Exposure Therapy for Posttraumatic Stress Disorder - PsycNET

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Volume 1, Number 4, 2008

Exposure Therapy for Posttraumatic Stress Disorder Jeremy S. Joseph and Matt J. Gray

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Abstract Posttraumatic stress disorder is an anxiety disorder characterized by symptoms of persistent reexperiencing of the event, pervasive avoidance of stimuli or thoughts associated with the event, and increased arousal. Furthermore, these symptoms need to persist for longer than one month. Etiological models of PTSD identify the interplay between intrusive thoughts and avoidance behaviors as key factors that maintain the disorder. The actual symptoms or the individual’s efforts to cope with them can significantly impair occupational functioning, resulting in costs to society as well as the individual. Fortunately, empirically validated treatments capable of alleviating these difficulties have been developed. Exposure therapy is generally regarded as the standard of care for PTSD. Shortterm symptom exacerbation can occur during exposure therapy but this is no less true of other trauma-focused interventions. Furthermore, ample evidence supports the notion that exposure therapy is efficient, cost-effective, and readily implemented. A case example is used to illustrate how exposure therapy can work when treating a client with PTSD. Keyword: Exposure therapy, treating victims, PTSD

PTSD is an anxiety disorder precipitated by a real or perceived life threat, experiencing or witnessing significant accidents or injuries, or sexual assault. The individual must have experienced (or witnessed) such an event and in addition exposure to this event must have elicited intense fear, helplessness, or horror (APA, 1994). Exposure to events known to produce PTSD is far from uncommon; a large-scale epidemiological study of nearly 6,000 U.S. citizens estimated that approximately 61% of men and 51% of women have experienced at least one traumatic event at some point in their lives (Kessler, Bromet, Highes, & Nelson, 1995). Although a high percentage of individuals are commonly exposed to such events, few develop chronic psychopathology as a result. Lifetime estimates of PTSD following a traumatic event depend on the nature of the event experienced, with some events resulting in higher incidence of PTSD than others. For example, approximately 49% of rape victims develop PTSD compared to 4% of natural disaster survivors (Breslau et al., 1998). Lifetime prevalence of PTSD in the population at large is estimated at between 5% and 10%, making it one of the most common anxiety disorders (Ballenger et al., 2000). The large discrepancy between experiencing a trauma and developing PTSD suggests the presence of several mediating factors. For example, number of prior traumatic experiences, type of traumatic experience, and quality of social support can buffer against the development of PTSD or serve as a vulnerability. As a result, diagnosis of PTSD involves more than simply experiencing a traumatic event. In addition, an individual must be experiencing the following: (1) at least one symptom of persistent reexperiencing of the event as evidenced by intrusive memories of the event, nightmares, flashbacks, or reactivity to reminds of the trauma; (2) three or more symptoms of pervasive avoidance of stimuli or thoughts associated with the event, including emotional numbing; and (3) two or more persistent symptoms of increased arousal, such as hypervigilance, sleep difficulties, irritability, or exaggerated startle responses (APA, 1994). Furthermore, the above symptoms must persist beyond one month following the traumatic event and must significantly impair social, educational, or occupational functioning. The rationale behind this requirement rests on the finding that it is normal and probably adaptive for individuals to experience these symptoms in the immediate aftermath of a trauma. As a result, symptoms present within the first month

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following the event are not considered pathological. Although this cutoff point might appear arbitrary, there is strong evidence to suggest the persistence of these symptoms beyond the first month is associated with the development of PTSD and the need for treatment to ameliorate symptoms (e.g. Brewin, Andrews, Rose, & Kirk, 1999).


