The Facts About Prolonged Exposure Therapy for PTSD

This is a picture of a person holding their head in their hands.In a recent article in The New York Times Sunday Review, US Marine Corps Veteran David J. Morris chronicled his experience getting treatment for post-traumatic stress disorder at a Veterans Affairs hospital. In his essay, he detailed his adverse reactions to Prolonged Exposure (PE) therapy, one of the only PTSD treatments to have wide-reaching empirical support.

In PE therapy, individuals are asked to approach — in both imaginary and real-life settings — situations, places, and people they have been avoiding. The repeated exposure to the perceived threat disconfirms individuals’ expectations of experiencing harm and over time leads to a reduction in their fear. The APS journal Psychological Science in the Public Interest last year provided a comprehensive report on PE and other evidence-based treatments.

In a brief online interview, APS asked Harvard University psychological scientist Richard J. McNally, whose lab studies PTSD and other anxiety disorders, to share his observations about Morris’ article and to provide the facts about the evidence for PE’s effectiveness.

APS: As a scientist who has extensively studied treatments for PTSD, what are your overall impressions about the article “After PTSD, More Trauma”?

McNally: David Morris is a former Marine officer who experienced multiple traumatic events as a civilian war correspondent embedded within American combat units in Iraq. He is a thoughtful and excellent writer. Troubled by PTSD symptoms, he sought help at the San Diego VA and received Prolonged Exposure (PE) therapy, the treatment with the strongest evidence of efficacy. Sadly, however, his distress did not diminish during imaginal exposure sessions, and he terminated treatment early. His case is atypical; most patients do benefit, and many recover from PTSD. Although his symptoms apparently worsened temporarily, persistent worsening is very rare for patients receiving PE. One recent study of over 300 female assault survivors revealed that 8.1% of patients on a wait list experienced reliable worsening of their symptoms, whereas none of the patients receiving PE did so.  Accordingly, people with PTSD run a greater risk of their symptoms worsening if they do not receive PE than if they do receive it, even though a minority does fail to improve from this treatment. Fortunately, Morris found Cognitive Processing Therapy (CPT) helpful.

APS:  Is more research on PE needed, in your opinion? Are there factors about the treatment that we still don’t understand?  

McNally: There is no uniformly effective treatment for PTSD akin to antibiotics for bacterial infections. There is no “magic bullet” for curing PTSD, at least not yet. To say that PE and CPT are evidence-based, efficacious interventions for PTSD means that multiple, rigorous randomized controlled trials have shown that on average they are statistically and clinically more effective in diminishing PTSD symptoms than are other approaches. It does not mean that everyone recovers. Accordingly, we still have much room for improvement. For example, clinical scientists have recently discovered that ruptures in the therapeutic relationship that are not repaired can impede progress in PE. This exemplary work shows how researchers can discover correctible problems that can prevent an otherwise effective treatment from working well.

Comments

I find it disappointing that Harvard PTSD researcher Richard J. McNally does not even mention EMDR as an effective, evidence-based treatment for PTSD that is far easier to tolerate and just as, if not more, effective. Many people find they need EMDR to reprocess the trauma they experienced in the Prolonged Exposure therapy itself. As long as politics inhibit getting the word out about effective methods to treat trauma we will continue to see needless continued suffering. The research on EMDR’s effectiveness and a search engine to find Certified EMDR therapists can be found at the EMDR institute’s website http://www.emdria.org

Absolutely! I’m a certified EMDR trauma therapist and there is much evidence that EMDR is more effective than other methods due to its holistic, integrative approach. Yet, I’ve found that even EMDR can retraumatize a client, so practitioners of any trauma healing therapy need to proceed carefully and conservatively, building trust and creating safety with safe-regulation training (deep breathing, yoga, tapping, guided relaxation, exercise, healthy lifestyle choices, etc.) before jumping right in to serious trauma work. Remember, the body has to keep pace w/the mind.

EMDR did not help or lessen my symptoms of Complex or Chronic PTSD.

PE saved my life and it has allowed me to recover from severe complex PTSD. I would not be here today if it were not for PE, Dr Andrew Ekblad.

