Private: Prolonged Exposure Therapy

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Prolonged Exposure (PE) therapy is, along with EMDR, the other most-researched treatment for postraumatic stress disorder, and very established in the academic mainstream. (Of course, this does not guarantee it is the best approach for a particular person; this is also true for EMDR, and true of any treatment when it comes to unique individuals rather than groups of research participants.)

The theory behind how PE works is the Emotional Processing Model of Edna Foa and Michael Kozak. These authors have presented this model in several influential papers, particularly these:

  • Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.
  • Foa, E.B., & Kozak, M.J. (1998). Clinical applications of bioinformational theory: Understanding anxiety and its treatment. Behavior Therapy, 29, 675– 690.

While these are long and fairly technical papers, some people may find reading them to be useful. Their theory can be summarized briefly as follows:

  • People with anxiety disorders, including postraumatic stress disorder (PTSD), suffer from pathological “fear structures” in their “memory networks.”
  • Fear structures are networks of information that provide a program to detect and escape threats. These structures contain information about the stimuli associated with the feared situation (e.g., threatening faces, sexual images) and responses to it (i.e., bodily responses of fearfulness, escape behaviors), as well as information about the relationship between these responses.
  • Pathological fear structures include extreme response elements (e.g., pounding heart, shaking body), unrealistic expectations about the likelihood of harm (i.e, convinced one will be harmed in very safe situations with one or two aspects reminiscent of the original abuse), and resistance to change even in the face of contradictory information (e.g., repeated experiences of people getting angry without becoming violent).
  • The fear structure in PTSD is large and can “pull in” all kinds of stimuli that remind the person of the original trauma. It is continually but incompletely activated, such that people with PTSD from child abuse repeatedly get “triggered” by reminders of their trauma but, because they immediately engage in escape and avoidance behaviors, don’t get the experience that the reminders themselves are not actually dangerous.
  • The goal of treatment is to modify the pathological fear structure. This is accomplished by helping clients experience the stimulus aspects of the original trauma(s) in a safe setting, and experience them fully, so that they can truly learn that reminders of the trauma (aside from actually dangerous situations) are not dangerous and need not result in massive fear, avoidance and escape responses. In this way, it is possible to incorporate “corrective information” into the fear structure (e.g., I am safe even when remembering. Just because something reminds me doesn’t mean it’s happening again).
  • For treatment to be effective, it must fully activate the fear structure, and it must provide corrective information that truly does not fit with the pathological structure and thus can effectively modify it.

Based on this description of the model and how it views effective treatment, it makes sense why traditional exposure therapies like Prolonged Exposure, in constrast to EMDR, insist that clients narrate their traumatic memories in detail, in sequence. This is seen as the only way to ensure that the fear structure is fully activated: if clients are allowed to “jump around” or to associate to other memories (as in EMDR), the thinking goes, then they might avoid key aspects of the memory and fear structure. And if they do not activate it fully, they will not be able to truly incorporate corrective information and transform the fear structure so it is no longer pathological.

In short, traditional exposure therapies like PE insist that clients narrate the trauma out loud, in detail, from start to finish, so the therapist can be sure that the client is fully activating the fear structure, fully engaging with the emotions, and really getting the full benefit of the treatment. Similarly, clients are required to listen to an audiotape of their narration of the trauma in between sessions – again, to ensure full activation and incorporation of corrective information as hearing the tape over and over again generates less and less fear and avoidance responses. However, it should be noted that many therapists modify traditional exposure therapy by beginning with less traumatic memories, by not requiring the “homework” of listening to oneself narrate the trauma on audio tape, and in other ways that reduce its stressfulness.

Importantly, we have focused on EMDR and PE, two highly-researched treatments for transforming traumatic memories, but there are certainly others that people with histories or unwanted or abusive experiences in childhood have found helpful. One common component is exposure to distressing aspects of the memory in a safe and structured setting.

Again, the most important point: There are effective and relatively rapid methods for dealing with intensely distressing memories. People do not have to be tortured by them for years.

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