Etiology of PTSD Although the three symptom categories (reexperiencing, avoidance/numbing, and hyperarousal) are described in isolation, it is important to note that they are intimately interconnected. Etiological models of PTSD supported by the strongest empirical evidence have discussed the interplay between intrusive symptoms and avoidance symptoms in maintaining the disorder. In particular, conditioning models (e.g., Keane, Zimering, & Caddell, 1985) hold that during a traumatic event, intense fear is an unconditioned response to the traumatic event (the unconditioned stimulus). This emotional response (fear) is paired with stimuli that are present during the assault. Accordingly, a conditioned fear response is elicited by cues that have been paired with the traumatic event (i.e., conditioned stimuli), such that those stimuli are later capable of triggering significant fear, anxiety, and distress when they are encountered following the trauma. However, a simple classical conditioning model cannot fully account for PTSD because repeated encounters with the conditioned stimuli in the absence of further harm should result in extinction of the fear response. Yet this is not the case, which is why avoidance symptoms are integral to the maintenance of the disorder. As applied to PTSD, Mowrer’s (1960) two-factor model posits that this initial classical conditioning process is followed by operant conditioning (Keane et al., 1985, Shalev et al., 1996). Specifically, a trauma victim tries to avoid trauma-relevant cues, and this avoidance is negatively reinforcing in that it manages to reduce the experience of fear and anxiety. Avoidance is immediately rewarded by a reduction in aversive emotional states, but extinction of the classically conditioned fear and anxiety response never occurs because exposure to trauma cues is successfully avoided. More recent etiological models of PTSD have retained a primary emphasis on these classical and operant conditioning processes, but have also incorporated cognitive factors such as perceptions of predictability and control as being influential in the development and expression of posttraumatic psychopathology (e.g., Foa & Kozak, 1986). PTSD is debilitating and the struggle to cope with this disorder often leads to secondary clinical problems. Substance dependence disorders and secondary depression are the frequent result of efforts to avoid the cues, conversations, or places that remind the individual of the traumatic event (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Kessler et al., 1995). In addition to the overwhelming burden that this disorder places on the individual, PTSD is also associated with significant costs to society. The actual symptoms or the individual’s efforts to cope with them can significantly impair occupational functioning (based on measures of reduced productivity), resulting in a conservatively estimated financial loss of over $3 billion in the United States (Ballenger et al., 2000). To summarize, PTSD is fairly prevalent, significantly debilitating to the trauma victim, often accompanied by secondary complicating problems, and exacts a hefty toll on society. Fortunately, empirically validated treatments capable of alleviating these difficulties have been developed.

Treatment Rationale Exposure therapy is generally regarded as the standard of care for PTSD (Rothbaum et al., 2000) because it is not only effective but also easily administered and does not require extensive training to be effectively implemented (Foa & Meadows, 1997; Marks et al., 1998; Tarrier & Humphreys, 2000). The rationale for exposure therapy derives logically from empirically validated etiological models of posttraumatic stress, described earlier. If in fact avoidance of triggers associated with the traumatic

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experience prevents extinction of the conditioned emotional response, it makes sense that systematic exposure to such cues will promote the reduction of the fear response. With repeated exposure to traumatic memories and trauma-related cues, their association to actual trauma and their capacity to elicit significant levels of distress are greatly attenuated. Exposure therapy can be imaginal in nature or in vivo, although most treatment protocols use a combination of both. In the former, trauma victims are asked to close their eyes and vividly imagine their traumatic event. They are asked to describe it aloud using the present tense, and to use as much detail in their telling as possible. This account is recorded and the client is usually asked to listen to themselves at last once per day between sessions. This procedure is repeated in and across sessions until there is a significant reduction in anxiety and distress. During in vivo exposure, clients are asked to purposely expose themselves to activities, places, or other cues that they have been avoiding since the trauma and that are objectively safe. Obviously, trauma survivors should continue to avoid contexts that are objectively dangerous (e.g., a sexual assault survivor would do well to avoid the perpetrator). Two comprehensive reviews of psychosocial treatments for PTSD have concluded that cognitivebehavioral treatments generally, and exposure therapy specifically, have been the most rigorously tested and validated treatment methods for PTSD (Resick, Monson, & Gutner, 2007). The authors of both reviews commend exposure therapy as the “treatment of choice for PTSD” because of its demonstrated efficacy in varied trauma populations, and its relative ease of use. A more recent meta-analysis of 61 treatment-outcome trials of psychological treatments for PTSD found that among treatments demonstrating positive therapeutic outcomes, exposure therapy was associated with the largest effect size (see Foa, 2000). As mentioned above, etiological models of PTSD have implicated cognitive variables such as predictability and control as being key factors in the development of the disorder following a traumatic event. Interestingly, treatments developed specifically to target these cognitive variables have not outperformed exposure therapy (Marks et al., 1998; Tarrier, Pilgrim, et al., 1999; Tarrier, Sommerfield, et al., 1999). Rather than suggesting that these cognitive factors are unimportant, what these results suggest is that they can be modified by exposure as well as cognitive interventions that are expressly designed to target them. As clients in exposure therapy confront their fears that lead to avoidance, their maladaptive cognitions that developed following trauma are disconfirmed. In summary, exposure does more than reduce aversive affective states; the alleviation of conditioned fear and anxiety is accompanied by cognitive changes as well.

