapy for PTSD (Foa, Hembree, & Rothbaum, 2007), has been the principal guide for providers learning and implementing Prolonged Exposure Therapy (PE) for patients with PTSD. The original manual describes the session by session PE protocol in detail, supplemented with case examples and transcripts from the authors extensive experience treating survivors of sexual assault and other traumas.
In the updated version, Foa and colleagues have been joined by Sheila Rauch, an outstanding PTSD researcher and clinician from Emory University Medical Center, and the Atlanta Veterans Administration. I recently had the privilege and pleasure to speak with Dr. Edna Foa, the Senior author and creator of Prolonged Exposure therapy, and to correspond with Dr. Sheila Rauch the newest member of the team, about the updated manual. I learned all about the new manual as well as some savory bits about relaxed breathing, imaginal exposure processing and the future of PE treatment.
Chrestman: The original PE manual, Prolonged Exposure Therapy for PTSD (Foa, Hembree, & Rothbaum, 2007), is almost 13 years old but it’s still the principal guide for providers learning and implementing PE for patients with PTSD. It describes the treatment protocol session-by-session in detail and the transcripts and examples are still incredibly useful for both novices and experienced clinicians. How did you know it was time for a revision?
Rauch: It had been 10 years and so much research has been done with PE in figuring out how it works and how to effectively train providers in how to use it well. We wanted to integrate all that new knowledge into the manual.
Foa: PE has not changed in principle, but there are subtleties that needed to be described or revised to help people understand the treatment better. In the past 10 years many outcome and process studies on PE were conducted and published and the manual needed to be updated to include this knowledge. I asked Sheila Rauch to join because she is an outstanding researcher whose work focused on veterans and we wanted to include more information about PE in with veterans. Much of the new literature on PE came from veterans and some from active duty personnel, and needed to be included.
Chrestman: What are the major differences between the 2007 version and the new version?
Rauch: We moved from the previous components to refine the treatment to three components (copied below from the manual):
1) Education about common reactions to trauma, what maintains trauma-related symptoms, and how PE reduces PTSD symptoms.
2) Repeated real-life exposure (called “in vivo” exposure) to situations, people, or objects that are objectively safe or low risk but that the person is avoiding because they are trauma-related and cause emotional distress, such as anxiety, shame, or guilt.
3) Repeated “imaginal exposure” to the trauma memories (that is, revisiting and recounting the trauma memory in a person’s imagination) followed by processing the details of the event and the emotions and thoughts that the person experienced during the trauma. This is accomplished through discussion of the experience of recounting the trauma memories.
Chrestman: So, the breathing retraining is no longer a component of PE?
Foa: I was never convinced that breathing retraining needed to be emphasized as one of the PE components because it created confusion. On the one hand, we tell PTSD patients that fear and anxiety in situations that are not dangerous are unrealistic and need to be overcome by exposure, on the other hand we tell them they need to do the breathing retraining everyday so they won’t feel anxious.
In workshops, we were de-emphasizing the breathing but the manual still presented it as equally important to the other components of the treatment. Many colleagues asked us, “When are you going to take it out of the protocol?” I never wanted it to be part of PE. I believe it can be potentially harmful as a safety behavior and safety behaviors interfere with learning not to avoid safe situations. They prevent disconfirmation of the patients’ fear. By using breathing during exposures, patients may conclude that their exposure was successful for the wrong reasons, not due to their own strength, their power and effort, but due to a special technique or a safety behavior - the breathing.
In the past, my collaborators wanted to keep it in and I agreed because at that time we thought it might still provide something useful. Therapists and patients like it also.
in the new version we decided not to take it out but to deemphasized it. It is embedded in the manual but not as one of the main techniques of PE. We are also careful to explicitly tell the patients that we don’t want them to use it during any exposures, but more for everyday life anxieties and distress - say during a work meeting. It’s a subtle and useful technique to help one during daily activities that provoke stress.
Chrestman: Any other important differences?
Foa: We expanded the section on processing as well. The processing is not as clear cut as the other techniques. It is more fluid. We provided more detail about how to do the processing after imaginal exposure. It is important to note that processing is not cognitive therapy. It is part of imaginal exposure. It is not really a technique by itself. We start with processing wherever the patient is at. We tell patients that every imaginal exposure is a success. If they are having extremely distressing reactions, or not, if they experience habituation in the first imaginal exposures or not, we normalize their experience. Using open ended questions, we then want the patient to tell the therapist what they learned during imaginal exposure, anything new that happened, what they felt, what they thought. It may look more like good, traditional psychotherapy. We are leading them through their own experience, not feeding them with any particular ideas or information.
