PROLONGED EXPOSURE
THERAPY FOR PTSD
Based on Prolonged Exposure Therapy for PTSD:
Emotional Processing of Traumatic Experiences
(Foa, Hembree, & Rothbaum, 2007)
University of Mississippi Medical Center/G.V. “Sonny”
Montgomery VAMC Psychology Internship Training Program
Overview


Treatment Rationale
Treatment Components
Psychoeducation
Breathing Retraining



In vivo exposure Treatment Components



Common Problems



In vivo exposure (cont.)
Imaginal Exposure
Avoidance
Under/Over-engagement
Other Considerations


Measuring progress & termination
Therapist reactions
PTSD Diagnosis
Necessary Trauma for PTSD – DSM-5
Criterion A:
1) Exposure to a traumatic event;
2) Witnessing of an event;
3) Indirect learning that the event occurred;
4) Indirect exposure of details*






Sexual assault
Motor vehicle accident
Physical assault
Witness death or serious injury
Combat
Torture
Children may experience different response

Diagnostic Symptoms of PTSD – DSM-5
Criterion B: Intrusion

Trauma is persistently reexperienced (memories,
dreams, flashbacks, psychological or physiological
reactivity to stimuli)
Criterion C: Avoidance

Persistent avoidance of trauma stimuli
Diagnostic Symptoms of PTSD – DSM-5
Criterion D: Negative Thoughts and Mood

e.g., Continuous negative emotionality; distorted blame
Criterion E: Hyperarousal

Persistent symptoms of increased arousal
(concentration, sleep, anger, startle, hypervigilance,
reckless behavior)
Diagnostic Symptoms of PTSD (cont.)
Criterion F:
 Symptoms must persist for more than 1 month
Criterion G:
 Symptoms cause significant distress or impairment
Criterion H:
 Not induced by substances and/or medical conditions
Treatment Rationale and Myths
Rationale for the Treatment Program

The program focuses on addressing trauma related fears and
symptoms.

Three main factors prolong post-trauma problems:
1.
2.
3.

Avoidance of trauma related situations (e.g., sleeping without a light,
going out alone)
Avoidance of trauma related thoughts and images (e.g., avoiding talking
about memory)
The presence of automatic cognitions: “The world is extremely
dangerous;” “The victim is extremely incompetent.”
These avoidance strategies prevent the client from processing
the trauma, from modifying the automatic cognitions (e.g.,
trauma reminders are not dangerous).
Rationale for the Treatment Program
The two primary procedures are:
1.
Imaginal exposure


2.
Repeated reliving of the traumatic event.
Confronting painful experiences enhances the processing of
these experiences.
In vivo exposure




Repeatedly approaching trauma related situations that are
avoided since the trauma.
Very effective in reducing excessive fear and unnecessary
avoidance.
Enables the client to realize that these situations are not
dangerous.
Bonus: behavioral activation
Both exposures modify automatic cognitions associated with the
trauma.
“What the heck was I thinking, I was 8 years old! It was not my fault.”
Myths regarding exposure therapy




Patients prefer other treatments
Patients will likely experience increased PTSD
symptoms
Efficacy evidence for exposure therapy does not
generalize to the real world because RCT samples
do not represent patients seen in real clinical
practice
Exposure therapy leads to symptom exacerbation
and high dropout rates
Myths regarding exposure therapy




Patients prefer other treatments
Patients will likely experience increased PTSD
symptoms
Efficacy evidence for exposure therapy does not
generalize to the real world because RCT samples
do not represent patients seen in real clinical
practice
Exposure therapy leads to symptom exacerbation
and high dropout rates
Becker et al. (2007). An analog study of patient preferences for
exposure versus alternative treatments for PTSD. Behaviour Research
and Therapy. N=160
Top Choice (%)
Top 2 (%)
Exposure
51%
71%
Cognitive Behavioral Therapy
22%
58%
Psychodynamic
16%
38%
Sertraline
9%
24%
Thought Field Therapy
3%
7%
My Buddy Therapy
1%
2%
EMDR
0%
0%
Becker et al. (2009). Law enforcement preferences for PTSD treatment
and crisis management alternatives. Behaviour Research and Therapy.
N=379
Top Choice (%)
Top 2 (%)
Exposure
26%
59%
Cognitive Behavioral Therapy
37%
57%
Psychodynamic
13%
29%
Sertraline
9%
22%
Brief eclectic psychotherapy
9%
21%
EMDR
2%
6%
Myths regarding exposure therapy




Patients prefer other treatments
Patients will likely experience increased PTSD
symptoms
Efficacy evidence for exposure therapy does not
generalize to the real world because RCT samples
do not represent patients seen in real clinical
practice
Exposure therapy leads to symptom exacerbation
and high dropout rates
Myths regarding exposure therapy
Foa et al. (2002). Does Imaginal Exposure Exacerbate PTSD Symptoms? Journal of
Consulting and Clinical Psychology.

