Prolonged exposure vid PTSD: vad det är

Varför PTSD består enligt Foa, hur prolonged exposure arbetar med undvikande och vad evidensen säger. Kursens första lektion, fri att läsa.

Prolonged Exposure (PE)

What you will learn

You will practise with Johanna, a 34-year-old pharmacist with PTSD after a van ran a red light and struck her car eight months ago. She opens in a panel beside the text, the practice lab, and stays there while you read.

By the end of the course you will be able to recognise avoidance in the room, explain to a patient why approaching the memory helps, and agree with them which memory the treatment will work on.

You will be able to build a distress scale from the patient's own life, turn the situations they avoid into a graded list they can attempt, and set practice between sessions that actually happens.

You will be able to guide the patient through telling the memory aloud, keep the telling at a level they can work at, let their own conclusions form afterwards instead of supplying them, and find the moments that still carry the charge once the account is fluent.

What is PE?

Prolonged exposure is a manual-based talking treatment for posttraumatic stress disorder in adults, delivered in roughly 8 to 15 weekly sessions. It is for the person whose life has quietly reorganised itself around avoiding what happened to them: the place they no longer go, the road they no longer drive, the conversation they steer away from. Most people who go through a trauma recover without any treatment. PTSD is what it looks like when that recovery has been interrupted, and PE is an attempt to restart it.

Prolonged exposure was developed by Edna Foa and colleagues for posttraumatic stress disorder. It is delivered from a published therapist manual, which is why each session has a set structure, and why a course can teach it session by session.

Who is it for?

PE is for adults who meet criteria for PTSD. That is the population the guidelines address: NICE recommends individual trauma-focused cognitive behavioural therapy for adults with PTSD and names prolonged exposure among the interventions, and the American Psychological Association lists it among its recommended first-line treatments. The trials behind that recommendation were run in civilian and military samples.

PTSD, the diagnosis in brief

PTSD is diagnosed after exposure to actual or threatened death, serious injury or sexual violence: lived through, witnessed, learned of in a close family member or friend, or met repeatedly through work. The reaction has four parts, and the diagnosis needs at least one symptom from each of the first two and at least two from each of the last two. The event comes back unbidden: memories, dreams, flashbacks, distress or bodily reactions at reminders. Reminders are avoided. Thinking and mood have shifted for the worse: blame, persistent negative feelings, detachment, loss of interest, gaps in memory of the event. The body stays on alert: irritability, hypervigilance, exaggerated startle, poor concentration, disturbed sleep.

The symptoms have lasted more than a month, cause real distress or impairment, and are not the effect of a substance or another medical condition. A dissociative subtype is specified where depersonalisation or derealisation is prominent, and a delayed expression where the full picture appears only six months or more after the event. Paraphrased from the DSM-5-TR criteria (American Psychiatric Association, 2022); the manual, not this summary, is the reference.

Who is it not for?

Who it is not for matters as much. A trauma history is not by itself a reason to do PE: the guidelines recommend it for the diagnosis, not for the event. Where there is no persisting avoidance, there is nothing for the method to work on.

The second boundary follows from what exposure is for. Approaching an avoided situation only teaches the patient something where the alarm is wrong, so the situations the patient practises approaching have to be reasonably safe in fact. Where the danger is present rather than remembered, there is no false alarm to correct, and the question in front of you is safety rather than treatment. That question is settled before PE starts, not inside it.

The trials behind this method were run in adults with PTSD. They do not settle whether PE works for complex PTSD or for the dissociative subtype, so the absence of those two from this page is not a verdict.

How does it work?

PE is built on one specific account of why PTSD persists. In the weeks after a trauma, intrusive memories, arousal and fear are normal, and for most people they fade: the memory gets retold, revisited, and gradually filed as a terrible thing that happened in the past. PTSD, on this account, is the interruption of that natural process. The person survives the event and then, entirely understandably, starts avoiding everything that touches it: the place, the people, the conversations, and above all the memory itself.

The avoidance works. That is the problem. Every avoided forest path and every pushed-away image buys immediate relief, and the relief teaches the brain that the memory was dangerous and the avoidance saved you. What the memory never gets is the chance to be experienced from safety long enough for two facts to register: remembering is not being attacked again, and the distress, if you stay with it, changes. Foa and Kozak called the machinery behind this a fear structure, and their claim was that recovery requires activating it while feeding it corrective information. In practice that means approaching, deliberately and repeatedly, in two channels: the world, and the memory.

