Prolonged Exposure Therapy: How It Works, What to Expect, and Who It Helps

Prolonged Exposure Therapy (PE) is a structured, evidence-based psychotherapy developed by Dr. Edna Foa at the University of Pennsylvania in the 1990s. It is one of the most rigorously studied and widely recommended treatments for posttraumatic stress disorder (PTSD), and it is grounded in emotional processing theory — the idea that trauma-related fears are maintained when people avoid confronting the memories, situations, and feelings associated with their traumatic experience.

At its core, PE works by helping individuals gradually and systematically approach trauma-related memories, feelings, and situations they have been avoiding. This avoidance, while understandable and even protective in the short term, tends to reinforce and maintain PTSD symptoms over time. By confronting these feared stimuli in a safe, therapeutic context, the brain learns that the memories themselves are not dangerous and that the distress they produce is tolerable and temporary.

PE is rooted in well-established principles of learning theory, particularly the concept of habituation — the natural process by which repeated, prolonged contact with a feared stimulus leads to a reduction in the fear response. It also draws on the concept of cognitive change: as individuals process their trauma, rigid and unhelpful beliefs (such as "the world is entirely dangerous" or "I am permanently broken") are naturally challenged and revised.

PE is recognized as a first-line treatment for PTSD by multiple authoritative bodies, including the American Psychological Association (APA), the U.S. Department of Veterans Affairs (VA), the Department of Defense (DoD), and the International Society for Traumatic Stress Studies (ISTSS).

Prolonged Exposure Therapy consists of four primary components, introduced progressively across treatment. Understanding each component helps demystify the process and prepares individuals for what treatment actually involves.

• Psychoeducation about trauma and PTSD: In early sessions, the therapist explains common reactions to trauma, how PTSD develops and is maintained, and the rationale behind exposure-based treatment. This helps normalize the individual's experience and provides a clear framework for understanding why avoidance, while natural, perpetuates symptoms.
• Breathing retraining: A simple diaphragmatic breathing technique is taught as a general stress management tool. It is not used during exposure exercises themselves — the goal during exposure is to fully experience and process emotions rather than dampen them — but it can be helpful for managing day-to-day anxiety.
• In vivo exposure: This involves gradually and repeatedly approaching real-world situations, activities, or places that the individual has been avoiding because they are reminders of the trauma — even though they are objectively safe. For example, someone who was assaulted in a parking garage might avoid all parking structures. In vivo exposure involves creating a hierarchy of avoided situations ranked by difficulty and systematically working through them between sessions.
• Imaginal exposure: This is the centerpiece of PE. During imaginal exposure, the individual recounts the traumatic memory aloud in the present tense, with their eyes closed, in vivid detail — describing what happened, what they saw, heard, felt, thought, and experienced physically. This recounting is typically recorded so the individual can listen to it between sessions as homework. The recounting is repeated across multiple sessions, usually for 30 to 45 minutes per session, followed by a processing discussion with the therapist.

The combination of in vivo and imaginal exposure addresses both the external avoidance (situations and activities) and internal avoidance (memories, thoughts, and emotions) that sustain PTSD. Over time, the distress associated with these stimuli diminishes — not because the memory is erased, but because the individual's relationship to the memory fundamentally changes.

Prolonged Exposure Therapy was developed specifically for posttraumatic stress disorder (PTSD) and remains most strongly indicated for this condition. According to the DSM-5-TR, PTSD is characterized by intrusion symptoms (flashbacks, nightmares), persistent avoidance of trauma-related stimuli, negative alterations in cognition and mood, and marked changes in arousal and reactivity, persisting for more than one month following exposure to actual or threatened death, serious injury, or sexual violence.

PE has been studied and demonstrated effectiveness across a wide range of trauma types, including:

• Military combat trauma
• Sexual assault and rape
• Childhood physical or sexual abuse
• Terrorist attacks and mass violence
• Motor vehicle accidents
• Natural disasters
• Intimate partner violence

Beyond PTSD, emerging research has explored the application of PE principles to related conditions, though with varying levels of evidence:

• Co-occurring PTSD and substance use disorders: Modified protocols (such as the Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure, or COPE) have shown promising results in treating both conditions simultaneously.
• Co-occurring PTSD and major depressive disorder: Because depression frequently co-occurs with PTSD, PE studies routinely show significant reductions in depressive symptoms alongside PTSD improvement.
• Acute stress disorder: Brief modified PE protocols have been studied as early interventions following trauma.
• Complicated grief and moral injury: Adaptations of PE have been explored for these related experiences, though the evidence base is still developing.

