Prolonged exposure therapy

After a frightening or terrible event, it is natural to push the memory away. Many people also stay away from places, people or activities that bring it back. Avoiding brings quick relief. But over time, it can keep the fear alive and make PTSD (post-traumatic stress disorder) last longer.¹

Prolonged exposure therapy, often called PE, is a talk therapy that helps you stop avoiding, one planned step at a time. With a trained therapist, you go back over the memory and slowly return to safe situations you have been dodging. Over the weeks, many people find the memory loses much of its power.^1,2

How PE works

Fear is meant to protect you. After trauma, though, your brain may treat harmless reminders as if the danger is happening again. A crowded store, a siren, or a smell can set off alarm.¹

Each time you escape a reminder, your brain learns, "Good thing I got away." The fear stays strong. PE turns this around. When you stay with a memory or a safe situation long enough, your brain learns that the memory is painful but not dangerous, and that you can cope.²

PE was developed by psychologist Edna Foa and her colleagues. It follows a written manual, so trained therapists deliver it in a similar way.^2,3 It is done one-on-one, not in a group.¹

What happens in PE

The first sessions

Your therapist explains how PE works and asks about your life and what happened to you. You learn about common reactions to trauma. You also learn a slow breathing skill to help calm your body when anxiety rises.^1,2 For similar skills you can practice now, see the cyclic sigh and box breathing.

In vivo exposure: facing real-life reminders

"In vivo" is Latin for "in life." Around the second session, you and your therapist list the people, places and activities you have avoided since the trauma.¹ Examples might be driving past a certain corner, watching the news, or sitting with your back to a door.

You rank the list from easier to harder. Then, between sessions, you practice facing these safe situations, starting with the easier ones.^1,2 You and your therapist choose every step together. This is the same "fear ladder" idea used in exposure therapy for other fears.

The goal is to face situations that are safe but feel scary. PE never asks you to put yourself in real danger.

Imaginal exposure: going back over the memory

Around the third session, you begin talking through the trauma memory in detail, in the present tense, as if it were happening now.^1,2 Your therapist guides you, checks how upset you feel, and keeps you at a pace you can handle.¹

This part of the session is recorded. Between sessions, you listen to the recording as part of your practice.^1,2 Afterward, you and your therapist talk about the feelings and thoughts that came up. This is often called processing.² Over time, many people find they can think about the event without being flooded by it.

Homework between sessions

PE asks for practice between visits. You do your in vivo steps and listen to your session recording.¹ A free VA app called PE Coach can record sessions, remind you of homework, track your symptoms and guide breathing practice. It is meant to be used only while you work with a PE-trained therapist, not as self-help.¹⁰

How well does PE work?

PE is one of the most studied treatments for PTSD.^1,4

• Guidelines. The 2023 VA/DoD guideline gives its strongest rating to PE, cognitive processing therapy (CPT) and EMDR. It also recommends these therapies over medicine as a first choice.³ The American Psychological Association lists PE as a first-line treatment.²
• In plain numbers. Across studies, about 57 out of 100 people who get a trauma-focused therapy like PE improve in a meaningful way after about 3 months. That compares with about 36 out of 100 people on medicine and about 8 out of 100 who get no treatment.⁵
• Compared with other therapies. In a large trial of women veterans and service members, PE reduced PTSD symptoms more than a supportive talk therapy, and fewer people still had PTSD afterward. In another trial, PE and CPT worked about equally well.⁴
• Compared with medicine. One trial compared PE, the antidepressant sertraline, and both together. All three groups improved about the same amount.⁴ See medicines for PTSD.
• Lasting results. Benefits may start after a few sessions and often last after treatment ends.¹

Results are not the same for everyone. Some people improve a lot, some a little, and some need another approach. If PE is not helping, ask about switching to another proven therapy.