10.5% reported an increase in PTSD symptoms, 21.1% in anxiety,
and 9.2% in depression following first imaginal exposure session

Patients who had an increase in symptoms were no more likely to
drop out of treatment than patients who did not have an increase

Treatment outcome was not related to symptom exacerbation

For those who experienced symptom exacerbation, the increase
lasted 1-2 weeks
Myths regarding exposure therapy




Patients prefer other treatments
Patients will likely experience increased PTSD
symptoms
Efficacy evidence for exposure therapy does not
generalize to the real world because RCT samples
do not represent patients seen in real clinical
practice
Exposure therapy leads to symptom exacerbation
and high dropout rates
Myths regarding exposure therapy

Coffey et al. 2013


Intent to treat sample



65% PTSD sxs reduction
70% depression sxs reduction
Treatment completers sample (≥ 8
sessions)



PTSD-alcohol dependent
sample (N=120)
75% PTSD sxs reduction
78% depression sxs reduction
6-mo alcohol outcomes

Over 90% days abstinent from
alcohol and drugs
Participant Demographics (N=120)
Age
33.7 (10.2)
Sex (female)
46.7%
Race
White
Black/African American
80%
18.3%
Employment
Full-time
Part-time
Unemployed
55%
9.2%
35.8%
Any co-occurring drug dependence
98.3%
Current comorbid psychiatric diagnosis
Major depression
Other anxiety disorder
80.8%
69.7%
Alcohol Dependence Scale total score (substantial)
25.67
Clinician Administered PTSD Scale total severity
79.26
Total Criterion A events
9.6 (2-22)
Myths regarding exposure therapy




Patients prefer other treatments
Patients will likely experience increased PTSD
symptoms
Efficacy evidence for exposure therapy does not
generalize to the real world
Exposure therapy leads to symptom exacerbation
and high dropout rates
Myths regarding exposure therapy
Hembree et al. (2003). Do Patients Drop Out Prematurely From Exposure
Therapy for PTSD? Journal of Traumatic Stress.

Identified 25 controlled studies of cognitive behavioral treatment for PTSD
that included data on dropout
 Exposure alone= 20.5%
 Stress inoculation training (SIT) or cognitive therapy (CT) alone = 22.1%
 Exposure + CT or SIT = 26.9%
 EMDR= 18.9%
 Controls (overwhelmingly a waitlist)= 11.4%

Compared to other treatments



Meta-analysis of 19 medication trials for PTSD = 32% (Van Ettten & Taylor, 1998)
Depressed survivors of CSA receiving specialized therapy in CMHC =
40% (Fisher, Winne, & Ley, 1993)
Depressed patients receiving CT in private practice = 50% (Persons et al., 1998)
Session Descriptions
Session 1

Overview of Treatment
 Main tools = imaginal & in vivo exposure
 10-12 weekly sessions, 60-90 mins each
 The
manual uses 90 min. sessions but they can be
completed in 60 min.




General rationale for PE
Trauma interview
Introduction of breathing retraining
Assign homework:
 Practice
breathing retraining (10 mins, 3xs/day)
 Listen to session 1 audiotape
 Review “Rationale for Treatment” handout
Session 2 – Part 1



Homework review
Discuss Common Reactions to Trauma
Assign homework:
 Read Common Reaction to Trauma Handout
several times
 Continue breathing retraining practice
Session 2 – Part 2





Homework review
Discuss rationale for in vivo exposure
Introduce SUDS and anchor points
Construct in vivo hierarchy
Assign homework:
 Practice
situations selected for in vivo exposure
 Review in vivo list of avoided situations & add to it
 Continue breathing retraining practice
Session 3
Homework review
 Discuss rationale for imaginal exposure
 First imaginal exposure to the trauma memory
 ~30-45 minutes
 Assign homework:

 Listen
to imaginal exposure audiotape 1x/day
 Practice in vivo exposures daily
 Continue
breathing retraining practice
Sessions 4-9


