Program Profile: Prolonged Exposure Therapy

This is a cognitive–behavioral treatment program for assault survivors who have posttraumatic stress disorder (PTSD). The program is rated Effective. Women in the treatment group experienced statistically significant reductions in the severity of PTSD, depression, and anxiety symptoms and a statistically significant improvement in social functioning, compared with women in the control group, at follow up.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

Prolonged Exposure (PE) Therapy is a cognitive–behavioral treatment program to reduce the symptoms of posttraumatic stress disorder (PTSD), depression, anger, guilt, and general anxiety. PE Therapy reduces PTSD symptoms such as intrusive thoughts, intense emotional distress, nightmares and flashbacks, avoidance, emotional numbing and loss of interest, sleep disturbance, concentration impairment, irritability and anger, hypervigilance, and excessive startle response.

Target Population

PE Therapy is targeted at individuals who have PTSD or sub-diagnosis of PTSD, such as victims of crime or traffic accidents, adults exposed to violence as children, and veterans.

Program Components

The program consists of a course of individual therapy designed to help clients process traumatic events and thus reduce trauma-induced psychological disturbances. PE Therapy has four components:

• Imaginal exposure—repeated recounting of the traumatic memory (revisiting of the traumatic memories)
• In-vivo exposure—gradually approaching trauma reminders (e.g., situations, objects) that, despite posing no harm, cause distress and are avoided
• Psychoeducation about common reactions to trauma and the cause of chronic posttrauma difficulties
• Breathing retraining for the management of anxiety

It can be used in a variety of clinical settings, including community mental health outpatient clinics, veterans’ centers, military clinics, rape counseling centers, private practice offices, and inpatient units. Treatment is individual. Standard treatment consists of 8 to 15 once- or twice-weekly sessions, each lasting 70 to 90 minutes:

• Sessions 1 and 2 are aimed at psychoeducation and information gathering, presentation of the treatment rationale, discussion of common reaction to trauma, construction of a list of avoided situations for in-vivo exposure, and initiation of in-vivo homework. Clients are taught to reduce anxiety by slow, paced breathing.
• Sessions 3 to 8 (or 11) include homework review, imaginal exposure (i.e., 30 to 45 minutes of repeated recounting of traumatic memories), processing of imaginal exposure experience, reviewing in-vivo exposure, and homework assignments.
• The final session consists of imaginal exposure, review of progress and skills learned, and discussion of the client’s plans for maintaining gains.
• The treatment course can be shortened or lengthened depending on the client’s needs and the rate of progress.

Key Personnel

Treatment is conducted by therapists trained to use the PE Manual, which specifies the agenda and treatment procedures for each session.

Study

Foa and colleagues (1999) assessed the effects of several treatment conditions on women victims of assault (both sexual and nonsexual) and presenting with chronic posttraumatic stress disorder (PTSD). The sample was randomized into four treatment conditions through a pretest screening and followed by a posttest and three follow-up measurements at 3, 6, and 12 months. The four treatment conditions were Prolonged Exposure (PE) Therapy (n = 25), Stress Inoculation Training (SIT) (n = 26), a mixture of PE and SIT (n = 30) and a waiting list (WL) condition to act as a control group (n = 15). After 5 weeks, participants in the WL group were offered treatment. The CrimeSolutions review of this study focused on the comparisons between the PE Therapy treatment group and the WL control group. There were no significant differences among the four groups on demographics and pretreatment measures of psychopathology. However, some differences were found among groups in relation to employment status.

Participants were not eligible if, during intake, they presented with current schizophrenia, bipolar disorder, organic mental disorder, alcohol or drug dependence, or severe suicidal ideation, or if they were in a current intimate relationship with their assailant. Of the 96 participants in the final sample, 63 percent were white, 36 percent were African American, and their average age was 34.9 years. Ten percent of the sample did not finish high school, 18 percent had high school diplomas, 41 percent had some college, and the remainder had a bachelor’s degree or higher. Roughly a third of the sample had a household income below $10,000, while 38 percent had an income greater than $30,000. Forty-eight percent of the sample reported at least one incident of childhood physical or sexual abuse.

The PE treatment group received nine biweekly sessions: the first two were 120-minute sessions; the next seven each lasted 90 minutes. The instruments used to measure outcomes were the PTSD Symptom Scale—Interview, the Social Adjustment Scale, and two self-report measures: the Beck Depression Inventory and the State—Trait Anxiety Inventory. At pretreatment intake, a Structured Clinical Interview for DSM–III–R Disorders with Psychotic Screen was also conducted to determine eligibility.

Results were analyzed by group mean comparisons (analysis of covariance [ANCOVA] and multivariate analysis of covariance [MANCOVA]) as well as intent-to-treat analysis. It should be noted, however, that sample sizes in this study were small. The study authors did not conduct subgroup analyses.

Study

Foa and colleagues (2005) assessed two treatment conditions compared with a waiting list (WL) control group (n = 26). The first treatment group received Prolonged Exposure (PE) Therapy (n = 79), while the second treatment group received PE Therapy and Cognitive Restructuring (CR) [n = 74]. After 9 weeks, participants in the WL group were offered treatment. The CrimeSolutions review of this program focused on the comparisons between the PE Therapy treatment group and the WL control group.

