Session 2

In Session 2, the patient will learn about common reactions to trauma. He or She will begin to construct a list of situations they have been avoiding (called the In Vivo Exposure Hierarchy). In order to find out how much discomfort or anxiety certain situations provoke, the patient and the therapist will use the Subjective Units of Discomfort Scale (SUDS) that runs from 0 to 100. In vivo exposure homework assignments begin with situations that make the patient feel a bit anxious but that seem manageable, and these situations will gradually progress to more upsetting situations.

Introduction

Posttraumatic stress disorder (PTSD) is a fear and stress disorder that may develop after an event that is experienced or witnessed and involves actual or perceived threat to life or physical integrity to oneself or a loved one. This chapter discusses the characteristics of the disorder and explains both prolonged exposure (PE) therapy and Emotional Processing Theory. Readers will learn about the benefits and risks of the treatment as well as what is involved. The main tools of this therapy program, imaginal exposure and in vivo exposure, are presented.

Final Session

In this final session, the patient reviews the skills learned in the treatment program and looks at his or her overall progress. The patient is encouraged to very deliberately keep practicing the skills learned in therapy over the next several months (or as long as necessary), and, if they run into problems, they are advised to call the therapist for a booster session. There may be times in the future when it feels as though the posttraumatic stress disorder (PTSD) symptoms are coming back or seem to be worsening. This might happen at times of stress or maybe during times of change. Moving, getting a new job, getting married, having babies, children moving out, and children getting married are all generally happy times, but they can be stressful. The patient’s body has learned to react to extreme stress with PTSD symptoms, and he or she may notice some of these symptoms in the future. It does not mean that they are relapsing, but does mean that they need to pay attention.

Session 1

In Session 1, the patient learns about the overall treatment program and the procedures that will be used, including both imaginal exposure (reliving the trauma in imagination) and in vivo exposure (reexperiencing the trauma situation in real life). The patient will complete the Trauma Interview with the therapist and learn breathing retraining. Finally, the patient will be taught about how session recordings will be used and will learn about homework expectations.

Is This Program Right for You?

Not every trauma survivor needs a trauma-focused treatment like prolonged exposure (PE). Many studies have shown that natural recovery works very well for many people who experience a traumatic event. In fact, posttraumatic stress disorder (PTSD) symptoms and other trauma reactions are very common and happen for almost everyone right after a trauma, but then these symptoms and reactions decrease a lot for many people, especially over the first 3 months. This chapter helps trauma survivors determine if PE therapy is appropriate for them, and, if so, the chapter provides motivation for treatment.

Intermediate Sessions

Up to this point, each time the patient has done an imaginal exposure, he or she has described the entire memory of what happened from the beginning to the end of the trauma. When the patient reaches the point in treatment of experiencing a decrease in anxiety and distress, at least with some of the relatively less disturbing parts of the memory, the patient and therapist will do the imaginal exposure a little differently. Beginning around Session 5 or 6, emotional processing of the trauma memories can be made more efficient by the patient focusing primarily or exclusively on the “hot spots,” which are the most currently distressing parts of the trauma.

Anticipating and Solving Problems

Even with all of the authors’ experience working with survivors of trauma with this treatment, and even with all of the hard work of patients and therapists, sometimes it is difficult for trauma survivors to get all they can out of prolonged exposure (PE) therapy. This chapter discusses common problems that may interfere with treatment and provides strategies for working through such problems and difficulties. Common problems that get in the way of treatment and improvement include avoidance, not being connected enough to the emotions associated with the memory (underengaged) or being connected too much (overengaged) during revisiting and recounting traumatic memories, not tolerating emotional distress, and persistently feeling other negative emotions, such as anger.

Session 3

Imaginal exposure, or revisiting the trauma memory in the patient’s imagination, is a procedure in which the patient is asked to go over the traumatic event while saying it out loud repeatedly, in the present tense. In Session 3, the patient will do his or her first imaginal exposure to the trauma memory, followed by processing this experience with the therapist. In processing, the therapist will ask the patient to describe his or her thoughts and feelings about the imaginal exposure and to pay attention to how that impacts the associated distress.