Homework review
Imaginal exposure (30-45 mins)
 *Hot



spots
Process imaginal exposure
Plan in vivo exposure
Assign homework:
 Listen
to imaginal exposure audiotape 1x/day
 Practice in vivo exposures daily
 Continue breathing retraining practice
Final Session (Session 10 or 12)
Homework review
 Brief imaginal exposure (20-30 mins)
 Process imaginal exposure
 Change over course of therapy
 Review skills & treatment progress
 Discuss plans for continuing to use exposure
skills
 *Booster session

Clip from Session 1
https://www.youtube.com/watch?v=2CTWhYRwy2
Q
Through minute 13
Facilitating the Therapeutic Alliance
The therapeutic alliance is key in PE—must
communicate our care and commitment

Praise
client for coming to treatment and acknowledge courage
Communicate understanding of the client’s symptoms
Incorporate examples in treatment descriptions (e.g., common
reactions)
Validate client’s experience and be non-judgmental
Work collaboratively
Incorporate the client’s judgment regarding pace and targets
of therapy
It may be the first time relating the trauma narrative…
your reaction is important
Maintaining focus on PTSD & PE




The overall aim is to provide emotional support through the
crisis, yet keep PTSD as the major focus
Remind client that adhering to treatment, and thereby
decreasing PTSD and associated symptoms, is the best help
you can give
Applaud healthy coping and adherence
If appropriate, attribute response to crises as related to
PTSD – predict that these situations will improve as PTSD
does


The “crisis” may not be viewed as a “crisis” or would be better
tolerated if PTSD symptoms are reduced
Bottom Line: Keep these conversations brief… they could be
forms of avoidance. Do not let a crisis prevent in-session
exposures.
Treatment Components
Format of Treatment Program
Behavioral program
 9-12 sessions
 60 or 90 minute sessions
 Weekly homework assignments
 Importance of weekly attendance

Primary Treatment Components
1.
2.
3.
4.
5.
6.
Psychoeducation
 What is PTSD
 Rationale
Breathing Retraining
Common Reactions
SUDS Development
In-Vivo Exposure
 Hierarchy development
 Homework assignment
Imaginal Exposure
Psychoeducation & Breathing
Common Reactions to Trauma

Fear and anxiety
 re-experiencing

the trauma flashbacks, nightmares
Hypervigilance
 over-alertness,
startle
 Irritability, anger, trouble concentrating

Avoidance of trauma reminders
 Emotional
numbing
 Loss of interests, depression
Feeling of “going crazy”
 Shame and guilt
 Poor self image

Common Reactions to trauma
Reviewing the Common Reactions Handout can
normalize PTSD symptoms

 “These reactions
are so common following traumas we
had to make up a handout”
Interactive Conversation

Focus
on not reading
Gains valuable info for hierarchy
Be sure to follow-up to gather further
information if the person says “yes, I’ve
experienced this thing”
Breathing Retraining





The way we breathe affects the way we feel
Exhalation, not inhalation, is associated with
relaxation
Slow down your breathing to avoid hyperventilation
Regular inhale
Concentrate on slow exhalation while saying CALM (or
RELAX) to yourself



Exhale on two-count
The therapist models breathing retraining for client
Client then attempts breathing retraining
In Vivo Exposure
Rationale for In Vivo Exposure


Trauma related fears are sometimes unrealistic or
excessive (e.g., going to a shopping mall, fear of all
men).
Repeated in vivo exposure:
 Is
counter to negative reinforcement and avoidance
 Results in extinction, so that the target situation
becomes increasingly less distressing
 Fosters the realization that the avoided situation is
quite safe
 Disconfirms the belief that anxiety in the feared
situation continues “forever”
 Enhanced sense of self control and personal
competence
How to Implement In Vivo Exposure


SUDs Introduction
Work on SUDS rating scale
 100=Trauma
 Other
items on rating scales should not be traumarelated

Check the rating scale:
 What
is SUDS right now?
 What would SUDS be in different non-trauma related
situations?
 Fender
bender
 Call from school—kid is sick
 Get a tax audit
 Identity stolen
How to Implement In Vivo Exposure






Present the treatment rationale
Give daily life examples of in vivo exposure and extinction
(e.g., a child fearing a big but safe dog like a Golden Retriever)
Develop a list of situations the client has been avoiding since
the trauma
Ask client to rate the intensity of anxiety (SUDS level) s/he
experiences when imaging confronting each situation
Arrange the situations in a hierarchy according to their SUDS
Notes:



If the client cannot identify circumstances, suggest typically avoided
situations.
Also, get creative and think of unusual responses as well
 E.g., being afraid to get hands dirty or touch meat
Inquire about the objective safety of the situations.
Example of an In Vivo Hierarchy








50 = Staying at home alone during the middle of the day
60 = Driving to a friend’s home in a safe neighborhood in the
day time
70 = Driving to a friend’s home in a safe neighborhood after
dark
75 = Walking down a street in her parent’s neighborhood
80 = Staying alone in her room on the campus with door locked
85 = Walking with a friend on campus
90 = Walking on campus during daytime
100 = Walking on campus at night
Items MUST be objectively & generally SAFE
Hierarchy Construction
Session 2B Video
https://www.youtube.com/watch?v=rZgsYs1xO5I
-from minute 24-31 is explanation about avoidance
-from min 34.30-53:30min
How to Implement In Vivo Exposure (cont.)

Homework Assignment
 Begin
with assigning exposure to situations that
evoke moderate levels of anxiety (e.g., SUDs = 4060)
 Instruct the client to remain in each situation for
30 to 45 minutes, or until his/her anxiety
decreases considerably (i.e., 50%)
 Easier to simply assign 30-45 min

Great Resources:
 Phone
Apps: http://www.myvaapps.com/
Considerations for In Vivo Exposures
1.
Gather as much information as possible from earlier sessions
so you already have some ideas for the in-vivo hierarchy.

2.
3.
They might not even know what they’re avoiding, so we need to
be on the lookout!
Ask them to generate list of things they’ve avoided for
homework.
Find out their access to internet and other resources

Lots of good videos/pictures online they can do, especially for
things that can’t be achieved easily (e.g., watching a fight or war
movie)



Can do on phone or computer
Sound Bible website great resource
But make sure you watch it first and give them the SPECIFIC
information… don’t send them to watch on their own!
Considerations for In Vivo Exposures
1.
Remind—don’t engage in avoidance behaviors (no
matter how subtle) during imaginals.

2.
3.
4.
Ask about safety behaviors!
The SUDS ratings are a guess, so hierarchy items rated
as a 50 might be an actual 80, or an actual 20.
We want to get an easy win up front, so don’t let that
first in-vivo be something that would be too
overwhelming.
Need to be careful of having hierarchy items that are
too broad and therefore cover numerous avoided
items.
Role of Safety Behaviors
Validating the initial development of safety behaviors
Safety behaviors may prevent SUDS from reducing
and inhibit new learning from occurring
Try getting them to keep track of safety behaviors

Next
time, do same exercise with less safety behaviors
Safety behaviors are often hidden
Cell phone
You (therapist
Water
bottle
= safe person)
Imaginal Exposure
Rationale for Imaginal Exposure
Repeated recounting of the trauma

Reduces distress associated with trauma





fewer intrusive memories and nightmares
Results in extinction, so trauma can be remembered without
intense, disruptive anxiety
Reduced distress/avoidance allows pt. to process trauma


Lower distress
i.e., organize, make sense of it, “file it in the right drawer”
Helps distinguishing between “thinking” about the trauma and
actually “re-encountering” it
Fosters realization that engaging in the trauma memory does
not result in loss of control or “going crazy”
Enhances sense of self control and personal competence
Implementing Imaginal Exposure
If multiple traumas


Collaboratively choose the most intrusive and distressing
memory currently
“Which would you remove/get rid of, if possible?”
Implementing Imaginal Exposure
Instructions to client

Recall the memory as vividly as possible
 Include details of the event (e.g., thoughts, feelings)
 Not
a newspaper account
 Describe




what you experienced regarding the senses
Imagine the trauma is happening now
Stay in touch with the feelings the memory elicits
Describe the trauma in present tense
Close eyes
Implementing Imaginal Exposure
Instructions to client (cont.)