The participants were women diagnosed with PTSD as a result of adult rape, nonsexual assault, or childhood sex abuse. The participants were referred by police departments, victims groups, and other professionals. Enrollment was done through the Center for the Treatment and Study of Anxiety and the Women Organized Against Rape, a Philadelphia, Pa., community clinic for victims of sexual assault. Women were excluded from the study if they were in an abusive relationship; currently diagnosed with an organic mental disorder, schizophrenia, or psychotic disorder; were at high risk of suicide; had recent history of serious self-harm; had unmedicated bipolar disorder; were substance dependent; or were illiterate in English. The average sample age was 31 years, and the average number of years since the trauma was 9. Sixty-nine percent of the sample listed sexual assault as their trauma. The majority (62 percent) of women were single, 49 percent were white, and 44 percent were African American. Forty percent of the participants were in full-time employment, 44 percent had some college, and 47 percent reported an income below or equal to $15,000.

The study used the PTSD Symptom Scale—Interview, the Beck Depression Inventory, the Social Adjustment Scale, and the PTSD Symptom Scale—Self-Report. Measurements were taken pretest, posttest, and then at 3, 6, and 12 months following the intervention. The Structural Clinical Interview for DSM–IV Axis I Disorders with Psychotic Screen was used at pretest to diagnose participants and assess their eligibility.

In addition to intent-to-treat analysis using ANOVA and independent sample t–tests, the study employed repeated analysis on a completer-only subsample (n = 52 for PE only, and n = 44 for PE/CR).

All PE treatment participants received eight weekly sessions between 90 and 120 minutes. At the eighth session, their PTSD Symptom Scale—Self-Report score was compared with their pretest score. Participants showing a 70 percent reduction received only one more (a ninth) session. Others continued to a maximum of 12 sessions. After the 9-week period, the WL group was offered treatment. They were not included in follow-ups. The study authors conducted subgroup analyses on the completer-only subsample (52 for PE only).

Study

Resick and colleagues (2002) compared the effects of Prolonged Exposure (PE) Therapy and Cognitive–Processing Therapy (CPT) to a Minimal Attention (MA) waiting list control condition for chronic PTSD in female rape victims. An intent-to-treat sample (n = 171) was randomized into the three conditions (121 were completers). There were 41 women in the CPT group, 40 women in the PE group, and 40 women in the MA group. The MA group was offered treatment after 6 weeks. The CrimeSolutions review of this study focused on the comparisons between the PE Therapy treatment group and the MA control group.

The participants were excluded if they presented current psychosis, developmental disabilities, suicidal intent, drug or alcohol dependence, or illiteracy, and if they were in an abusive relationship or being stalked. Participants needed to be at least 3 months posttrauma. Overall, the average sample age was 32, with an average of 14.3 years of education, and 76 percent of the sample had never been married or were divorced or separated. The sample was 71 percent white and 25 percent African American. Thirty-one percent of the sample was taking psychotropic medication. The average time since the rape was 8.5 years, and 48 percent of the sample reported at least one rape other than the indexed trauma. Forty-one percent reported childhood sexual abuse.

The study used several instruments to measure posttrauma effects: the Clinician-Administered PTSD Scale, Structured Interview for DSM–IV—Patient Version, Standardized Trauma Interview, PTSD Symptom Scale, Beck Depression Inventory, Trauma-Related Guilt Inventory, and Expectancy of Therapeutic Outcome. PE participants (and CPT participants) received nine sessions of 60 to 90 minutes, with one session a week. The MA group was offered treatment after 6 weeks. Assessment was made at pretreatment, posttreatment, at 3 months, and at 9 months.

This study used intent-to-treat analysis with last observations carried forward (LOCF) as well as random effects regression. This allowed for a more complete picture of the results and was chosen because of missing data due to drop outs. The completer subsample was analyzed separately using MANOVA for the three groups at pretreatment and posttreatment and then for the two treatment groups across the four assessment periods. The authors conducted subgroup analyses on the completer-only subsample (121 were completers).

The Prolonged Exposure (PE) Manual specifies the agenda and treatment procedures for each session.

Therapists’ guide:

Foa, Edna, Elizabeth Hembree, Barbara Rothbaum. 2007. “Prolonged Exposure Therapy for PTSD: Emotional Process of Traumatic Experiences - Therapist Guide (Treatments that Work).” Oxford University Press. 

Patients’ treatment guide:

Rothbaum, Barbara, Edna Foa, Elizabeth Hembree. 2007. “Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook.” Oxford University Press.

Subgroup Analysis

Foa and colleagues (2005) conducted subgroup analyses on the completers-only subsample. They found that women who completed Prolonged Exposure (PE) Therapy treatment were more likely to show improvements in social functioning, compared with women who did not complete PE treatment, at the 12-month follow up. This difference was statistically significant. Resick and colleagues (2002) also conducted subgroup analyses on the completers-only subsample; however, they found no statistically significant differences between completers and non-completers, at the 9-month follow up.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Asukai, Nozomu, Azusa Saito, Nobuko Tsuruta, Junji Kishimoto, and Toru Nishikawa. 2010. Efficacy of Exposure Therapy for Japanese Patients With Posttraumatic Stress Disorder Due to Mixed Traumatic Events: A Randomized Controlled Study. Journal of Traumatic Stress 23(6):744–50.