Notably, PE is specifically designed for trauma-related conditions. It is not a general-purpose treatment for anxiety disorders such as generalized anxiety disorder, social anxiety disorder, or obsessive-compulsive disorder, though these conditions have their own well-supported exposure-based treatments.

A standard course of Prolonged Exposure Therapy typically consists of 8 to 15 sessions, each lasting approximately 90 minutes. Sessions are usually conducted weekly, though some protocols use more intensive formats (such as twice-weekly or daily sessions over a compressed period). Here is a general overview of the treatment arc:

Sessions 1–2: Assessment, psychoeducation, and treatment planning. The therapist conducts a thorough assessment of PTSD symptoms, trauma history, and current functioning. The rationale for PE is explained in detail, and breathing retraining is introduced. The therapist and client begin to identify avoided situations for in vivo exposure assignments. Critically, the therapist also identifies the "index trauma" — the traumatic event that will be the primary focus of imaginal exposure. If multiple traumas are present, one is typically selected to begin with, usually the one most closely tied to current symptoms.

Sessions 3–4: Introduction of imaginal exposure. The individual begins recounting the traumatic memory aloud in session. This is often the most challenging part of treatment. The therapist provides a warm, supportive presence and guides the process. After the imaginal exposure (typically 30–45 minutes), the therapist engages the client in a processing discussion, exploring what came up during the recounting, what was most difficult, and what was learned. The session recording is assigned as homework — listening to it daily between sessions.

Sessions 5–10+: Continued imaginal and in vivo exposure. Imaginal exposure is repeated in each session, often with the therapist encouraging the individual to add more sensory detail and to focus on the parts of the memory that carry the most distress (known as "hot spots"). Over repeated recountings, a clear pattern typically emerges: initial distress levels decrease both within and across sessions. In vivo exposure assignments are progressively expanded, working up the hierarchy of avoided situations. Processing discussions deepen, often naturally leading to significant shifts in how the individual understands and feels about the trauma.

Final sessions: Review, relapse prevention, and termination. The therapist and client review progress, identify remaining areas for continued growth, and discuss strategies for maintaining gains. The individual is encouraged to continue approaching previously avoided situations independently.

Between-session homework is essential. PE is not a treatment that works solely within the therapy room. Listening to the imaginal exposure recording and completing in vivo exposure assignments between sessions are critical components. Research consistently shows that homework compliance is associated with better outcomes.

Prolonged Exposure Therapy has one of the strongest evidence bases of any psychotherapy for PTSD. Decades of rigorous research support its effectiveness, and it has been designated an "A"-level recommended treatment (the highest level of recommendation) by both the APA Clinical Practice Guideline for PTSD (2017) and the VA/DoD Clinical Practice Guideline for PTSD (2023).

Key findings from the research literature include:

• Large effect sizes: Meta-analyses consistently demonstrate that PE produces large reductions in PTSD symptoms compared to waitlist controls and active comparison conditions. Effect sizes (Cohen's d) in the range of 1.0 to 1.5 are commonly reported for pre- to post-treatment change, which represents substantial clinical improvement.
• Diagnostic remission: Research suggests that approximately 41% to 95% of individuals no longer meet diagnostic criteria for PTSD following PE, depending on the study population, trauma type, and how remission is defined. A commonly cited figure from controlled trials is that roughly 50% to 60% of individuals achieve loss of PTSD diagnosis by the end of treatment.
• Broad applicability: PE has been validated across diverse populations, including military veterans, active-duty service members, sexual assault survivors, refugees, and individuals with chronic PTSD of many years' duration. It has been studied across cultures and countries, with consistently positive results.
• Durability of gains: Follow-up studies generally show that treatment gains are maintained at 3, 6, and 12 months post-treatment, and in some studies, symptoms continue to improve after treatment ends.
• Comparable to other first-line treatments: Head-to-head trials comparing PE to Cognitive Processing Therapy (CPT) and other trauma-focused treatments generally find comparable effectiveness, suggesting that multiple evidence-based options are available for PTSD.
• Effectiveness with comorbid conditions: PE has demonstrated effectiveness even when PTSD co-occurs with depression, anxiety disorders, substance use disorders, traumatic brain injury (TBI), and chronic pain — conditions that were historically considered contraindications but are now recognized as manageable within the PE framework.

Notably,, like all treatments, PE does not work for everyone. A meaningful minority of individuals — often estimated at 30% to 50% depending on the population — either drop out of treatment prematurely or do not achieve clinically significant improvement. Understanding why some individuals do not respond, and how to improve retention and outcomes, remains an active area of research.

Prolonged Exposure Therapy is a safe and well-tolerated treatment when delivered by a trained clinician, but it does involve confronting painful material, and it is important to have realistic expectations about the process.