Case Example The case description that follows is provided as an illustration of how exposure therapy functions. Mr. S. is a White 34-year-old male who was referred for assessment and treatment of symptoms secondary to being kidnapped and repeatedly assaulted during a drug purchase. At the time of his presentation for treatment, he had been married for five years and had a 4-year-old daughter. The relationship between Mr. S. and his wife had been troubled by frequent arguments and emotional distancing following an affair she had with one of his coworkers three years prior. Mr. S. began using cocaine following his wife’s disclosure of her affair. He estimated that he used cocaine approximately two or three times per week for two years until voluntarily seeking treatment. He also smoked marijuana regularly since the age of 18, but stopped at the same during his treatment for cocaine. According to Mr. S., he left home following a particularly upsetting argument he had with his wife and went to the apartment of his former drug dealer. After purchasing cocaine and using some of it, the dealer robbed him at gunpoint. Not satisfied with the amount of money that Mr. S. was able to provide, the dealer forced him into a car drove to several ATMs throughout the night, demanding that he withdraw more money from his accounts. The dealer then picked up two friends and called Mr. S.’s wife

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in the morning threatening to kill her husband if she did not meet them in the parking lot of her work with money. She stated that she would try to meet their demands by calling friends and relatives and have the ransom by the end of the day. The perpetrators then drove Mr. S. to a secluded field where they proceeded to beat him. At one point they called Mr. S.’s wife and held the phone to his head while they hit him so she could hear her husband scream. They then drove Mr. S. to the meeting location but because his wife had not yet arrived, one of the perpetrators stabbed Mr. S. with a box cutter. Immediately after this, several policemen arrived and apprehended the drug dealer and his friends, as Mr. S.’s wife had alerted the police to the situation. In addition to the stab wound, Mr. S. sustained several bruises and abrasions as well as a concussion. He was taken to the hospital, treated, monitored overnight, and released the next day.

Chief Complaints Mr. S. presented for treatment approximately four weeks following this incident. He reported experiencing frequent nightmares of the event, significantly diminished sleep, overwhelming anxiety, and constantly worrying about reprisal from the perpetrators. He resumed work approximately one week after the assault, but reported that his concentration was significantly impaired. In addition to the nightmares, he reported that he had vivid memories of the assault repeatedly throughout the day. Furthermore, these intrusive thoughts were accompanied by intense anxiety and strong physiological arousal. Although he made serious efforts to suppress such thoughts and to avoid all reminders of the trauma, he could not prevent frequent, distressing memories of the event.

