Prolonged Exposure (PE) for PTSD

  • On 09/24/2025
  • Starts at 12:00 pm
  • Ends at 1:00 pm
  • Offered Virtually Via Zoom
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Trainer: Jana Keith-Jennings, LCSW

Jana Keith-Jennings Therapist at Queer Therapy NYC
More About Jana Keith-Jennings

Training Description

For the last few years EMDR has continued to rise in popularity and ubiquity as the go-to clinical approach to treating PTSD and C-PTSD for clients with trauma as well as many other different symptoms and presenting problems. But it is certainly not the only treatment for PTSD, and in terms of evidence-based research, not necessarily the most effective for all clients depending on a variety of factors including history, severity of symptoms, and even things like neurodivergence. This training focused on Prolonged Exposure (PE) is meant to offer another approach to trauma therapy in service of expanding therapists' working knowledge of available approaches, so that they may make more informed choices for clients based out of understanding who may benefit from one approach vs. another, and why.

Training Objectives

  • What is Prolonged Exposure?
  • PE (Prolonged Exposure) vs EMDR (Eye Movement Desensitization and Reprocessing)
  • Benefits of PE
  • Who is PE appropriate for?
  • PE and Complex PTSD

Trainer Bio

Jana Keith-Jennings is a therapist living and working in Brooklyn trained in both traditional PE and the DBT version of PE. They work primarily with clients with complex cases including various forms of PTSD and C-PTSD, OCD, borderline tendencies and eating disorders.

Training Materials

What is PTSD?

Post Traumatic Stress Disorder is a fear and stress disorder that may develop after a person has been directly, indirectly, or vicariously exposed to one or more event that involved actual or threatened death, serious injury, or sexual violence (known as criterion A in DSM).

Criterion A Traumas that typically lead to more severe impairment are early childhood developmental trauma (childhood sexual and physical abuse), assaultive trauma (rape, physical assaults), and multiple (complex) traumas are associated with increased severity, complexity, and suicidality in individuals with PTSD.

Complex Trauma typically the result of experiencing or witnessing multiple or chronic forms of trauma, often starting in childhood and often resulting in maladaptive coping strategies that further perpetuate a person’s vulnerability to further traumatic experiences. Includes symptoms such as more complex emotional flashbacks, toxic shame, more pronounced mood disturbances, social anxiety and relationship challenges. Some view Marsha Linehan’s conceptualization of Borderline Personality Disorder as diagnostic model for complex trauma.

PTSD most commonly develops soon after an event and can decrease over time on its own. However, for some people, the symptoms can continue to emerge or first emerge after a 6-month delay (or more), become chronic, and interfere with daily functioning. PTSD can also develop long after a traumatic event and can be the result of cumulative trauma.

20 PTSD symptoms criteria are organized across 4 main cluster of symptoms:

  • intrusive symptoms
  • avoidance symptoms
  • negative changes to cognition and mood
  • hyperarousal symptoms
  • dissociative symptoms

Complex PTSD (not in DSM, but in ICD-11) same diagnostic criteria as PTSD plus 3 additional clusters of symptoms:

  • affect dysregulation
  • negative self-concept
  • disturbances in relationships

Screening measure: the PTSD checklist for DSM -5 (PCL-5)

What is Prolonged Exposure (PE)?

Prolonged Exposure was originally developed by Dr. Edna Foa and colleagues in the 1980’s shortly after PTSD was first included in the DSM-3. It was originally developed for women with sexual-assault related PTSD and is now used in a wide variety of trauma populations. The original PE is a structured protocol is based on a combination of traditional exposure therapy techniques and Foa’s Emotional Processing Theory. 1

Emotional Processing Theory:
Fear is represented in our memory as a “program” for escaping danger. The “fear structure” includes different kinds of information:

  • what we are afraid of, called the feared stimuli (e.g., a bear)
  • the fear responses (e.g., heart rate increases, sweat etc)
  • the meaning associated with the stimuli (e.g., bears are dangerous) and the responses (e.g., fast heartbeat means I am afraid)

When a fear is realistic, we call it normal fear, and the fear structure contains information about how we can best respond to the real threat. So, feeling fear or terror if we see a bear and acting to escape are appropriate responses and can be seen as normal and helpful fear reactions.

