Intermediate Sessions

Beginning around Session 5 or 6, emotional processing of the trauma memories can be made more efficient by having the patient focus primarily or exclusively on the most currently distressing parts of the trauma, which the authors term the “hot spots.” The therapist helps the patient identify his hot spots and then select one to begin the imaginal exposure. This should be one of the most distressing parts, if not the most distressing part, of the trauma. Therapy continues with the focus on the patient’s hot spots during the imaginal exposure until each has been sufficiently processed, as reflected by diminished Subjective Units of Distress Scale (SUDS) levels and the patient’s behavior (e.g., body movement, facial expression). This may take several sessions, depending on the number of hot spots, the patient’s pace, and the amount of time spent listening to exposure recordings as homework.

Session 1

In the beginning of this first PE session, the therapist presents the patient with an overall rationale for PE and describes the main tools of the therapy: imaginal exposure and in vivo exposure. The therapist uses the Trauma Interview to collect general information about the immediate presenting problems, the patient’s functioning, the traumatic experience(s), physical and mental health since the trauma, social support, and use of alcohol and drugs. The Trauma Interview is also designed to aid in the identification of the target trauma. This is the traumatic memory that will be the focus of treatment. Identifying the target trauma is a critical element of effective PE. The patient is also taught breathing retraining in this session.

Tailoring Treatment to the Individual

Even with a foundation of strong therapeutic alliance and a clear rationale for treatment that the patient understands and accepts, and even when the therapist has followed the procedures described in the previous chapters, sometimes the patient does not seem to improve as much as we would expect. Common obstacles to the expected decreases in posttraumatic stress disorder symptoms and related distress include avoidance, being under- or overengaged emotionally during revisiting and recounting the trauma memory, intolerance of emotional distress, and persistent dominance of a specific negative emotion that diminishes the processing of other important emotions that the patient needs to digest.

Session 3

This session presents imaginal exposure, or revisiting the trauma memory in imagery, a procedure in which the patient is asked to visualize and emotionally connect with the traumatic memory while recounting the experience aloud, in the present tense. The standard procedure is designed to (1) enhance the patient’s ability to access the salient aspects of the trauma memory, (2) promote emotional engagement with the trauma memory, and (3) invite narration of the memory in the patient’s own words. After the imaginal revisiting, the therapist processes the experience with the patient. Processing involves encouraging the patient to talk about reactions to revisiting the trauma memory and to discuss feelings and thoughts about the trauma or its meaning in her life. Imaginal recounting of the trauma memory creates powerful opportunities for learning. It is common for patients to emerge from imaginal (and in vivo) exposure with new awareness or insights.

Assessing Trauma Survivors and Implementing PE in Practice

The authors begin this chapter by looking at who a good candidate for prolonged exposure (PE) therapy is; not every trauma survivor needs a trauma-focused treatment like PE. It is important to have as part of the assessment process or prior to start of PE, one or two preparation sessions that include reviewing the reasons that the client wants to recover from his trauma-related difficulties that may enhance treatment outcome and retention. This material is followed by the presentation of guidelines for the assessment of trauma survivors with whom a therapist is considering using this therapy. The chapter continues with a discussion of some important considerations in using PE with trauma survivors. Finally, the chapter concludes with recommendations for assessing and supporting a patient’s engagement in treatment.

Final Session

This final session reviews what the patient has learned in the course of prolonged exposure (PE), what has changed or improved, and what the patient needs to continue to do. Also reviewed are concepts (e.g., facing rather than avoiding trauma memories and reminders) and skills the patient has learned. The therapist prepares the patient for the likelihood of a temporary increase in posttraumatic stress disorder and related symptoms when under significant stress, such as on the anniversary of the trauma or more general difficulties at work or in the family. Working with a patient in PE can be emotionally intense for both the patient and the therapist, and terminating therapy can be difficult for the patient. If the therapist is terminating treatment at this point, he or she should take time to offer the patient feedback and to say goodbye.

Session 2

This session instructs the therapist on how to interactively present to the patient “common reactions to trauma,” an educational discussion that describes and validates the patient’s experience of PTSD symptoms, associated problems, and relationships among these experiences. Hope is instilled by helping the patient realize that many of his distressing symptoms are directly related to the PTSD and that much of this may improve as a function of treatment. In vivo exposures are discussed, as well as the Subjective Units of Distress Scale (SUDS) and the patient’s in vivo exposure hierarchy is constructed. A list of situations typically avoided by trauma survivors is also provided to help guide the therapist in constructing a hierarchy. After this session, patients will begin in vivo exposure practice. For most patients, the in vivo exposure practices are done between sessions as homework exercises.

Foundations of Prolonged Exposure

Foundations of prolonged exposure (PE) include (1) education about common reactions to trauma, what maintains trauma-related symptoms, and how PE reduces posttraumatic stress disorder (PTSD) symptoms; (2) repeated in vivo confrontation with situations, people, or objects that the patient is avoiding because they are trauma-related and cause emotional distress such as anxiety, shame, or guilt; and (3) repeated, prolonged imaginal exposure to the trauma memories followed by processing the details of the event, the emotions, and the thoughts that the patient experienced during the trauma. The aim of in vivo and imaginal exposure is to enhance emotional processing of traumatic events by helping the patient face the trauma memories and reminders and process the emotions and thoughts, as well as the details of the trauma that emerge during revisiting experiences.