Is PE hard? Side effects and dropout

PE asks you to face what hurts most, so it can feel hard. The main side effect is mild to moderate distress when you talk about the memory or try a new activity. This usually does not last long and tends to ease as you keep practicing.¹ Some people feel worse for a short time before they feel better.

Not everyone finishes. In a 2023 trial of 178 veterans, about 1 in 3 people (36%) dropped out of PE. Only about 1 in 8 (13%) dropped out of a shorter therapy called written exposure therapy. That shorter therapy worked about as well in that study.⁶ Learn about it and other options on trauma-focused therapies.

Who can try PE

PE has been tested in adults with PTSD after different kinds of trauma, including military service and sexual assault.⁴ Having another problem at the same time, such as alcohol or drug use, does not automatically rule out trauma-focused therapy.³ Tell your therapist about all your health and life issues so you can plan together.

PE is one of several strong choices. Some people prefer cognitive processing therapy, which focuses more on changing painful beliefs about the trauma. Others choose EMDR. The VA suggests picking together with your clinician, based on what fits you.⁴

PE in later life

It is never too late to get help for PTSD.⁹ Some older adults find that old memories return after retirement, a loss, or an illness. More free time and looking back on life can make symptoms stand out.⁹ Read more on PTSD in older adults and veterans.

Here is what research says about PE and other trauma-focused therapies for older adults:

• Nothing in the research rules it out. VA experts say older adults can usually start standard PTSD therapy, with changes only when needed.⁷
• It can work, though maybe a bit less strongly. In a trial of older veterans, an adapted form of PE helped. The response was smaller than in studies of younger people, and the reasons are not yet clear.⁸
• Heart health. Some people worry that reliving trauma could strain the heart. In one study of people with PTSD after heart problems, monitoring during imaginal exposure did not show cause for concern. If you have a heart condition, your doctor can check with your therapist and help monitor you.⁷
• Memory problems. Mild or moderate thinking problems do not by themselves rule out PE. A therapist may do a short memory screen first.⁷ Very few studies have included people over 75 or people with memory loss, so less is known for them.⁷
• Getting there. Video visits can help if driving or transportation is hard. Many VA centers offer PE, and smaller sites may offer it by video.^1,7

For older adults with chronic worry rather than trauma, see anxiety in later life.

How to find PE

Ask any therapist directly: "Are you trained in prolonged exposure?" Look for someone with experience treating trauma who offers PE, CPT or EMDR.¹¹

• Directories. The VA lists online directories of PE-trained therapists, such as those kept by Emory University and the University of Pennsylvania. It also points to SAMHSA's treatment locator at 1-800-662-4357.¹¹
• Veterans. Almost all VA medical centers offer PE in their PTSD programs. Vet Centers also offer counseling for veterans and families.^1,11
• Cost. Check which plans a therapist accepts and what you will pay.¹¹ See paying for therapy and what Medicare covers for mental health.

More tips are on how to find a therapist. If you care for someone with PTSD, see supporting someone with PTSD.

Common questions

Will talking about the trauma make me worse?

Distress often rises for a while when you start. It usually eases with practice, and your therapist keeps you at a pace you can manage.¹ Avoiding the memory, not facing it, is what tends to keep PTSD going.²

Do I have to tell my therapist every detail?

Imaginal exposure does involve going over the memory in detail, in a safe setting with a guide.² You and your therapist decide how to start. You can share your worries before you begin.

Can I do PE on my own?

No. PE is meant to be done with a trained therapist. Even the PE Coach app is designed only for use during professional care.¹⁰ For coping skills you can use on your own, see coping with trauma symptoms.

Can I do PE by video?

Yes. Many VA sites offer PE through video visits.¹ Ask any therapist whether they offer it by video.

Can I take medicine during PE?

Some people take medicine for PTSD while in therapy. Research has not clearly shown whether combining the two works better than either one alone.³ Talk with your doctor about whether medicine fits your plan. Do not start, stop or change a medicine on your own.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.