Two terms carry the rest of this page. Exposure is the method's basic move, and emotional processing is the change it is trying to produce.

Exposure: Approaching, on purpose and repeatedly, something the person has been avoiding: a place, an activity, or the memory itself. The point is to stay with it long enough for the fear to rise and then change on its own, rather than to leave as soon as it does. In PE every exposure is planned with the patient in advance and graded, never sprung on them.

Emotional processing: The change PE is trying to produce: the trauma memory becomes an ordinary, if painful, past event rather than a present threat. The theory holds that this requires the fear to be activated (the person actually feels it) while corrective information arrives (nothing bad happens, the distress moves, the meaning shifts). Exposure is simply the most reliable way to arrange both at once.

The technique follows the theory closely: each part of PE is a planned, repeated way of approaching what the patient has been avoiding, so that the memory and the avoided situations can be experienced from safety. PE has three parts.

In vivo exposure
Gradually approaching safe situations, activities or reminders avoided because of the trauma.
Imaginal exposure
Deliberately revisiting the agreed trauma memory aloud in session with therapist support.
Processing
The conversation immediately after the narrative, where whatever shifted gets put into words.

Around these three parts sits the craft: a rationale the patient actually accepts, a distress scale anchored in their own life, a graded list of avoided situations built from their real week (the hierarchy), and the judgment to steer intensity in both directions.

The balance to hold

This method can fail in two directions, and from the outside both can look like proper technique.

Pushing without reading the patient. The exposure goes ahead while the patient has gone numb and absent, or an assignment that is not actually safe is approved because it sounded like courage. The therapist has pushed beyond what the patient can usefully tolerate.

Retreating from the distress. The narrative is cut short, the assignment is softened, or rising distress is rescued the moment it appears rather than ridden out. Sometimes the therapist's own discomfort contributes to this. Notice the urge to reassure, soften or rescue, and consider whether responding to that urge would reinforce the avoidance the treatment is trying to address.

As you practise with Johanna, watch for both directions: pushing past what the patient can safely tolerate, and retreating because the distress is difficult to stay with.

What the evidence says

How strong the support for PE is, where it stops being stronger than the alternatives, and which parts of the mechanism are still contested.

PE is one of the most studied psychological treatments for PTSD. The standard reference is a meta-analysis by Powers and colleagues (2010). Against waiting lists and psychological placebo the effect was large, on both primary and secondary outcomes, and it held at follow-up. The same analysis contains the less quotable half of the result: against other active treatments, including cognitive processing therapy and EMDR, there was no significant difference. PE works; the evidence that it works better than the alternatives is thin.

The guideline picture is unusually consistent. The American Psychological Association's PTSD guideline recommends PE as a first-line treatment. NICE guideline NG116 recommends individual trauma-focused cognitive behavioural interventions for adults with PTSD, names prolonged exposure among them, and expects a typical course of 8 to 12 sessions, more if clinically indicated. The US Department of Veterans Affairs describes PE as carrying the strongest recommendation in every major clinical practice guideline.

Three findings complicate the picture. First, in the largest trial in military personnel (Foa and colleagues, 2018), PE delivered weekly did reduce symptoms, but it did not separate significantly from present-centered therapy, a comparison treatment built to contain no exposure at all. The same trial produced a genuinely useful positive finding: ten sessions of PE compressed into two weeks were no worse than the same ten spread over eight, which matters for anyone designing services. Second, dropout. Across pooled PTSD trials, roughly one patient in five leaves treatment early. Imel and colleagues' meta-analysis is more precise: dropout varies enormously between studies, and trauma focus itself does not systematically raise it, with one exception, comparisons against present-centered therapy. Fear of exposure is a reason patients and clinicians avoid PE; the data say the picture is more even than the reputation.

Third, the mechanism is genuinely contested. The manual's account, habituation (distress falling as the exposure goes on) feeding emotional processing, predicts that distress declining within a session marks learning. Craske and colleagues (2014) assembled the laboratory evidence that it often does not: how much fear drops during an exposure is a poor predictor of outcome, and what seems to matter more is expectancy violation, the gap between what the patient predicted and what actually happened. In practice the debate changes how you read the distress numbers, not the procedure.

Why learn PE?

PE is an established trauma-focused treatment for PTSD. Its explicit structure makes the clinical work easier to learn and practise.

