If you have lived through something frightening, dangerous, or overwhelming, the aftermath can be hard to shake. Intrusive memories, a jumpy nervous system, and a pull to avoid anything that reminds you of what happened can all be signs of post-traumatic stress disorder (PTSD). You are not alone. More than half of adults are exposed to a potentially traumatic event in their lifetime. Most recover on their own, but a meaningful minority develop chronic PTSD (McLean & Foa, 2011).
PTSD is treatable. One of the best-studied treatments is Prolonged Exposure (PE) therapy. Newer research shows it can also help with complex childhood trauma, including abuse by a parent or caregiver (Oprel et al., 2026). Several Eden Valley clinicians are trained in PE. This post explains what it is and what treatment looks like, session by session.
Why avoidance keeps fear alive
Fear is a survival reflex. Trauma happens when that response gets stuck and switches on in situations that are no longer dangerous. A car backfiring, a certain smell, or a street corner can become linked in memory to the original threat. Harmless reminders then bring back the full fear response.
Waiting for fear to fade does not undo it. The nervous system needs new, corrective experience: repeated, safe encounters with the memory and its reminders. Those encounters teach the brain that the situation is not dangerous and that the feeling can be tolerated (McLean & Foa, 2011). That is what PE is built around.
What is Prolonged Exposure therapy?
PE is a structured, evidence-based form of cognitive behavioral therapy. Dr. Edna Foa and colleagues developed it for PTSD. It rests on emotional processing theory, which says two things keep PTSD going:
- avoiding trauma-related thoughts, feelings, and situations
- distorted beliefs that form after trauma, such as seeing the world as entirely dangerous or yourself as fundamentally incompetent
Avoidance feels protective, but it blocks the new information the brain needs. PE breaks that cycle with two core techniques, plus structured processing of what comes up:
- Imaginal exposure: repeated, detailed retelling of the trauma memory
- In vivo exposure: deliberately approaching safe situations you have been avoiding
What treatment looks like
PE follows a consistent structure. It usually runs about 8 to 15 weekly sessions of 60 to 90 minutes, depending on progress. Here is the general shape.
Session 1: Orientation and groundwork
Your therapist explains the treatment and why avoidance keeps PTSD symptoms alive. They gather a detailed trauma history. The session ends with breathing retraining, a slow-breathing skill you practice twice a day to manage distress between sessions.
Session 2: Understanding reactions and building a hierarchy
You learn about common reactions to trauma, including intrusive memories, hyperarousal, avoidance, guilt, and shame. You learn that what you feel is a recognized, treatable response. You learn the Subjective Units of Distress Scale (SUDS), a 0 to 100 rating you use to track distress. Together you rank 10 to 15 avoided situations by distress. In vivo homework starts with a situation in the low-to-moderate range. You stay in it until anxiety drops or about 45 to 60 minutes have passed.
Session 3: First imaginal exposure
Your therapist often explains the rationale with an analogy: a wound has to be cleaned out before it can heal. Then you are guided through your first full imaginal revisiting of the memory. With eyes closed, you describe it aloud in the present tense, including thoughts, feelings, and body sensations, for about 40 minutes. You give SUDS ratings every few minutes. Afterward you talk through what came up. You receive an audio recording of the exposure to listen to daily.
Sessions 4 through about 14: The middle of treatment
Each session follows a similar rhythm. You review homework, do about 40 minutes of imaginal exposure, process it together, and plan the next week's in vivo assignments. Around session 5 or 6, the work often narrows to the most distressing "hot spots" of the memory. Over time, sessions focus on re-examining trauma-related beliefs and building a more realistic view of the event and what it means in your life.
Final session: Looking back and planning ahead
You do a shorter imaginal exposure of about 20 minutes that covers the whole memory. Then you compare how it feels now with how it felt in Session 3. You review your progress on the hierarchy, talk about relapse prevention (including that symptoms may rise and fall later and how to respond), and reflect on what helped most and least.
Throughout, clinicians help you stay in a window of emotional engagement: connected enough to the memory for real processing, but not so overwhelmed that you lose your footing in the present. Structured tools, including the Clinician-Administered PTSD Scale (CAPS-5), track symptoms and progress.