Chrestman: How would you distinguish processing from formal cognitive therapy?
Foa: In cognitive therapy you have distinct components and a way of doing it. It’s a procedure. There are certain questions to ask. “What makes you believe X…...? How much do you believe X……?” There is homework related to the procedure. It is more prescriptive. It has a clear format. Processing is more fluid and spontaneous. The therapist goes with what the patient is saying, helping the patient clarify or realize what they learned or what happened during imaginal exposure. In later sessions, we are expanding beyond what happens during the particular imaginal exposure and helping the patient to generalize learning to other situations in life.
Additionally, I think that we deal with the unrealistic fear and anxiety via imaginal and in vivo exposure alone. In the in vivo exposures for example, the patient learns that going to places they are afraid of is not dangerous. They also learn to discriminate between what is safe and unsafe. Anxiety, fear of falling apart, and fear of being revictimized or retraumatized often decreases with exposure alone. The processing is more helpful with the other emotions - Guilt, shame and anger for example.
Chrestman: Emotional Processing Theory is pretty specific about the importance of processing immediately after imaginal exposure, while the trauma memory structure is activated. Is this another important difference?
Foa: That’s right. Taking advantage of the memory structure being activated due to the imaginal exposure is very important. In their everyday life, when the trauma comes to mind, patients try to avoid engaging with it. They don’t attempt to process that information and learn anything about it. It is like they come to the doorway of the room but don’t go into the room to see what furniture is there. In Imaginal exposure we are going into the room and we see what is really there, what really happened. They experience their memories, thoughts and emotions in the context of what happened when it occurs right after the imaginal exposure, because they are actually thinking and realizing what happened in the context of the trauma. If you ask them the same question outside that context, they are not as open to reconsider their emotions, cognitions and perceptions of what happened.
For example, a patient was raped by some friends and the rape was organized by her boyfriend. Every time the gang rape comes to mind she thinks, “I never told them I didn’t like it. If I did, they wouldn't do it. So, it is all my fault.”
When she engaged in the memory she described how much she fought and how much she communicated in many ways that she did not like it, and did not want to be raped. They did it anyway. With this realization, she was able to understand that she fought and expressed her wishes. She saw that she was not responsible for the rape, they were.
Rauch: In addition to these changes, we include more details on working with military and veterans. We have added sections addressing complex trauma, guilt and moral injury. There are additional clinical examples as well from our experiences working with the military.
Chrestman: Given it is designed to be short and easy to use, I wonder if you had to leave out anything interesting or maybe more advanced in the service of brevity. Is there anything else you wish you wish you could have included?
Foa: I don’t think so. Everything crucial I learned from 2007 is in the revised manual.
Rauch: I wish we could have included the many effective variations for how to use PE, including specifics on augmentation with exercise, and cognitive enhancers or other strategies; and new models of care like PE for Primary Care (PE-PC) and the intensive outpatient model of PE.
Chrestman: In the next 10 or 12 years, what do you think will be the new horizon for PE and PTSD research?
Foa: Effectiveness and efficiency. PE is 8-15 sessions. I think it can be more efficient. I also think we can make it more palatable for patients. Do we need to do it with eyes closed, for example? Is writing as effective, or spoken narrative, for example? Can the patient get as engaged emotionally when writing? If that is possible it will reduce patient’s fear of engaging in exposure, make it more palatable.
Chrestman: Anything else you want to let people know about PE or the revised manual?
Foa: We know that very few, if any patients are getting worse [from PE]. The myth that people will get worse is unsupported. In fact, many with PTSD are cured. Obviously, some patients don't get better, however. There are those who don’t recover completely. Who are these people? If we give them another treatment do they get better? Is there a way for us to learn how to identify who for each treatment gets better? CPT [Cognitive Processing Therapy] and PE are equally effective generally, but are they the same people?
Rauch: Implementation of PE (and other psychotherapies) remains low due to many factors. Getting the word out to people suffering with PTSD that treatment works, and to providers that they can truly provide transformative intervention to their patients through the use of PE needs to continue. Reducing the suffering of trauma survivors with PTSD is our goal and effective treatment is the key. PE works!!
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Kelly Chrestman, Ph.D., is not usually a celebrity interviewer but is most often a Prolonged Exposure Therapy Subject Matter Expert and curious/nosy person. She trains and consults on PE and other topics as a military behavioral health psychologist at CDP. If you're also curious/nosy, click here for more information about her.
Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. A. M. (2019). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Second Edition. New York, New York: Oxford University Press.