How PTSD Develops

PTSD develops when pathological fear structures form after trauma. Fear structures include stimuli that elicit phsycological and behavioral responses, as well as thoughts about the meaning of the stimulus and response.

These fear structures become pathological when someone who has experienced trauma (sexual abuse) encounters a stimulus that is objectively safe (a memory of the abuse or a person who resembles the perpetrator); responds with intense distress (racing heart, sweating, urges to run away) and assumes negative meanings about themselves, others, or the world associated with the trauma (“I am incompetent”, or “people are likely to harm me”).

Pathological fear structures are maintained by avoidance of trauma related stimuli, which provides short term relief from distress but maintains PTSD in the long run by preventing inaccurate meanings from being disconfirmed.

Foa proposed that two conditions are necessary for successfully changing the unrealistic and abnormal fear structure and thereby reducing a person’s distress:

  • First, the person’s fear and anxiety need to be triggered or activated. If this is not done, the fear structure cannot be changed.
  • Second, realistic information (e.g., talking about the traumatic experience and remembering that it did not cause you to break down) needs to replace the original, unrealistic information in the fear structure (e.g., I will fall apart if I allow myself to talk or think about the trauma).

Exposure Therapy meets these 2 conditions. In exposure therapy, people are helped to confront safe but anxiety-arousing situations to decrease their excessive fear, anxiety, and distress.

DBT PE-A Complex Trauma Protocol

In 2005 Melanie Harned began developing a version of PE to be part of the DBT protocol, designed for individuals with PTSD who are too high risk and unstable to receive trauma-focused treatments as a first-line intervention. 3

Harned found that fear was not the primary trauma-related emotion that her clients were experiencing-instead plagued by intense levels of shame, guilt, and disgust and thought it would be necessary to target these negative self-directed emotions during the PTSD treatment.

Harned shifted the focus from PE’s emphasis on the role of problematic trauma-related beliefs as the primary factor that drove the avoidance that maintains PTSD and instead emphasized the role of intense trauma-related emotions and the efforts to avoid them as part of the core problems that also maintain PTSD. She also shifted goal from emphasizing emotional habituation during exposures to emotional tolerance-to use exposure as an opportunity to violate client’s expectancies about negative outcomes of experiencing and expressing emotions.

Harned added pre-treatment stabilization and preparation phase for clients with suicidality and self-harm

Harned added traumatic invalidation as part of PTSD Criterion A traumas to be considered. Traumatic invalidation is defined as “extreme repetitive invalidation of individuals’ significant private experiences, characteristics identified as important aspects of themselves, or reactions to themselves or to the world”. Traumatic invalidation can occur in the family of origin, and in other important relationships, groups, or institutional contexts, as well as at the societal or cultural level for individuals from marginalized groups, such as racial, ethnic, sexual and gender minorities. Can be seen as effective mechanism to address complex trauma symptoms as well.

How PTSD is Maintained

People with PTSD often have problematic beliefs about themselves, others, and emotions that developed because of the trauma they experienced, and/or because of they way the trauma was dealt with afterwards (how people responded to disclosures about the trauma).

These beliefs cause them to interpret trauma cues (any stimuli that they associate with the trauma-internal or external) negatively (e.g., “I’m not safe”), which sets off strong emotions (e.g., fear etc).

Pathological fear structures are maintained by avoidance of trauma related stimuli, which provides short term relief from distress but maintains PTSD in the long run by preventing inaccurate meanings from being disconfirmed.

These emotions (fear, guilt, shame, disgust, anger/body sensations) are often intensely distressing and lead to additional negative interpretations (e.g., “I can’t tolerate this”, “I’m bad”, “I’m not safe”).