Exposure always works – it has to – it is in our biology to work. However, sometimes treatment providers fail and fail to provide adequate orientation to Prolonged Exposure. In session habituation is NOT required for PE for PTSD to effective. What is effective is the duration of imaginal exposure (at least 20 minutes of actual exposure) irrespective of SUDs ratings. Some individuals do not experience habituation in session but still have corrective learning of re-experiencing without catastrophe. People need to be oriented that their distress may not go down in session but across sessions. If he remained with the treatment – there’s little doubt it would have be successful. It is up to the treatment provider to assist people to remain with the treatment.

No, exposure is not always effective.There is nothing about our biology that implies we must desensitize to anything we are exposed to.The research literature clearly shows that exposure is not effective i significant number of cases, and that the effects are temporary

thank you for saying this. PE is the default therapeutic approach to the VA where I get services. I didn’t even realize I was engaging in PE until I realized every single VA provider I visited required me to detail my experiences in Iraq. At one point I was required to recount the stories to 3 separate providers in a matter of 2 hours. I quickly stopped going to the VA because re-telling my experiences was so distressing that after each visit I’d be so exhausted, depressed, angry, anxious, and irritated for the next 3-4 days that I couldn’t function. It was so dibilitating I couldn’t possibly see a reason why I should continue going to the VA and engaging in something that made my symptoms worse.

While EMDR is an evidence based treatment, it is erroneous and irresponsible to claim that EMDR is more effective than PE. Please look at the actual research on both of these treatments before making public claims about what you believe to be true. Clinicians should be more responsible when making such claims publicly than the commentator above. PE is the only treatment for PTSD with enough documented support to meet the Institute of Medicine’s rigorous standards and be named the gold standard treatmebt by them for PTSD.

Emily, I’m sorry but is that why we have 22 veterans committing suicide everyday? I understand what you are saying regarding the research but you know statistics don’t lie either, and statistically speaking there are no real effective treatment to PTSD. It doesn’t take a PhD to see reason.

Not since the dark ages when torture was accepted as the cure for not kissing the ring of some fat guy in a robe, has gross quackery been so successful in passing itself off as acceptable, even recomended.as a “therapy.
To be fair…what was done to me broke all the rules. I was accosted in the waiting room of a va clinic, ordered into an adjacent classroom and treated like the suspect in a murder investigation on an episode of NYPD SPECIAL CRIMES UNIT! Within a few hours after this experience I was handcuffed in a State Trooper’s car on my way towards a legitimate, that is, NOT VA psychiatric hospital. While there a REAL psychiatrist explained my experience, including many details on how my treatment constituted an example of a rampant form of malpractice that had unfortunately gathered acceptance in the psychiatric profession.

PE is evidence based. EMDR is evidence based. There is only more research about PE because it has been around longer. Dr. Arutt was not stating that it’s a fact that EMDR is more effective, she just stated that it is “easier to tolerate and just as, if not more, effective.” We all know that our different experiences with myriad therapies lead us to form and hold different beliefs and opinions. We also know that 70% of the therapy that actually occurs is due to the therapeutic relationship formed. Not to mention the fact that each clinician may excel at a certain therapy and therefore just prefer to use it. Personally, I like to use TF-CBT and mindfulness. That doesn’t mean the therapeutic intervention is more effective, it just means I am more comfortable using it and therefore yield more effective therapeutic results using those techniques.

While in counseling session’s I would hear a bell ring from the computer. At first It didn’t take but after about the third session I found that strange. Even the counselor looked at the dark screen with a look of anger or frustration. While shopping ONE day my friend bought a bell and brought it back to her house. When the neighbor and her four year old were over the neighbors girl rang the bell over and over like 30 or more times. I know this may sound strange but sometimes when J am out and about people will beep their horns twice. I fear bells or bleeps because I am afraid I was hypnotized and it went wrong. I was suppose to start PE for my combat related PTSD but the sessions with the bell ringing weren’t with my psychologist. Anyhow any feedback would be appreciated.

Sincerely,

Robin J.