Temporary increase in distress: The most commonly reported side effect is a temporary increase in distress, particularly in the early-to-middle stages of treatment when imaginal exposure begins. This is expected and is part of the therapeutic process — not a sign that treatment is failing. Most individuals experience a peak in distress around sessions 3 to 5, followed by a gradual decline as habituation and emotional processing take hold.

Vivid dreams or temporary symptom exacerbation: Some individuals report an initial increase in nightmares, intrusive thoughts, or emotional reactivity as they begin engaging with trauma material they have long avoided. These effects are typically transient.

Dropout rates: Dropout is a real concern across trauma-focused therapies. Studies of PE report dropout rates typically ranging from 15% to 30%, though rates vary significantly by setting and population. Common reasons include the emotional difficulty of the treatment, logistical barriers (transportation, scheduling 90-minute sessions), and sometimes a mismatch between patient expectations and the treatment approach. Research is ongoing to identify strategies for improving retention, including more flexible delivery formats.

Limitations and considerations:

• Not suitable for everyone in every moment: Individuals in active suicidal crisis, those with severe dissociative disorders, or those who are actively psychotic generally need stabilization before beginning PE. However, the field has moved away from long lists of contraindications — many conditions once thought to preclude PE (such as substance use disorders or mild-to-moderate dissociation) are now understood to be compatible with treatment.
• Therapist competence matters: PE requires specific training, and outcomes are significantly influenced by therapist adherence to the protocol. Poorly delivered exposure therapy — for example, ending exposure exercises prematurely when distress is high — can potentially reinforce avoidance rather than reduce it.
• Cultural considerations: While PE has been studied cross-culturally, the specific format (recounting trauma aloud to another person, homework involving audio recordings) may be more acceptable in some cultural contexts than others. Culturally responsive adaptations have been developed and are an important area of ongoing research.
• Logistical demands: The 90-minute session length and the requirement for regular between-session homework represent a greater time commitment than some other therapeutic approaches, which can be a barrier for some individuals.

Finding a therapist specifically trained in Prolonged Exposure Therapy requires some intentional searching, as not all therapists who treat PTSD have received formal PE training. Here are practical steps for finding a qualified provider:

• The PE Consultant Network: The Center for the Treatment and Study of Anxiety at the University of Pennsylvania (Dr. Foa's institution) maintains resources for locating PE-trained therapists.
• The VA Healthcare System: For veterans, the VA has made PE one of its primary evidence-based treatments for PTSD and has trained thousands of providers. Veterans enrolled in VA care can request PE-trained clinicians through their local VA medical center or community-based outpatient clinic.
• Psychology Today's Therapist Directory: Searching with the filter "Prolonged Exposure" or "trauma" can help identify providers, though it is important to ask directly about formal PE training and supervision.
• The ISTSS Clinician Directory: The International Society for Traumatic Stress Studies maintains a directory of trauma-focused clinicians, many of whom are trained in PE.
• Professional training networks: Organizations such as the Medical University of South Carolina's National Crime Victims Research and Treatment Center and the STRONG STAR Consortium have trained clinicians in PE.

Questions to ask a potential provider:

• "Have you received formal training in the Prolonged Exposure Therapy protocol developed by Dr. Edna Foa?"
• "Have you received supervision or consultation on PE cases?"
• "How many PTSD patients have you treated with PE?"
• "Do you follow the manualized PE protocol, including both imaginal and in vivo exposure?"

It is important to distinguish between a therapist who uses some exposure techniques and one who has been specifically trained in the PE protocol. The manualized structure of PE is part of what makes it effective, and deviations from the protocol (such as skipping imaginal exposure) reduce its efficacy.

The cost of Prolonged Exposure Therapy is comparable to other individual psychotherapy, but the 90-minute session length and typical course of 8 to 15 sessions are important to factor in.

Insurance coverage: Most health insurance plans, including Medicare and Medicaid, cover outpatient psychotherapy for PTSD, which includes PE. However, coverage specifics — including copays, deductibles, session limits, and whether 90-minute sessions are reimbursed at a higher rate — vary widely by plan. It is essential to verify benefits with your insurer before beginning treatment. Some plans may only authorize standard 45- to 60-minute sessions, which can require the therapist to request authorization for extended sessions.

For veterans: PE is available at no cost through the VA healthcare system for eligible veterans. The VA has been a national leader in implementing PE and has trained thousands of clinicians across its system. Veterans who live far from VA facilities may access PE through VA telehealth services.

Telehealth delivery: Research supports the effectiveness of PE delivered via telehealth (video sessions), and this has significantly expanded access, particularly for individuals in rural areas or those with mobility limitations. The COVID-19 pandemic accelerated the adoption of telehealth PE, and evidence suggests outcomes are comparable to in-person delivery.