To get relief from this distress and increase a sense of safety the person then engages in some type of avoidance. Avoidance can be any behavior that reduces distress or increases a sense of safety (e.g., leaving the situation, distracting, suppressing emotions, self-destructive behaviors

This avoidance provides temporary relief but keeps PTSD going in the long run by preventing new learning about the accuracy of interpretations and problematic beliefs.

Prolonged Exposure Protocol

Avoidance is the primary factor that maintains PTSD, including avoidance of trauma-related emotions, thoughts and situations. Although avoidance works in the short-run to reduce distress, in the long run it maintains PTSD by preventing corrective learning. DBT PE works by gradually approaching trauma memories and situations so that you can learn that they are safe and can be tolerated, which will make them less distressing.

DBT PE uses in vivo exposure (approaching avoided but safe situations in real life) and imaginal exposure (repeatedly telling the story of the trauma out loud) followed by processing (talking about and evaluating trauma-related beliefs and emotions) to treat PTSD. DBPT and exposure therapy more broadly is effective in reducing PTSD and improving overall functioning for most clients.

Treatment consists of 4 main parts:

  • psychoeducation
  • in vivo exposures
  • Imaginal exposures
  • Emotional processing

Who is PE DBT/PE appropriate for?

  • clients that meet full diagnostic criteria for PTSD, as well as individuals with subthreshold PTSD, as well as those who have PTSD symptoms in relation to non-Criterion A events may also be appropriate if these symptoms are the source of significant distress or impairment.
  • clients that meet the criteria for complex PTSD
  • clients that have any type of trauma that has led to significant PTSD symptoms, including events that do not meet Criterion A of the DSM-5 PTSD diagnosis
  • clients with a history of acute or chronic traumatic invalidation that has resulted in PTSD symptoms
  • clients with PTSD and complex presentations including pervasive emotion dysregulation, behavioral dysregulation including life-threatening behaviors and impulsive and self-destructive behaviors, comorbid diagnoses, and therapy interfering behaviors
  • clients that have PTSD that has at least some memory of a traumatic event that can be described in narrative form. Memories do not need to be fully elaborated or complete.
  • There is not yet evidence to support (or refute) DBT PE or standard PE with preadolescent children. Therefore, it is recommended that children with PTSD utilize treatments with established empirical support for this age group.

Prolonged Exposure vs. EMDR

  • EMDR developed by Francine Shapiro in 1990’s, deemed effective treatment for PTSD in 2000. 2
  • research shows that both treatments are effective for the treatment of PTSD-with different outcomes and efficacy research supporting distinctly different measures of remission
  • EMDR has been researched and applied to treat a number of other mental health conditions beyond PTSD-broadly used
  • EMDR requires much more training, supervision and certification to implement-techniques are specific
  • Both models use “SUDS” metrics to track pt’s progress in different ways
  • EMDR differs from PE in a few main ways: it is generally a shorter, faster approach and clients/clinicians tend to view it as more “positive” experience than PE due to protocol that does not involve eliciting intense negative emotions for a long period of time as part of change process
  • it does not: involve extended time spent in preparation or post-exposure processing, involve detailed descriptions of the event, specific focus on the event, the direct challenging of beliefs or negative cognitions, extended imaginal exposure, in vivo exposure, or homework
  • Some research that shows there might be a benefit to combining the approaches. For example, one study showed that PE and EMDR can be successfully combined, though most importantly the sequence matters- participants reported a strong preference to applying PE first (in the morning), and then EMDR (in the afternoon) and found it more effective than the reverse.