Does it work?
PE is among the most researched treatments in mental health care. Randomized controlled trials with combat veterans, sexual assault survivors, refugees, and civilians have found PE outperforming waitlist, supportive counseling, and relaxation comparisons (McLean & Foa, 2011). Clinical practice guidelines from the American Psychological Association (2017) and the U.S. Departments of Veterans Affairs and Defense (2023) recommend PE as a first-line treatment for PTSD.
A 2026 study of veterans adds a clue about why. Mindfulness was never taught in treatment, yet participants' mindful awareness grew during PE. That growth predicted lower PTSD symptoms and less problematic anger at six-month follow-up (Khalifian et al., 2026).
What about complex childhood trauma?
A common question is whether PE fits trauma from childhood, especially trauma involving a parent or caregiver. For years, many clinicians assumed these clients needed a slower, phased plan: build emotion-regulation and relationship skills first, then start trauma-focused work like PE.
A 2026 randomized controlled trial in the Journal of Anxiety Disorders tested that assumption. Adults with PTSD related to childhood sexual and/or physical abuse were split into two groups over the same sixteen weeks. One group had eight sessions of an emotion-regulation skills phase (STAIR) followed by eight sessions of PE. The other group had sixteen sessions of PE alone (Oprel et al., 2026).
Both groups improved by similar, large amounts in emotion regulation and in PTSD symptoms. Starting right away with PE built emotional coping skills as well as a skills phase did. Early gains in emotion regulation also did not predict better PTSD outcomes later, in either group. Clients did not need to master emotion regulation first. PE appeared to build that capacity along the way.
This does not make a phased approach the wrong choice. For some people, starting with skills feels more comfortable, and that is a collaborative decision between client and therapist. But for clients who are ready and willing, this research supports going straight to PE, without first earning access to trauma processing.
Is PE right for you?
PE is not a quick fix, and it is not always easy. Facing painful memories on purpose is hard work, and some added distress in the early sessions is normal. Many people who finish treatment report fewer intrusive memories, less avoidance, better sleep, a calmer nervous system, and a renewed sense of control. Results vary, and no one can promise an outcome. Pacing and goals are set together, not imposed.
If you are wondering whether PE could help you or someone you love, an initial conversation is a good first step. Our clinicians will learn your history, answer your questions, and help you decide whether PE or another approach fits. Reach out through our contact page.
Eden Valley clinicians offering Prolonged Exposure
- Dr. Savannah Lord
- Rachel Charash
- Julia Patkin
This post is for general educational purposes and is not a substitute for individualized clinical assessment. If you are in crisis or having thoughts of harming yourself, call or text 988 (Suicide & Crisis Lifeline) or go to your nearest emergency room.
Sources
- McLean, C. P., & Foa, E. B. (2011). Prolonged exposure therapy for post-traumatic stress disorder: A review of evidence and dissemination. Expert Review of Neurotherapeutics, 11(8), 1151-1163.
- American Psychological Association. (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults.
- U.S. Department of Veterans Affairs & Department of Defense. (2023). VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder.
- Foa, E. B., & Rothbaum, B. O. (1998). Treating the Trauma of Rape. Guilford Press.
- Hembree, E. A., Rauch, S. A. M., & Foa, E. B. (2003). Beyond the manual: The insider's guide to Prolonged Exposure Therapy for PTSD. Cognitive and Behavioral Practice, 10(1), 22-30.
- Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. A. M. (2019). Prolonged Exposure Treatment Session Checklists, in Prolonged Exposure Therapy for PTSD (2nd ed.). Oxford University Press.
- Weathers, F. W., et al. (2018). CAPS-5, Past Week. National Center for PTSD.
- Khalifian, C. E., et al. (2026). Improvement in mindful awareness during prolonged exposure treatment leads to reduction in PTSD symptoms and anger expression. Psychological Trauma: Theory, Research, Practice, and Policy.
- Oprel, D. A. C., et al. (2026). Phase-based treatment versus immediate prolonged exposure for childhood abuse-related PTSD: The role of emotion regulation improvement in predicting PTSD symptom reduction. Journal of Anxiety Disorders, 121, 103174.