Will gather SUDS ratings about every 5 minutes
Clinician may ask questions to elicit more detail
We also asked about the vividness of the image
approximately every other time we ask about SUDS
ratings (0-100)
Begin imaginal ASAP following instructions!
Homework

Listen to tapes of imaginal exposure once a day and
record SUDS
Following Imaginal Exposure
Reinforce client for having the courage/willingness
to do the imaginal!
Brie processing




What was the client’s reaction to the imaginal exposure?
If SUDS decreased during, point that out to client. If not,
congratulate them for staying with the difficult memory
Clients often discuss increased awareness of what
happened during the trauma
Discuss differences that occur over time in their
experience of recounting the trauma memory
Timing Your Session
60-minute session
Set agenda as the person walks in the door
 5 minutes for brief homework checking (no problem-solving)
 Break “how are you doing?” habit

8:00—Set agenda; review homework and measures BRIEFLY;
remind instruction and rationale for imaginal as needed
 8:10—Start imaginal (35 minutes, ending with a few minutes of
diaphragmatic breathing)
 8:45—End imaginal
 8:45—Problem-solve previous homework; assign new
homework (5 minutes)

Imaginal Exposure to Hotspots
Hotspots: Portions of the memory that remain
distressing even though most everything else in
the narrative is not (i.e., SUDS < 20)
Typically not addressed until at least halfway
through treatment
Identify the most distressing moments during the
recounting by



Self-report of client
SUDS levels
Facial expressions and body language during imaginal
Imaginal Exposure to Hotspots
Once/if identified:




Specify the beginning and end of the hotspot (about 5
minutes)
Ask client to repeat the recounting without pause
between repetitions
Ask client to recount as many details as possible
Help the client focus on feelings and thoughts by
probing
DON’T MAKE A ROOKIE MISTAKE!
THE MOST COMMON MISTAKE
NEW PE THERAPISTS MAKE IS
FOCUSING ON HOT SPOTS TOO
SOON!
DON’T MAKE A ROOKIE MISTAKE!
THE MOST COMMON MISTAKE
NEW PE THERAPISTS MAKE IS
FOCUSING ON HOT SPOTS TOO
SOON!
Therapist-Client Alliance During Imaginal
Express support and empathy with client’s distress
Periodically reassure client that he/she is safe (e.g., “I know
this is tough; you are doing a good job staying with it”)
Monitor client’s emotional response

Probe for thoughts and feelings encouraging emotional engagement

If client becomes overwhelmed with distress (e.g., threatening to
stop imaginal exposure), conduct imaginal with client’s eyes open
(perhaps looking at the floor)
Allow sufficient time to discuss and process experience and
calm client as needed

Use breathing retraining after
Session 3 Video - Imaginal
https://www.youtube.com/watch?v=YZbJZMm
oLwU
Video Clip - Foa
https://www.youtube.com/watch?v=9aTDIiTr99
Y
Factors that Impair Engagement
Factors that Impair Effective Emotional
Engagement in Imaginal Exposure

Avoidance

Under-engagement

Over-engagement
Avoidance
Addressing Avoidance


Validate client’s fear and urges to avoid
Review the rationale for treatment
Avoidance reduces anxiety in the short term but prevents
new learning in the long term
 The incident was dangerous, but the memories are not


Use analogies/metaphors to support the rationale
e.g., “Holding your nose”never get used to bad smell
 e.g., emotional hot stove

Addressing Avoidance

“Roll with resistance”

Review reasons why client sought PTSD treatment

How do symptoms interfere with life satisfaction?

Review the progress that client has already made

Provide a lot of support and encouragement


If needed, schedule inter-session phone contact to provide
support and discuss homework progress
Problem-solve solutions to concrete obstacles
together
Addressing Avoidance
What about when resistance comes up during imaginal exposure?

Encourage to continue on— “It is in your best interest to
continue.”

Be observant of when client might be wanting to stop (e.g., pay
attention to body language), and be prepared for the resistance.

Right before starting another retelling:


Over-reinforce: “You are doing a GREAT job; you are not letting the
fear/avoidance win; start over and do just as you were doing!”
If they REFUSE, last resort:

Listen to last imaginal tape

Do in-session in vivo exposure
*Do not reinforce avoidance*!!
Facilitating Homework Compliance

Reiterate the rationale


Client must understand why she is being asked to do homework
Find out what is getting in the way:

Organization (e.g., lost sheet, forgot)

Practical issues (e.g., no time, no privacy)

Avoidance

Intervention guided by nature of compliance problem(s)

If extinction not evident in homework completed over
multiple sessions, ask about safety behaviors
Under-engagement
Identifying Under-engagement



Difficulty accessing memory (low SUDS and/or vividness)

Emotionally disconnected/detached from memory

Difficulty visualizing event

Rushes through retelling
Discrepancy in reporting of SUDS & vividness

May describe trauma in detail, but report low SUDS and vividness
during retelling

May report high SUDS during imaginal retelling, but appearance
is discrepant with the high rating
Narrative may sound like a “police report”
Addressing Under-engagement

Reiterate the rationale for imaginal exposure

It is essential that client understand why she or he is being asked to
confront this painful memory

Explore feared consequences of engagement with the
memory

Validate client’s feelings while, at the same time, helping
her realize that being in distress is not dangerous

Avoid conversations during retelling

Reduces emotional engagement with memory
Procedures to Increase Engagement in
Imaginal Exposure

Encourage client to keep eyes closed and use present tense (if
not already doing so)

Probe for details, sensory information, feelings, and thoughts
with brief questions.