Assessment Based on the DSM-IV criteria (APA, 1994), Mr. S. exceeded the minimum criteria for the diagnosis of PTSD. Mr. S. reported several reexperiencing symptoms such as nightmares, intrusive memories of the assault during waking hours, and significant reactivity to reminders of the event. He also exhibited avoidance and numbing symptoms that characterize the disorder. For example, he stopped watching television altogether because of the many legal, medical, and law enforcement dramas that often depict violent crimes. Unfortunately, trauma cues are often ubiquitous, and, like nearly all trauma victims, Mr. S. was unable to avoid all such reminders. Paradoxically, his extreme attempts to avoid these cues only served to maintain the disorder. He also reported feeling detached from others and having a sense of a foreshortened future. In regards to the symptom category of increased arousal, he reported sleep difficulties, trouble concentrating, hypervigilance, and an exaggerated startle response. In addition to clear symptoms of PTSD, Mr. S. reported experiencing a very depressed mood. He attributed this depression to feelings of guilt about his relapse and not being an adequate father to his daughter. Moreover, his wife was generally unsupportive as she continued to assert that the abduction never would have happened had he remained abstinent from drugs and alcohol. He reported drinking two to three beers per night since the assault in order to relieve his anxiety and to facilitate falling asleep. Given the many ways that trauma victims attempt to avoid thoughts and feelings related to the trauma, it is not surprising that substances are often abused in an attempt to cope with the overwhelming thoughts and feelings related to the trauma. Fortunately, Mr. S. did not resume cocaine abuse following his traumatic experience. Finally, he stated that he had been experiencing frequent headaches since the assault.

Medical Consultation Mr. S.’s frequent headaches were the most pressing physical complaint. It was possible that he could have sustained neurological damage as a result of the brutal attack, so further evaluation by a physician was required. Subsequent neurological testing revealed no significant cognitive functioning impairments or structural damage. His headaches were monitored by his physician and gradually remitted

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over time. Not only was this important to evaluate and treat in its own right, but any cognitive deficits stemming from the trauma could have implications for psychotherapy. For example, problems with concentration could interfere with his ability to engage in therapeutic exercises in session. Mr. S. also began taking an SSRI (selective serotonin reuptake inhibitor) to address his depressive symptoms, but SSRIs can also facilitate the treatment of PTSD (Friedman, Davidson, Mellman, & Southwick, 2000).


History Although a trauma is necessary for PTSD to occur (for a discussion on the controversy surrounding this criterion, please see Long et al., 2008), it is not sufficient, as evidenced by the fact that the majority of people who experience a traumatic event do not develop the disorder. In order to fully understand the onset of PTSD, attention must be paid to preexisting factors that have been identified as sources of vulnerability to developing PTSD following a traumatic event. Prior exposure to a trauma, personal history of psychiatric disorder, and family history of psychiatric disorder all predict chronic PTSD (Marshall, Spitzer, & Liebowitz, 1999). Mr. S. reported that his childhood was quite difficult, as his father was an alcoholic and was often abusive towards his mother. He grew up in a dangerous neighborhood and witnessed violence frequently. His parents divorced when he was 9 years old. From this basic personal and family history, it is apparent that all of these events were risk factors deserving consideration. In addition to previous stress events, peritraumatic and posttraumatic environment factors can also affect the likelihood of developing PTSD. For example, kidnapping and assault are associated with a very high incidence of subsequent PTSD diagnoses (Breslau et al., 1998). Considerable evidence also exists that social support is associated with positive posttraumatic adjustment (e.g., Taft, Stern, King, & King, 1999). Unfortunately, Mr. S.’s wife did not offer much support in the aftermath of his trauma, which may have negatively impacted his symptom course and recovery. Before beginning trauma-focused treatment, it is necessary to first evaluate the recovery environment and identify any factors that might hinder therapeutic progress. Safety planning is especially important. If the client is not objectively safe or unrealistically concerned with a recurrence of the trauma, exposure to trauma cues in an effort to extinguish the conditioned emotional response is highly inadvisable.