Bryant, Richard A., Julie Mastrodomenico, Kim L. Felmingham, Sally Hopwood, Lucy Kenny, Eva Kandris, Catherine Cahill, and Mark Creamer. 2008. “Treatment of Acute Stress Disorder: A Randomized Controlled Trial.” Archives of General Psychiatry 65(6):659–67.

Doane, Lisa Stines, Norah C. Feeny, and Lori A. Zoellner. 2010. “A Preliminary Investigation of Sudden Gains in Exposure Therapy for PTSD.” Behavior Research and Therapy 48:555–60.

Eftekhari, Afsoon, Lisa Stines Doane, and Lori A. Zoellner. 2006. “Do You Need To Talk About It? Prolonged Exposure for the Treatment of Chronic PTSD.” Behavior Analyst Today 7(1):70–83.

Foa, Edna B., Elizabeth A. Hembree, Barbara Olaslov Rothbaum. 2007. “Prolonged Exposure Therapy for PTSD: Emotional Process of Traumatic Experiences—Therapist Guide (Treatments That Work).” Oxford University Press.

Galovski, Tara E., Candice Monson, Steven E. Bruce, and Patricia A. Resick. 2009. “Does Cognitive–Behavioral Therapy for PTSD Improve Perceived Health and Sleep Impairment?” Journal of Traumatic Stress 22(3):197–204.

Kazi, Aisha, Blanche Freund, and Gail Ironson. 2008. “Prolonged Exposure Treatment for Posttraumatic Stress Disorder Following the 9/11 Attack With a Person Who Escaped From the Twin Towers.” Clinical Case Studies 7(2):100–117.

Nacasch, Nitzah, Edna B. Foa, Jonathan D. Huppert, Dana Tzur, Leah Fostick, Yula Dinstein, Michael Polliack, and Joseph Zohar. 2010. “Prolonged Exposure Therapy for Combat- and Terror-Related Posttraumatic Stress Disorder: A Randomized Control Comparison With Treatment as Usual.” Journal of Clinical Psychiatry 71.

Powers, Mark B., Jacqueline M. Halpern, Michael P. Ferenschak, Seth J. Gillihan, and Edna B. Foa. 2010. “A Meta-Analytic Review of Prolonged Exposure for Posttraumatic Stress Disorder.” Clinical Psychology Review 30(6):635–41.

Rauch, Sheila A.M., Tania E.E. Grunfeld, Elna Yadin, Shawn P. Cahill, Elizabeth A. Hembree, and Edna B. Foa. 2009. “Changes in Reported Physical Health Symptoms and Social Function With Prolonged Exposure Therapy for Chronic Posttraumatic Stress Disorder.” Depression and Anxiety 26:732–38.

Rothbaum, Barbara Olaslov, Edna B. Foa, Elizabeth A. Hembree. 2007. “Reclaiming Your Life From a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook.” Oxford University Press.

Schnurr, Paula P., Matthew J. Friedman, Charles C. Engel, Edna B. Foa, M. Tracie Shea, Bruce K. Chow, Patricia A. Resick, Veronica Thurston, Susan M. Orsillo, Rodney Haug, Carole Turner, and Nancy Bernardy. 2007, “Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women.” Journal of the American Medical Association 297(8):820–30.

Taylor, Steven, Dana S. Thordarson, Louise Maxfield, Ingrid C. Fedoroff, Karina Lovell, and John Ogrodniczuk. 2003. “Comparative Efficacy, Speed, and Adverse Effects of Three PTSD Treatments: Exposure Therapy, EMDR, and Relaxation Training.” Journal of Consulting and Clinical Psychology 71(2):330–38.

Following are CrimeSolutions-rated programs that are related to this practice:

Psychotherapies for Victims of Sexual Assault

This practice examines interventions for adult sexual assault victims that reduce psychological distress, symptoms of post-traumatic stress disorder (PTSD), and rape trauma through counseling, structured or unstructured interaction, training programs, or predetermined treatment plans. The practice is rated Effective in reducing symptoms of trauma and PTSD in victims of sexual assault and rape.

Evidence Ratings for Outcomes

Mental Health & Behavioral Health - Trauma/PTSD

Psychotherapy with Adults Sexually Abused in Childhood

This practice comprises therapeutic approaches for adults who were sexually abused in childhood, and is designed to improve psychological distress, reduce maladaptive behavior, or enhance adaptive behavior through counseling, structured or unstructured interaction, or a predetermined treatment plan. The practice is rated Promising for decreasing posttraumatic stress disorder, trauma, and internalizing and externalizing symptoms.

Evidence Ratings for Outcomes

	Mental Health & Behavioral Health - Trauma/PTSD
	Mental Health & Behavioral Health - Internalizing behavior
	Mental Health & Behavioral Health - Externalizing behavior

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?