Posttraumatic Stress Disorder (PTSD) can be a debilitating and chronic condition affecting as many as 8% of the population in the U.S. Treatment guidelines state that controlled exposure to traumatic memories is a common element of effective treatments for PTSD. Exposure refers to the deliberate and systematic confrontation of feared objects or memories in a safe context. A modern variant of exposure therapy derives from a fear-based model of PTSD that comes out of Pavlovian conditioning theory, which also informs behavioural therapy for anxiety disorders. Prolonged exposure therapy (PE ) for PTSD provides the most sustained and intensive exposure to trauma memories or cues. However, more than 50% of patients with PTSD in clinical trials drop out of exposure-based treatments, and many patients retain residual symptoms. The results are even worse in military veterans. Some writers view exposure as potentially damaging, especially for multiply traumatized patients. In this paper, Rubenstein and colleagues review the history and research related to exposure-based therapies for PTSD to address whether in-session prolonged exposure is necessary to treat PTSD. The concept of exposure in a safe context as a treatment dates back to Janet and Freud in the 19th century and was systematized by Kardiner, a psychoanalyst who treated military personnel during World War II. Kardiner’s treatment tended to leave the intensity and duration of exposure up to the patient. PTSD was first conceptualized as a variant of anxiety disorder by classical conditioning behaviour therapists, like Wolpe, in the 1960s, during which the notion of prolonged exposure, response prevention, and habituation was advanced. However, prolonged exposure alone as a theory of therapy for PTSD has met with limited empirical support. New theories of PE suggest that cognitive changes, rather than duration of exposure, are necessary to reduce symptoms. Consistent with this idea and early 20th -century psychoanalytic models, “newer” treatments that do not require within-session prolonged exposure have been tested with good results. For example, present-centred therapy (PCT) focuses on establishing a supportive therapeutic relationship, providing psychoeducation, and engaging in problem-solving. Interpersonal psychotherapy (IPT ) addresses the interpersonal consequences of trauma and helps patients access social support. Acceptance and commitment therapy (ACT) reduces experiential avoidance and emphasizes acceptance rather than reduction of symptoms to increase tolerance of distress.
Practice Implications
As 19th and early 20th century clinicians concluded, exposure does not always result in PTSD remission; rather, psychological and social changes and a trusting therapeutic relationship are key. Recent theories challenge the idea that PTSD is solely a fear-based disorder. Non-exposure-based therapies can be effective because patients likely engage in spontaneous, self-directed exposure outside of therapy sessions and because they experience a sense of safety with a warm, trustworthy therapist during sessions. As Rubenstein and colleagues conclude, a one-size-fits-all model of treating PTSD is ill-advised, and treatments should address the “holistic ” needs of the patient rather than targeting trauma memories alone.
Rubenstein, A., Duek, O., Doran, J., & Harpaz-Rotem, I. (2024). To expose or not to expose: A comprehensive perspective on treatment for posttraumatic stress disorder. American Psychologist, 79(3), 331–343. https://doi.org/10.1037/amp0001121