Case Conceptualization In Mr. S.’s case, he expressed concerns regarding the possible retaliation by friends or family members of the perpetrators. Such pronounced suspiciousness can be delusional and an indication of a psychotic disorder. Given his recent assault history, Mr. S.’s concerns were quite reasonable and not unfounded. However, it was still necessary to allay these fears as much as possible before initiating therapy. As a result, Mr. S. made plans during the first session to register for a victim notification program that would alert him if and when any of the perpetrators were released from jail. He also obtained a toll-free phone number to learn the status of their legal cases and incarceration. Mr. S. also decided to purchase a home security system to allay his concerns about the possibility of a home invasion. Taking these steps helped to alleviate his fear of reprisal enough to allow s to proceed with traumafocused therapy. If his fears had persisted, it may have been necessary for him to reside temporarily with friends or family. Because social support is associated with positive treatment outcomes, it is important to encourage emotional disclosure to one or two supportive friends or family members also before the start of therapy. Unfortunately, his wife was so angry about his relapse that she was not able to offer much support. We decided to take a two-fold approach. First, Mr. S. was encouraged to discuss his difficulties with his brother, with whom he shared a close relationship. Second, his wife was encouraged to attend

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one of his first sessions, during which she was allowed to express her frustrations and was educated about PTSD and the importance of social support in the recovery process. They were both given a referral to a couple’s therapist, who began working with them on issues of trust and communication. Mrs. S.’s anger waned over time, and although she was never as supportive as other figures in Mr. S.’s life during therapy, she was less critical of him and agreed to work on their relationship.


Exposure Therapy In addition to safety planning and identifying sources of social support, the first three sessions consisted of psychoeducation about PTSD and the role that avoidance plays in maintaining the disorder. The success of exposure therapy for PTSD hinges on the degree to which patients understand the role that avoidance plays. We therefore advise therapists to ask patients to describe the rationale for exposure therapy in their own words prior to beginning exposure activities. Clear presentation of the rationale, followed by evaluation of the patient’s understanding of it, is probably the single most important aspect of trauma-focused therapy for PTSD. This is because clients are asked to engage in activities they would prefer to avoid and transient symptom exacerbation can precede significant treatment gains. As such, their understanding of the rationale and course of exposure therapy is a major influence on their level of compliance and adherence. Furthermore, informing patients that minor symptom exacerbation often occurs can be reassuring and facilitate commitment to therapy in the event that transient increases in intrusive symptoms do occur. Because trauma victims present with widely varying traumatic experiences, symptom levels, recovery environments, and individual differences, it is better to tailor both the duration and number of sessions to the needs of the individual rather than adopt a one-size-fits-all approach. Each session of exposure therapy should continue until the patient has experienced a significant reduction in anxiety (e.g. 50%), because ending a session when the client is still experiencing high levels of anxiety can result in greater sensitization (Frueh, Turner, Beidel, & Mirabella, 1996). Furthermore, exposure therapy does not fit the traditional 50-minute therapy session model. Although results are achieved more rapidly in later sessions, initial therapy sessions can average 90 minutes and occur more than once per week (Frueh et al., 1996). In terms of number of sessions, this also depends on factors such as the chronicity of the disorder, severity of symptoms, and degree of exposure the client is able to engage in between sessions. Exposure therapy usually continues until a client can begin a session by describing the traumatic event with minimal distress. Studies on exposure techniques have found that therapy typically ranges from 10 to 20 sessions (Rothbaum et al., 2000) although positive outcomes have been found in as few as four sessions (Foa, Hearst-Ikeda, & Perry, 1995). Imaginal exposure involves imagining the traumatic event as vividly as possible. Because most traumas are discrete events that rarely last more than several minutes, the entire event can be described in vivid detail. Focusing on the most distressing details is likely to produce the greatest change in the shortest time and it makes it easier to repeat the process multiple times within a session. If the clinician is not certain which aspects are the most distressing, he or she will be unable to encourage more vivid, detailed accounts of those aspects. Therefore, it is important to prompt the victim to identify the particular memories that cause the most upset. If a client reports that he or she is unable to discern the most distressing part of a prolonged trauma, then it is helpful to have him or her vividly imagine and describe the entire series of events in as much detail as possible. At key points throughout the narrative, the therapist can stop the client and ask him or her to provide an anxiety rating on a 0 to 10 scale, with 0 representing absolutely no distress and 10 representing the most distress imaginable. Clients are asked to close their eyes and describe in vivid detail, aloud, in present tense each portion of the event. As they proceeded, the therapist interjects with prompts and questions about sights,