It is an established treatment for PTSD. Guidelines recommend trauma-focused psychological treatment for adults with PTSD, and PE is among the recommended approaches. It is one option alongside other appropriate trauma-focused treatments.
Its procedures are explicit enough to practise. Sessions have a set structure, and the procedures specify what the clinician does and when. This gives clinicians concrete therapeutic behaviours and decisions to practise and review.
It addresses trauma-related avoidance. PE may be particularly relevant when avoidance is maintaining PTSD symptoms and restricting the patient's life: not going out, not driving that road, or not seeing those friends. The clinician and patient can identify that pattern and plan how to approach avoided situations safely.

PE can be demanding. A clear rationale, preparation and informed agreement help the patient understand and choose the work. Clinicians need to attend to the patient's response as treatment proceeds; engagement and treatment continuation are influenced by patient, treatment and contextual factors.

About this course

This part is about how the course is run rather than about the method: how to move through the modules, how the conversations with Johanna are scored, and where the sources are.

How to move through this course

Read a module, then do what the card at its end says. Each drill, the practice conversation the card sends you into, opens the lab at the session the module teaches: reading about the hierarchy puts you in Session 2, reading about hot spots (the moments in the memory that stay distressing after the rest has settled) puts you in a later one, and Johanna, the supervisor who reads the transcript afterwards, and the live coach beside you all arrive already knowing which session it is. Go in with one intention, the one the module's card asks for, rather than trying to do everything at once. The supervisor's feedback afterwards describes your technique rather than grading it: read it for the shape of what you did, and let its reading suggestions send you back into the text.

The course will also tell you when to move on. At the end of each module, a short prompt checks whether you have met Johanna in that session yet; you can always continue reading anyway. Sessions are never locked, and you can return to any drill as often as you like. The order is a recommendation with a clinical reason: the module on safety comes before the modules on the trauma narrative, so that you learn to recognise when a patient is overwhelmed before you learn to push.

What is scored

The lab scores your technique on twelve criteria, and each criterion has a module here. The modules are ordered as the treatment is ordered: what you must be able to do in session one is different work from what you must be able to do six weeks in.

There is no published, validated instrument for rating PE therapist competence, and trial fidelity ratings trace to an unpublished protocol. The twelve criteria are PsychBase's own wording, derived from the session components of the therapist guide. The supervisor's scores are a practice aid, not a validated assessment.

The twelve criteria you are scored on

The criteria are the same twelve everywhere, but no drill is scored on all of them: each module's card asks the supervisor to weight the one or two criteria that module teaches.

Each criterion below names its module. A drill opened from a module is scored on that module's criteria; the full twelve are used together only when you run a whole treatment.

Recognising and interrupting avoidance. Notices avoidance in whatever form it takes this session and interrupts it while keeping the alliance. Taught in Seeing avoidance.
Rationale delivery. Builds the treatment rationale with the patient, out of the patient's own avoidance, rather than delivering it at them. Taught in Presenting the rationale.
Establishing the treatment target. Identifies which memory the treatment will target and holds that boundary against competing material. Taught in Finding the target.
Anchoring the distress scale. Turns the 0 to 100 distress scale into something anchored in this patient's own experience. Taught in Anchoring the scale.
Building the in-vivo hierarchy. Converts described avoidance into a graded list of concrete, repeatable, genuinely safe assignments. Taught in Building the hierarchy.
Safety and boundaries. Keeps the work inside the agreed target and the patient's stated limits. Taught in Safe enough to practise.
Between-session practice. Sets practice specific enough to actually do, and reviews what happened without shaming. Taught in Between-session work.
Setting up and guiding the narrative. Sets up imaginal exposure and keeps the account in the present tense with sensory, cognitive and emotional detail. Taught in Guiding the narrative.
Tracking distress. Obtains distress ratings often enough to steer the session, briefly enough not to break engagement. Taught in Tracking distress.
Titration and pacing. Keeps the patient engaged at a level they can work at, neither pushing through shutdown nor retreating from distress. Taught in Titration and pacing.
Processing after the exposure. Helps the patient's own re-evaluation emerge, rather than supplying, correcting, or reassuring it. Taught in Processing after exposure.
Hot spots. Finds the moments in a now-fluent account that still carry charge, and works one at a time, repeatedly. Taught in Working the hot spots.

Nästa lektion: Seeing avoidance

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