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How Does Prolonged Exposure Therapy Work?

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How Does Prolonged Exposure Therapy Work

Prolonged exposure therapy is one of the most effective treatment options available for anxiety disorders like PTSD, phobias, OCD, and panic disorder. However, many people are still unclear on exactly how it works to reduce anxiety and treat trauma.

In this detailed guide, we’ll take a deep dive into prolonged exposure therapy, explaining step-by-step how it works, what to expect during treatment, and why it’s so successful at diminishing fear responses over the long run.

What is Prolonged Exposure Therapy?

Prolonged exposure therapy, often abbreviated as PE therapy, is a type of cognitive behavioral therapy (CBT) that aims to treat anxiety disorders by having patients directly face and stay in contact with the situations, places, objects, or feelings that trigger their anxiety or trauma responses.

The core idea behind PE therapy is that through gradual and repeated exposure to feared stimuli in a controlled therapeutic environment, the patient’s emotional and physical stress response will habituate over time as they learn the stimuli do not pose any real danger. This helps break the conditioned association between the triggers and intense fear or anxiety.

PE therapy usually consists of 8-15 therapy sessions conducted either individually or in a group setting. Each session involves some type of prolonged exposure exercise that pushes the patient outside their comfort zone in a step-wise fashion.

The Two Key Components of PE Therapy

There are two main components to prolonged exposure therapy:

1. Imaginal Exposure

Imaginal exposure involves having patients vividly imagine and recount their traumatic experience out loud to the therapist for a prolonged period, usually 45-60 minutes. They are instructed to revisit the most distressing details of the memory and describe it as though it is happening in the present tense.

This form of exposure helps weaken the link between trauma memories and fear by repeatedly accessing distressing details in a safe therapy environment without consequences. Over time, habituation occurs as arousal levels decline.

2. In Vivo Exposure

In vivo exposure involves having patients directly face real external situations, objects, or places related to their fears in real-time with the support and guidance of their therapist.

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For example, someone with a fear of flying may sit on a plane or visit an airport for an extended period. Someone with PTSD could drive by the location where their trauma occurred. The goal is to experience distressing cues without avoiding or escape behaviors until habituation occurs naturally.

Both imaginal and in vivo exposure techniques are critical components of PE therapy to bring about real, lasting change. Repeated exposures to triggers, internally and externally, train the brain that these cues do not represent actual danger.

How Prolonged Exposure Therapy Reduces Anxiety Over Time

There is clear neurobiological evidence to explain why prolonged exposure therapy is so effective for treating anxiety disorders:

Weakening Conditioned Fear Responses

Through conditioning, our brains form automatic associations between neutral cues and the physical sensations of anxiety or fear. Prolonged exposure therapy helps break these conditioned responses by exposing patients to feared cues over and over without harm or negative consequences occurring.

This teaches the amygdala, which regulates emotions and fear responses, that the cues it associates with danger are in reality now safe. The brain learns to stop reacting to them with the same intensity of fear.

Habituation of Physiological Arousal

When exposed to feared situations or trauma reminders, anxiety levels initially spike as the body’s fight or flight response kicks in. However, with repeated exposures without escaping or avoiding, physiological arousal habituates as the stress response weakens.

The body learns it is not truly in danger and arousal decreases each subsequent time. Levels of stress hormones like cortisol decline instead of remaining dysregulated.

Correcting Maladaptive Cognitive Biases

Anxiety disorders involve cognitive biases that inflate perceptions of threat. Prolonged exposure gently challenges these irrational thoughts by exposing patients to real evidence that refutes their anxieties. Over time, it helps correct maladaptive thought patterns with more adaptive, reality-based ones.

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In summary, repeated exposures to formerly feared stimuli work to gradually extinguish conditioned fears on multiple levels – emotionally, physically, and cognitively. This process of habituation and extinction is how PE therapy achieves such impressive, long-lasting results.

An Example Prolonged Exposure Therapy Session

Now that we understand the theory behind prolonged exposure therapy, let’s look at what an actual session may entail in practice:

Imaginal Exposure Exercise

The therapist will guide the patient through a detailed imagining and verbal retelling of their traumatic memory. This typically involves:

  • Vividly recounting the traumatic event from start to finish.
  • Describing sights, sounds, smells, and physical sensations experienced.
  • Repeating the retelling for at least 30-45 minutes without avoidance.

Body sensations and distress levels are recorded beforehand and afterwards to monitor habituation.

In Vivo Exposure Assignment

Next, the therapist might assign an at-home prolonged exposure activity like:

  • Driving down the street where the trauma occurred.
  • Sitting near a crowded space like a mall or subway for an hour.
  • Handling items related to PTSD triggers.

Homework is to remain engaged with the distressing stimulus until anxiety reduces naturally. Progress is tracked each week.

Troubleshooting Difficulties

The final portion reviews challenges, builds coping skills, and problem-solves unhelpful avoidance strategies. Progress toward therapy goals is reinforced to maintain motivation.

By facing feared stimuli diligently with their therapist’s guidance, patients systematically overcome anxiety through habituation outside the safety of sessions. Prolonged exposure leads to real, lasting changes over weeks of dedicated practice.

Potential Side Effects and Contraindications

While prolonged exposure therapy is highly effective for anxiety when properly conducted, it’s not right for every single patient. Some potential issues to be aware of include:

  • Initially heightened anxiety/distress during exposures. However, this subsides as habituation occurs.
  • Potential for re-traumatization if memories involve unresolved abuse/safety issues. Therapists carefully screen for contraindications.
  • Not advisable during active psychosis, mania, or suicidality until stabilized.
  • Requires full patient cooperation and adherence to at-home practice. May not work as well for unmotivated individuals.
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For most appropriately screened clients, short-term increases in distress are outweighed by long-term reductions in anxiety, PTSD symptoms, and improved functioning. Still, this treatment path requires an experienced clinician.

How to Find a Qualified Prolonged Exposure Therapist

If after learning about how prolonged exposure therapy works you think it could help your anxiety disorder, here are some tips for locating a qualified provider:

  • Ask your primary care doctor or psychiatrist for a referral to therapists specializing in CBT and PE therapy.
  • Check the provider directories of reputable associations including ABCT, ICST, EMDRIA and CAMFT to find credentialed therapists nearby.
  • Look for therapists explicitly listing “prolonged exposure therapy”, “PE”, or “exposure and response prevention” in their services.
  • Ensure candidates have graduate clinical training and are licensed in your location (e.g. LCSW, LMFT, psychologist).
  • Consider therapists attached to academic medical centers or anxiety specialty clinics for the highest level of expertise.

Finding an experienced PE therapist is key, so don’t hesitate to interview potential providers before committing to treatment. With the right clinician, this technique can work wonders.

In Conclusion

In summary, prolonged exposure therapy targets anxiety disorders at an neurological level by gradually habituating patients to feared stimuli through repeated imaginal and in vivo exposures over several weeks. By facing trauma memories and anxiety triggers head on with a therapist’s guidance, the brain learns to stop overreacting to cues it wrongly associates with threat.

Physiological arousal decreases naturally each time. Irrational thought patterns are challenged and replaced with more realistic perspectives. Conditioned fear responses weaken substantially.

For dealing with trauma, PTSD, phobias or panic once and for all, prolonged exposure therapy provides a potent and evidence-based solution when properly administered by a qualified clinician. Understanding how it works on multiple levels empowers patients to make informed choices regarding their mental wellness journey.

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