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sounds, and smells to ensure they are not avoiding any aspects. Clients are also asked to recall thoughts, feelings, and bodily sensations during the assault. At the conclusion of this narrative, they are asked to rate their distress on the 0 to 10 scale; this serves as the baseline anxiety level for the session. This process is repeated until a 50% reduction in baseline has been achieved, at which point the session is terminated. At the start of each session, clients typically report an anxiety rating somewhat lower than the initial rating given in the previous session but higher than the rating provided at the end of the last session. Treatment typically requires successively fewer repetitions during each session. A benefit of the increase in remaining time is that it can be used to review compliance with imaginal in vivo exposure homework, to identify additional situations or trauma cues that the victim is avoiding, to plan in vivo exposure assignments accordingly, and to address any obstacles that might interfere with these assignments. When victims can discuss their traumatic event without experiencing negative affect, and when they can encounter unanticipated reminders of the event in the absence of significant distress, traumafocused exposure therapy may be discontinued. It is important to note that treatment is not capable of eradicating all memories of the traumatic event. Clients also need to understand that exposure therapy is not capable of rendering the lingering memories completely neutral either. After all, even people who do not develop PTSD following a traumatic event still have unpleasant thoughts and occasional memories about their experiences. Trauma-related thoughts and memories are still unpleasant after successful therapy, but they are relatively infrequent and generally manageable. Like most clients, Mr. S. found engagement in exposure to be much more tolerable than he had anticipated. Because Mr. S. experienced a trauma that occurred over a 24-hour period, it was necessary to determine which specific aspect of his experience was most distressing. Although the entire experience was traumatic, his memories of being locked in the trunk of a car and repeatedly beaten caused him the most anxiety. During his first session of imaginal exposure, Mr. S.’s initial anxiety rating was 9. When he returned the following week and described the event in detail, Mr. S.’s initial anxiety rating was 7, and it required nine iterations for his anxiety rating to drop to a 3. After 10 accounts of the event, which lasted for 75 minutes, his anxiety rating was 4. Each session was recorded on tape, which he listened to at least once per day between sessions. By the ninth session, Mr. S. was able to imagine the assault in session with an anxiety rating of 2 and, unlike earlier sessions, did not exhibit visible signs of distress. Therapy was terminated after this session. Regrettably, we did not retain process measures, but they conformed to the typical pattern of within-session habituation and increasingly rapid decrements between sessions.

Therapist-Client Factors Exposure therapy is widely regarded as the standard of care for PTSD (for a comparison between prolonged exposure and Eye Movement Desensitization and Reprocessing (EMDR), see Rothbaum, Astin, & Marsteller, 2005) because it is effective and readily administered. As the client provides the main “active ingredient” in exposure therapy in the form of his or her efforts to vividly imagine the trauma, this treatment relies relatively less on the client-therapist alliance. However, this is not to suggest that client-therapist factors are unimportant when conducting exposure therapy. As mentioned earlier, success depends on the extent to which the rationale for treatment is effectively communicated to the client. Clear descriptions at the beginning of the typical course, process, and any likely difficulties that may be encountered can facilitate rapport, alleviate any unnecessary anxiety, and enhance treatment compliance.

Common Misconceptions There are several misconceptions about exposure therapy. One is that exposure therapy only targets symptoms of anxiety and fails to address other posttraumatic difficulties (e.g., depression), or that