Ask in present tense (e.g., “How does it smell?,” “What are you
feeling in your body?”)

Keep probe questions very brief, infrequent, and directed only
at what the client is describing at that moment

If needed, role-play the proper procedure for client to
demonstrate the way trauma recounting should be done
Over-Engagement
Identifying Over-Engagement


If client is too distressed/dissociating/”checked-out”,
he is not processing

This is a form of avoidance!

Not terribly common.
Reports very high SUDS/vividness ratings that remain
high

Within and between sessions
Identifying Over-Engagement (cont.)

Appears visibly very distressed


This alone should not be considered evidence of overengagement (i.e., the memories are distressing to all
clients)
Difficulty maintaining sense of safety and
“groundedness”

May have flashbacks: Retelling becomes re-experiencing

Physical movements mirror actual actions

This is also quite common and may only indicate full engagement in
the task; explore with client before intervening
Addressing Over-Engagement

Reiterate the rationale

Client must understand why she is being asked to confront this painful
memory

Goal is to help the client successfully disclose some part
of the memory while managing distress

Discuss, in advance, ways to facilitate grounding and
support


Do not attempt a comforting touch unless you’ve discussed in advance
Reduce the vividness of the memory

Modify procedures
Procedures for Reducing Engagement
in Imaginal Exposure

Have client use past tense and/or keep eyes open

Increase use of empathic, “grounding” statements


“You’re doing a great job staying with it”

“I know that this is distressing, but you are safe here in my office”

“Remember, memories can’t hurt you”
If client seems “stuck,” ask “And now what’s happening?” to
move the memory forward


Can foster realization that, although horrible, this moment ended
If patient appears to dissociate, ask her/him to name and
describe 5 objects in the room
Procedures for Reducing Engagement
in Imaginal Exposure

Strongly praise client’s efforts

Help client appreciate that she is able to emotionally engage
in the memory and describe trauma while managing distress

Remind client that each exposure gets her closer to the life
she wants

If needed, do a few minutes of slow, paced breathing

If necessary, can write trauma narrative rather than vocalize it

Try reading out loud repeatedly

Alternately, can write repeatedly
Session Descriptions Review
Session 1





Overview of Treatment
 Main tools = imaginal & in vivo exposure
 10-12 weekly sessions, 60-90 mins each
General rationale for PE
Trauma interview
Introduction of breathing retraining
Assign homework:
 Practice
breathing retraining (10 mins, 3xs/day)
 Review “Rationale for Treatment” handout
Session 2 – Part 1



Homework review
Discuss Common Reactions to Trauma
Assign homework:
 Read Common Reaction to Trauma Handout
several times
 Continue breathing retraining practice
Session 2 – Part 2





Homework review
Discuss rationale for in vivo exposure
Introduce SUDS and anchor points
Construct in vivo hierarchy
Assign homework:
 Practice
situations selected for in vivo exposure
 Review in vivo list of avoided situations & add to it
 Continue breathing retraining practice
Session 3
Homework review
 Discuss rationale for imaginal exposure
 First imaginal exposure to the trauma memory
 ~30-45 minutes
 Assign homework:

 Listen
to imaginal exposure audiotape 1x/day
 Practice in vivo exposures daily
 Continue
breathing retraining practice
Sessions 4-9


Homework review
Imaginal exposure (30-45 mins)
 *Hot



spots
Process imaginal exposure
Plan in vivo exposure
Assign homework:
 Listen
to imaginal exposure audiotape 1x/day
 Practice in vivo exposures daily
 Continue breathing retraining practice
Final Session (Session 10 or 12)
Homework review
 Brief imaginal exposure (20-30 mins)
 Process imaginal exposure
 Change over course of therapy
 Review skills & treatment progress
 Discuss plans for continuing to use exposure
skills
 *Booster session

Questions??