Adaptive Information Processing Model

  • The Adaptive Information Processing model: we each have an innate information processing system that is designed to process information and restore mental health, just like the body is designed to physically heal itself.
  • Trauma, which is associated with numerous changes in the nervous system, results in a loss of neural homeostasis which negatively impacts the information processing system from functioning optimally, so the information that is acquired at the time of the trauma is stored in its disturbing state. Because it is stored in this disturbing state, that original memory material can be triggered by a variety of external and internal stimuli and be expressed as PTSD symptoms.
  • The procedural elements of EMDR including the bilateral stimuli, trigger a physiological state that facilitates information processing to it’s “adaptive resolution”. Client’s negative self beliefs and cognitions are not given greater weight than client’s sensory experience-because it is the affect feeding them that is the pivotal element in pathology. Narrative component not central aspect of protocol.
  • 8 phase protocol: client history, preparation and assessment, desensitization, installation, body scan and closure, and reevaluation
  • Therapy sessions start with client visualizing negative memory, the attendant belief, and the emotion it generates while simultaneously focusing on bilateral movement for a short periods of time. The therapist asks client if any new information or insight has emerged and assesses it to determine whether client is processing the information and evolving to a more adaptive plateau. Depending on what direction the client’s processing is going, the therapist guides the client to focus on the new information, or to stay with current image until client has fully processed memory and reached resolution phase.

Differences in approaches

EMDR is Better suited for these clients:
  • With more overall stabilization/less need of skills for coping/not high risk
  • Complex trauma
  • With shorter time periods to work/don’t want homework
  • Less in need of direct processing of experience and in vivo exposure
  • With other mental health challenges- anxiety disorders, phobias, panic disorders, OCD, mood disorders, addictions, couples
  • That are children
Prolonged Exposure is Better suited for these clients:
  • Better suited for clients:
    that struggle to attend to bilateral stimulation and visualization at same time/cannot do visualization
  • More intensive PTSD symptoms
  • with complex cases/intense and or chronic emotional dysregulation and “high risk” (DBT component may be necessary part of treatment)
  • that may benefit from exposure to emotions to build distress tolerance skills
    that struggle with chronic avoidance
    Would benefit from experiential aspect of exposures
  • First time trauma therapy/need more comprehensive processing and validation of their trauma through psycho-education component and therapist providing them with facts and feedback about the nature of their responses to trauma etc
  • would benefit from specific focus on traumatic invalidation and need to have specific experiences validated-especially if they previously excluded client from trauma work (DBT component may be necessary part of treatment)
  • Dissociative symptoms

What is Trauma?

Trauma-originally derived from the Greek word for wound, has been defined in medicine as a circumstance in which some part of the body has been suddenly damaged by a force so powerful that the body’s natural protections are unable to prevent injury and the body’s natural healing abilities are inadequate.

Freud was the first to define the term “psychic injury” by analogy to physical injury. Freud described psychic trauma as an event that “penetrates a kind of mental skin designed to protect a person from excessive external forces; trauma is essentially a breach in an otherwise efficacious barrier”. The breach is the result not only of ethe strength and impact of the external force, but of the inability of the organism or affected area to deflect, absorb, neutralize, or compensate for the injury.

Trauma as resource loss:

Psychological trauma is a circumstance in which an event overwhelms or exceeds a person’s capacity to protect their psychic well-being and integrity. It is a collision between an event (or a series of events) and a person’s resources, where the power of the event is greater than the resources available for effective response and recovery. Psychological trauma, like physical trauma, represents a complex relationship between an event and a response. The objective characteristics of a potentially traumatic event-its force, strength, or “dose”-can be quantified, but the impact of the event cannot be determined without taking into account the resources and vulnerabilities of the particular individual who sustains the injury.

Sources

1 Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences 2nd Edition Therapist Guide by: Edna B. Foa, Elizabeth A. Hembree, Barbara Olasov Rothbaum, and Sheila A.M. Rauch

2 Eye Movement Desensitization and Reprocessing (EMDR) Therapy by Francine Shapiro

3 Treating Trauma In Dialectical Behavioral Therapy: The DBT Prolonged Exposure Protocol (DBT PE) by Melanie S. Harned

4 Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program (companion workbook) by Edna B. Foa, Kelly R. Chrestman, and Eva Gilboa-Schechtman

5 Treating Survivors of Childhood Abuse and Interpersonal Trauma: Stair Narrative Therapy by Marylene Cloitre, Lisa R. Cohen, Kile M Ortigo, Christie Jackson, and Karestan C. Koenen

6 Making Meaning of Difficult Experiences: A Self Guided Program by Sheila A.M. Rauch PhD, and Barbara Olasov Rothbaum, PhD

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