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extinction of the fear response is its only benefit. Studies that have included other outcome measures have consistently found global and diverse treatment gains (Marks, Lovell, Noshirvani, Lavnou, & Thrasher, 1998; Tarrier, Pilgrim, et al., 1999; Tarrier, Sommerfield, Pilgrim, & Humphreys, 1999). Another misconception about exposure therapy is that it is associated with greater therapy attrition rates or that it can exacerbate the disorder. Comprehensive reviews conclude that cognitivebehavioral treatments for PTSD (including exposure therapy) have lower dropout rates than pharmacological treatments (Foa, 2000) and the dropout rate for PTSD is no different from the rates for other anxiety disorders (Ballenger et al., 2000). Some studies (e.g., Foa, Dancu, Hembree, Jaycox, Meadows, & Street, 1999) actually show lower attrition in exposure conditions relative to other psychosocial interventions for PTSD. Contrary to ubiquitous myths about exposure therapy, enduring adverse reactions are uncommon and are no more prevalent or severe than difficulties that arise in other treatments (e.g. cognitive therapy, Eye Movement Desensitization and Reprocessing, and stress inoculation training; Foa, Zoellner, Feeny, Hembree, & Alvarez-Conrad, 2002; Foy et al., 1996; Hembree, Foa, Dorfan, Street, Kowalski, & Tu, 2003). A final misconception about exposure therapy is that it is “cold,” unempathic, and mechanistic in its delivery. In fact, therapists who would attempt to provide exposure therapy in this way would find themselves faced with high attrition rates. Trauma-focused therapy of any type is difficult for trauma victims and requires a safe, supportive environment. Only a warm and emotionally responsive therapist will allow the client to risk discussing their trauma and to experience the emotional vulnerability that inevitably follows.

Course of Termination and Follow-Up Therapy does not simply end when the patient is able to engage in imaginal exposure in the absence of significant distress. It is still necessary to meet two or three more times to monitor symptoms and to again provide psychoeducation concerning urges they may have to avoid thoughts or reminders of the trauma and the importance of resisting these urges. In the event that their intrusive symptoms become more severe in the future, clients should be encouraged to contact the clinician for “booster sessions,” although this is typically not necessary. Following exposure therapy, Mr. S. continued relapse-prevention therapy to target substance abuse behaviors, and he and his wife continued couples therapy.

Effectiveness Overall, Mr. S. demonstrated significant and meaningful improvement by any reasonable standard. Subjectively he was able to recall and discuss his trauma and encounter reminders of it without experiencing the overwhelming anxiety with which he originally presented. Objectively, the moderate-tosevere symptom levels that he initially reported on assessment measures declined to very mild levels by the final session. Although he was still experiencing some mild and infrequent symptoms of PTSD, this is quite common and patients and family members should be aware of this fact from the beginning.

Summary Exposure therapy is the most frequently studied and validated treatment for PTSD. Despite the fact that more complex etiological models have replaced the original conditioning models that led to the development of exposure therapy, novel treatments that incorporate other components have not outperformed exposure-based techniques. Short-term symptom exacerbation can occur during exposure therapy but this is no less true of other trauma-focused interventions. Furthermore, ample evidence supports the notion that exposure therapy is efficient, cost-effective, and readily implemented. Based on this overwhelming evidence, we agree with others (Nemeroff, Bremner, Foa, Mayberg, North, & Stein, 2006; Taylor, 2004) in recommending exposure therapy as the intervention of choice when treating PTSD.

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Tarrier N., Pilgrim, H., Sommerfield, C., Faragher, B., Reynolds, M., Graham, E., et al. (1999). A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67, 13-18.


Tarrier, N., Sommerfield, C., Pilgrim, H., & Humphreys, L. (1999). Cognitive therapy or imaginal exposure in the treatment of posttraumatic stress disorder: Twelve-month follow-up. British Journal of Psychiatry, 175, 571-575. Taylor, S. (2004). Efficacy and outcome predictors for three PTSD treatments: Exposure therapy, EMDR, and relaxation training. In S. Taylor (Ed.) Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive Behavioral Perspectives (pp. 13-37). New York: Spring Publishing Co.

Author Contact Information

Matt J. Gray, Ph.D. Associate Professor and Director of Clinical Training University of Wyoming Department of Psychology Dept. 3415 1000 E. University Ave. Laramie, WY 82071 (307) 766-6303

Jeremy S. Joseph Associate Professor and Director of Clinical Training University of Wyoming Department of Psychology Dept. 3415 1000 E. University Ave. Laramie, WY 82071 (307) 766-6303

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