Prolonged Exposure Therapy (OJJDP Model Program Guide)

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Prolonged Exposure Therapy

Intervention:

Prolonged Exposure (PE) Therapy is a cognitive-behavioral treatment program for individuals suffering from posttraumatic stress disorder (PTSD). The program consists of a course of individual therapy designed to help clients process traumatic events and thus reduce trauma-induced psychological disturbances. Twenty years of research has shown that PE Therapy significantly reduces the symptoms of PTSD, depression, anger, and general anxiety. PE Therapy has three components:

Psychoeducation about common reactions to trauma and the cause of chronic posttrauma difficulties
Imaginal exposure—repeated recounting of the traumatic memory (emotional reliving)
In-vivo exposure—gradually approaching trauma reminders (e.g., situations, objects) that, despite posing no harm, are feared and avoided

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.

It can be used in a variety of clinical settings, including community mental health outpatient clinics, veterans’ centers, rape counseling centers, private practice offices, and inpatient units. Treatment is individual and conducted by therapists trained to use the PE Manual, which specifies the agenda and treatment procedures for each session. Standard treatment consists of 9 to12 once- or twice-weekly sessions, each lasting 90 minutes:

Sessions 1 and 2 are for information gathering, presentation of the treatment rationale, 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) are homework review, imaginal exposure (i.e., prolonged [40 to 60 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’ needs and the rate of progress.

Evaluation Methodology:

Study 1
The Foa and colleagues (1999) study assessed the effects of several treatment conditions on women victims of assault (both sexual and nonsexual) 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. 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.

Study 2
The 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]. 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.

Study 3
The Resick and colleagues (2002) study 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 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 (because of discontinued assessment of dropouts) as well as random effects regression. The completer subsample was analyzed separately using MANCOVA for the three groups at pretreatment and posttreatment and then for the two treatment groups across the four assessment periods.

Evaluation Outcome:

Study 1
PTSD Severity and Depression
The results of the Foa and colleagues (1999) study showed that the Prolonged Exposure (PE) Therapy treatment was effective in significantly reducing the severity of PTSD and depression, when compared with the wait list (WL) group. Similar results were also found for the other two treatment conditions, and the results were maintained throughout the follow-up.

Anxiety
The intent-to-treat analysis revealed that PE Therapy provided significantly improved results in posttreatment anxiety and follow-up global social adjustment, more so than the other treatment conditions (with larger effect sizes). Overall, the PE Therapy-only treatment condition provided the best results for participants, with effects lasting throughout the follow-up period.

Study 2
PTSD Symptoms
The results of the Foa and colleagues (2005) study showed that the PE Therapy treatment significantly reduced the symptoms of PTSD compared to the WL group in both the intent-to-treat and the completer samples, and these results carried over to the follow-up periods.

Depression
PE Therapy also reduced depression compared with the WL group in the intent-to-treat and completer samples, with effects carried on through the follow-up.

Social Adjustment and Functioning
PE therapy also significantly improved social functioning in the completer sample, compared with the WL group, with effects lasting through the 12-month follow-up. The addition of Cognitive Restructuring to PE Therapy did not create any significantly different outcomes between the treatment groups.

Study 3
PTSD Severity
Resick and colleagues (2002) found that the PE Therapy treatment group and the Cognitive–Processing Therapy (CPT) group showed significant differences in the severity of PTSD, compared with the Minimal Attention (MA) control condition, and those gains were maintained throughout the follow-up periods.

Depression
There were also significant differences between the treatment groups and the MA control group on the severity of depression, which were also maintained through the follow-up.

Trauma-Related Guilt
Both treatment conditions showed significant improvement of trauma-related guilt measurements, when compared with the control group (although the CPT condition provided better results for two of the four indicators in the Trauma-Related Guilt Inventory).

Other Information:

Implementation: The Prolonged Exposure 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.

References:

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.

Foa, Edna B., Constance V. Dancu, Elizabeth A. Hembree, Lisa H. Jaycox, Elizabeth A. Meadows, and Gordon P. Street. 1999. “A Comparison of Exposure Therapy, Stress Inoculation Training, and Their Combination for Reducing Posttraumatic Stress Disorder in Female Assault Victims.” Journal of Consulting and Clinical Psychology 67(2):194–200.

Foa, Edna B., Elizabeth A. Hembree, Shawn P. Cahill, Sheila A.M. Rauch, David S. Riggs, Norah C. Feeny, and Elna Yadin. 2005. “Randomized Trial of Prolonged Exposure for Posttraumatic Stress Disorder With and Without Cognitive Restructuring: Outcome at Academic and Community Clinics.” Journal of Consulting and Clinical Psychology 73(5):953–64.

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.

Resick, Patricia A., Pallavi Nishith, Terri L. Weaver, Millie C. Astin, and Catherine A. Feuer. 2002. “A Comparison of Cognitive–Processing Therapy With Prolonged Exposure and a Waiting Condition for the Treatment of Chronic Posttraumatic Stress Disorder in Female Rape Victims.” Journal of Consulting and Clinical Psychology 70(4):867–79.

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.

Program Specification:

New Rating:

Effective

Re-reviewed Date:

June 2011

Program Type:

Cognitive Behavioral Treatment

Gender-Specific Programming

Ethnicity:

African American

White

Other Ethnicity

Gender:

Female

Age:

15 - 70

Special Populations:

Females

Target Settings:

Rural

Suburban

Urban

Problem Behaviors:

Trauma Exposure

Risk & Protective Factors:

Risk

Family

Pattern of high family conflict

Individual

Life stressors

Mental disorder / Mental health problem / Conduct disorder

Victimization and exposure to violence

Peer

Peer rejection

Protective

Family

Effective parenting

Good relationship with parents / Bonding or attachment to family

Individual

Self-efficacy

Social competencies and problem solving skills

Peer

Good relationships with peers

Involvement with positive peer group activities

Additional Information:

SAMHSA: NREPP

Status:

Program is in operation at this time.

Performance Measures:

Suggested OJJDP Performance Measures for the Program Types(s):

Mental Health Services
Cognitive Behavioral Treatment
Logic Model: PDF
Performance Matrix:PDF

Contact Information:

Program Developer:
Edna B. Foa, Ph.D.
Director, Center for the Treatment and Study of An
3535 Market Street, Suite 600 North
Philadelphia, PA 19104
Phone: 2157463327
Fax: 2157463311
Email: Click Here
Website: Click Here

Training & TA Provider:
Tracy Lichner, Ph.D.
Director of Supervision Director of Supervision, Center for the Treatment and Study of Anxiety, Department of Psychiatry
University of Pennsylvania
Philadelphia, PA 19104
Phone: 215.746.3327
Fax: 215.746.3311
Email: Click Here
Website: Click Here