As a hypnotherapist, I tend to doubt you were hypnotized just by a bell ringing a few times–likely it was a computer situation. You may be experiencing an association; since you didn’t provide more information, were you in a hypnosis session, were you in a trance? If the counselor was unsure what was happening It probably wasn’t hypnosis. Unfortunately some people have a stigma about the benefits of hypnosis, which is effective for PTSD.

I have, since my comment above, discovered through my research the issue of “Complex PTSD. My experience was somewhat different. It was VERY complex, with my first ptsd producing trauma occurring shortly after birth and continuously since then until my mother died and stopped telling the family story about how she almost killed me when I was a baby and my Aunt Mildred Saved my life by pointing out how black my hair was….like hers. So right on!! to the last comment…. It’s not being so-called “evidence based that matters as much as whose evidence are you dealing with and there can be a lot of buried evidence that hasn’t been dug up yet.

It’s been quite a while since I posted that last comment.
I’ve been researching the issue elsewhere while engaging in my own recover program since then in my own way….right here in the library, getting on line, scouring the internet, engaging with my fellow residents at the “home for adults” where my friends include long term “nut cases” like me and some much worse…. and some so normal they they make the staff look like nut cases…which I think some of them are if they were sane enough to admit it. Many are on the road in that direction, if not already there. Tell you what…let’s all allow ourselves to be as nutty as we need to be, to get sane enough to help each other get along in this truly crazy world…Mark

I have genuinely treated a bevy of PTSD Veterans with EMDR who have participated in PE. Most said all they learned from PE was that after telling the story over 30 times, they have learned to tell it without crying or sobbing. Other than that, they report little if any relief.
After approaching the veterans with several (not 30 sessions) of EMDR, all have reported considerable relief and significantly diminished scores on the Mississippi Scale for Combat Related PTSD. Thank God there are over 130,000 EMDR therapists to clean up the PE messes.

It’s gratifying to watch the growing understanding and common sense compassion for the victims of trauma AND the victims of maltreatment of victims of trauma. It would would be nice if Victimization ITSELF could be banned, but that noble goal seems to be impossible to achieve given the savage nature of our species. Apparently these savage evolutionary origins have predetermined our common destiny….. or has it?
Are we PRE–DESTINED TO DESTROY OURSELVES, ONE WAY OR ANOTHER. LETS ALL PRAY, OR AT LEAST HOPE WE ARE NOT! I HAVE DESIDED TO GIVE THE ISSUE OF THE ABUSIVE PRACTICE OF EXPOSURE “THERAPY” A REST AND CONCENTRATE ON THE BROADER ISSUE OF OUR COMMON SURVIVAL IN A WORLD ALMOST PREDESTINED TO SELF DESTRUCTION. PLEASE PRAY FOR ME? OR AT LEAST, WISH ME LUCK.

I think PE therapy is not effective on all Trumatic events, like sexual assault. I have been in therapy for six weeks and the imaginal exposure doesn’t make sense to me. Every time I tell the story is as if I’m being raped all over again, I have become more detached from everyone, more depressed and more panic attacks

Just a note to say I’m doing a lot better after using this forum and seeing some progress on my “issue” and watching the VA sqwirm and react to the growing resistance to “Exposure Therapy” and it’s damaging effects on veterans.

I have never seen such suffering as that of a patient with PTSD perhaps aside from the many who have been “treated” with standard of care- starting out as an MFCC for county mental health in the 1990’s then proceeding to Med school – It stuck with me – all the damage I witnessed in the name of ” therapy” many years later I began researching ketamine therapy – ketamine being the ” buddy” drug in the Vietnam war- due to its safety and efficacy- 4 years have passed since I began offering this therapy, and it has been the single most effective /curative therapy I have ever witnessed.
Dr T

I have read the research and used all of the gold star methods to alleviate C-PTSD. 9 months of CBT therapy, EMDR, PE, and group therapy (both to bolster the education for self care and self compassion, and to develop tolerance for being tiggered by others who deal with PTSD. The only avenue untried for me is pharmaceutical. I am in recovery, and am pursuing my passions within my new limitations…while regularly testing those limits by degrees. Instead of preferring one treatment over another, I have benefited from them all at different times…and have found them all less effective at other times. They are all tools, and they all have steong effective histories which make them reasonable risks. Sheesh. Even Benadryl can give me a break from PNES on a day EMDR, grounding, and PE aren’t helping as much. Perhaps it has something to do with the fact that various parts of our brains are affected…and trauma memory work is cyclical. It would make sense that one tool works better for amygdalyl responses, and another tool works better for hyppocampal responses, and another tool works better for executive function responses ir processing. But this is my own theory. The point is, if one trick fails…there are more to try which may.

