Myths, Misconceptions, and Moving Forward: Successful Implementation of Prolonged Exposure
I was eager to write this blog when Ryan Van Wyk asked if I would be willing to contribute a post on Prolonged Exposure (PE) to the Minnesota Trauma Project website. As I’ve attended trauma conferences and talked with colleagues, it has amazed me the misconceptions in the field of mental health when it comes to exposure-based therapies. As a PE therapist and trainer myself, I have seen first hand the amazing changes that patients can undergo in 8-12 sessions; I’ve literally seen lives change and success maintained for years afterwards. It’s from this place of the incredible honor and fulfillment that I’ve experienced in providing this therapy that I write this post. While there is a lot that could be written about PE, the first step is to debunk some myths and misconceptions about PE. My hope here is to help demonstrate how this treatment is implemented in a manner that can help individuals struggling with Posttraumatic Stress Disorder (PTSD) in some very dramatic and enduring ways.
Before I explain some of the myths and misconceptions about PE, I think it would be useful to provide a somewhat brief overview of PE. PE is a cognitive-behavioral therapy (CBT) that is comprised of four essential elements: Education about trauma related symptoms and recovery processes; confronting real world situations that have been avoided since the trauma (i.e., in-vivo exposure); re-visiting/re-telling of the trauma narrative (i.e., imaginal exposure); and discussion of in-session emotions and thoughts following trauma re-visiting. A standard course of PE lasts, on average, between 9 and 12 sessions. There are a few specific contraindications for PE among individuals with PTSD: clients with unstable bipolar disorder or psychosis, imminent suicidal or homicidal intent, recent and severe violent behavior, active self-harm, or severe substance use disorders. Generally, it is important to delay PTSD treatment until such clinical risks can be sufficiently mitigated. The Institute of Medicine (IOM) reviewed the literature on successful PTSD treatments and concluded that exposure based treatments like PE were the only treatments that have a solid enough research base to be considered effective. Further, the most recent VA/Department of Defense (DoD) Clinical Practice Guidelines identified exposure therapy as one of four evidence-based psychotherapies for Veterans with PTSD (along with several other treatments including Cognitive Processing Therapy and EMDR).
Perhaps the most prevalent myth related to PE is that it is an unsafe treatment. Despite evidence to support it’s effectiveness across populations, many clinicians express concerns about client safety and acceptability of PE, typically based upon “what they have heard.” However, it has been my experience, and that of many other clinicians, that PE tends to be highly effective for the majority of patients (research has found around 80% show significant improvement), and in those cases where PE does not yield benefit, treatment yielded no noticeable reduction in symptoms (as opposed to a worsening). In the latter case, it is common that they struggle with confronting avoidance symptoms, and therefore, do not receive a full dose of the treatment. While the experiences of clinicians is useful in these discussions, the research literature allows us to examine these questions in a more systematic manner, and with larger numbers of patients. The research literature on PE has also supported its safety and acceptability. For example, one study examined whether clients experienced a worsening of symptoms while completing PE, and found that a minority (~11%) of patients showed an initial, temporary increase in PTSD symptoms, but this initial increase did not affect overall treatment outcomes and did not increase drop-out rates. Relatedly, a more recent study found that 0% of patients in PE showed worsening of PTSD by the end of treatment.