Intensive outpatient formats: Some programs offer PE in compressed, intensive formats — for example, daily sessions over two to three weeks rather than weekly sessions over several months. These intensive formats have shown comparable effectiveness in research and can be especially useful for individuals who travel for treatment or who have difficulty sustaining engagement over a longer period. However, intensive programs are less widely available and may involve travel costs.

Out-of-pocket costs: For those paying without insurance, individual therapy sessions with a doctoral-level psychologist typically range from $150 to $300 or more per session, depending on geographic location and provider experience. Given the 90-minute session format, costs may be at the higher end. Some clinicians offer sliding-scale fees, and community mental health centers may offer trauma-focused treatment at reduced rates.

Barriers to access: Despite its strong evidence base, PE remains underutilized relative to need. Barriers include a shortage of trained providers (particularly in rural and underserved areas), therapist reluctance to use exposure-based approaches (sometimes due to unfounded concerns about patient safety), the logistical demands of the protocol, and stigma associated with seeking mental health treatment. Advocacy for broader training and implementation continues within the field.

Prolonged Exposure Therapy is one of several evidence-based treatments for PTSD. If PE is not the right fit — whether due to personal preference, provider availability, or clinical considerations — other strongly supported options include:

• Cognitive Processing Therapy (CPT): Another first-line PTSD treatment recommended by the APA and VA/DoD. CPT focuses on identifying and challenging unhelpful beliefs ("stuck points") related to the trauma, such as excessive self-blame or distorted beliefs about safety and trust. It uses primarily cognitive strategies rather than prolonged imaginal exposure, which some individuals prefer. CPT typically involves 12 sessions of 50 minutes each.
• Eye Movement Desensitization and Reprocessing (EMDR): EMDR involves recalling trauma-related imagery while simultaneously engaging in bilateral stimulation (typically guided eye movements). It is recommended as a first-line treatment by the WHO and the ISTSS, and as a conditionally recommended treatment by the APA. The theoretical mechanism is debated, but its effectiveness for PTSD is well-supported by research.
• Written Exposure Therapy (WET): A briefer exposure-based treatment (typically 5 sessions) in which individuals write about their traumatic experience in session. WET has demonstrated non-inferiority to CPT in at least one randomized controlled trial and offers a lower time burden.
• Narrative Exposure Therapy (NET): Developed for survivors of multiple or prolonged traumas (such as refugees or survivors of political violence), NET involves constructing a chronological narrative of the individual's life, integrating traumatic experiences into a coherent life story.
• Pharmacotherapy: The SSRIs sertraline (Zoloft) and paroxetine (Paxil) are FDA-approved for PTSD and are recommended as first-line pharmacological treatments. Medication can be used alone or in combination with psychotherapy. Venlafaxine (Effexor XR), an SNRI, also has strong evidence for PTSD treatment. Current clinical guidelines generally recommend trauma-focused psychotherapy over medication when both are accessible, but medication is an important option, particularly when psychotherapy is not available or when symptoms are too severe to engage in therapy without pharmacological support.
• Stellate Ganglion Block (SGB) and other emerging interventions: Some newer approaches, including SGB (an injection near nerve tissue in the neck), MDMA-assisted therapy (currently under FDA review), and psilocybin-assisted therapy, are generating research interest. These should be considered experimental, and individuals should carefully evaluate the evidence before pursuing them.

The best treatment is one that is evidence-based, delivered by a trained clinician, and acceptable to the individual. A qualified mental health professional can help determine which approach is most appropriate based on the person's specific history, symptoms, preferences, and circumstances.

If you are experiencing symptoms that may be consistent with PTSD — such as intrusive memories or flashbacks, avoidance of trauma-related reminders, persistent negative changes in your thoughts or mood since a traumatic event, or feeling constantly on edge or easily startled — a professional evaluation is an important first step. These symptoms do not have to reach a specific severity threshold to warrant seeking help; even sub-threshold posttraumatic symptoms can significantly affect quality of life, relationships, and functioning.

A licensed mental health professional — such as a clinical psychologist, psychiatrist, licensed clinical social worker, or licensed professional counselor — can conduct a thorough assessment and discuss whether Prolonged Exposure Therapy or another evidence-based treatment is appropriate for your situation.

If you are in crisis: If you are experiencing thoughts of suicide or self-harm, contact the 988 Suicide and Crisis Lifeline by calling or texting 988. Veterans can press 1 after dialing 988 to reach the Veterans Crisis Line. You can also go to your nearest emergency department or call 911.

Seeking treatment for PTSD is not a sign of weakness — it is a decision to engage with one of the most well-studied and effective areas of psychological treatment. Recovery is achievable, and effective help is available.