Replay to Kevin I am very sorry you have been so distressed by the PE during your therapy. You have been exposed to the PE to soon which is retraumatising you causing your symptoms to become worse. You need to let your therapist know how you are feeling DO NOT keep these symptoms to yourself. My advise to you… when you have a flashback distracted yourself by getting up and doing something like making a cup of tea/coffee. Walking is good as it helps burn the physical engery of the fight/flight response. Medication & relaxation cds can help to reduce hyper-arousal helping to aid sleep. If all rlse fails look for another therapist. I am a Cbt psychotherapist who works with trauma/ptsd on a daily bases.

It’s interesting to read these comments and findings. Though it doesn’t surprise me that therapists hold so strongly to their own types of practice I think each form has it’s pro’s and con’s depending on the needs of the client. I’m currently in a PE program and find it very traumatizing because I have so many past traumas. If I only had one trauma, the PE could work, but with the sessions bringing all these others traumas to the surface and dissociation to the max I can’t say this is the right treatment for me. My distress at the end of the session was a 90 rating and I was just dismissed to deal with that on my own. How can this be healthy or helpful to a veteran? Plus my sessions are by Tele communication. We both, have audio and visual communication through out the session. Then the monitor is turned off?

Had PE therapy workshop recently and am astounded that VA is pushing this. This method would re-traumatize patients, in my opinion. CBT or EMDR will be more effective and put the person in less stress after sessions, IMHO. It seems barbaric to do this to veterans or anyone who has PTSD and need to get past their trauma.

I have recently been moved to an “Old
“” Folks home” where I don’t even have to walk to a library to get “on line. I’ll be looking for folks with similar stories here, there seems to be quite a few fellow veterans among them!.

Well, my adventures got crazy enough to get me to the right. maybe even “better place which I’m guessing means simply “anywhere bu the va. There are lots of veterans here but apparently no other connection where I’d have to worry about having to punch out a VA shrink.

I dropped out of PE at the VA in the Dfw area. Talk about being traumatized.
Then the therapists tells me it is silly and not dangerous. That my stress is silly. Belittling me because of my high stress level.
Telling me PE did not work because of my silly feeling not the therapy.
What ever. Talk aboit wanting to kill myself.

Hopefully MAPS is successful and in the near future we see MDMA-assisted psychotherapy available nationwide. This will be the most effective, lowest-risk option for treating PTSD.

My husbands art therapist decided she wanted to do exposure therapy. Told us it was the only way he would get better. I told her I didnt think it was a good idea, but he decided to do it anyway. The therapist told me that I needed to get on board with it or they would consider me an obstacle to him getting better, and she would have grave concerns about our relationship. Two sessions and he became so suicidal that he was admitted for 7 weeks. While in the hospital they continued the exposure therapy everyday for 90 minutes. He begged them to stop, but they wouldn’t. It was a nightmare. Finally he went on a hunger strike and they stopped.

I attended 4 sessions of the 8 session PET, at the VA hospital. Before the 4th session I broke off 1 tooth as PE exacerbated the Vietnam caused bruxism (teeth grinding). I quit PE therapy @ the 4th session. Because of PET I have now broken off 5 teeth, & the VA refuses to repair the damage that their therapy has caused.

I understand that not everyone can affort psychoanalytic treatment or that it might even be necessary for all trauma victims; however, it helpted me process my traumatic feelings and memories, make meaning of them, and, eventually, integrate them into a coherent narrative. Underneath one’s most recent trauma are often other traumas that need to be treated. Targeting only the tip of of the iceberg can only be so helpful.

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