PE Therapy Sessions: Structure and Main Components

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.

Highlights

  • Session 1: Treatment program and rationale for PE, information about the trauma and breathing retraining.
  • Imaginal exposure and processing begins in session 3, and continues for the remainder of therapy.
  • The hierarchy for in vivo exposure is constructed in session 2, and in vivo exposure homework continues for the remainder of therapy.

 

Transcript

Welcome to video 9, Structure of Sessions. We’ll review the sessions in detail in other modules. But in this video, I’m going to present an overview of the structure of sessions.
Session 1 begins by presenting the patient with an overview of the treatment program and a general rationale for PE. The second part of the session is devoted to collecting information about the trauma, the patient’s reactions to the trauma, and pre-trauma, stressful experiences. We use the trauma interview to guide us in developing this information.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

During the trauma interview, you and the patient will identify the trauma that’s currently the most upsetting to the patient—what we refer to as the index trauma—as well as identifying the beginning and endpoints of this trauma memory. And that’s going to be the trauma memory that will be revisited in imaginal exposure beginning in session 3.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

Session 1 ends with teaching the patient breathing retraining.
We introduce breathing retraining to provide the patient with a useful and handy skill to reduce general tension and anxiety that may interfere with daily functioning: for example, at work, or going to sleep, or in the shower. We don’t want patients to use this for their exposure therapy. We want to teach patients that exposure therapy works by itself. The breathing is to be used when they can’t use exposure therapy. Some patients find this breathing retraining very useful and use it often while others do not. And that’s okay.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA

Every session has homework. For homework from session 1, the patient is instructed to review the rationale for the treatment, listen to the recording of the session, and practice the breathing retraining. If you like handouts, we have handouts for all of this in the PE manual.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

Session 2 begins with reviewing the patient’s experience of homework. How did it go for them? How was listening to the recording of session 1? We want to review the treatment rationale and the practicing of the breathing skill. At the beginning of every session, we always want to review the patient’s homework. If you don’t ask about homework, they’ll stop doing it. Next in session 2, we present the patients with an opportunity to talk in detail about the reactions to the traumatic experiences and how that affected them.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

One of the most important parts of session 2 is talking about common reactions to trauma. This discussion is didactic and interactive. We don’t want it to be a monologue. We don’t want it to be a soliloquy. You’ll tell the patient about one common reaction and then ask if they’ve experienced it. It’s an interactive discussion.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

Next, the therapist will present the rationale for in vivo exposure. And following that, the therapist and patient will construct the hierarchy for in vivo exposure. These are the situations or activities and places that the patient has been avoiding. The patient will begin confronting situations for in vivo exposure as homework after this session.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

The therapist and patient will identify specific in vivo assignments for that week’s homework. The patient is also encouraged to continue practicing the breathing exercises, listening to the session recording at least one time before the next session, and to read and think about the common reactions to trauma.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

In some clinical and research settings, session 2 can be a long session and may be divided and broken up into two separate sessions. In that case, the first session is devoted to the discussion of the common reactions to trauma and the patient’s experience. And then the second part of session 2 would be devoted to in vivo exposure.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

Session 3, as always, begins with homework review and then the therapist presents the rationale for exposure therapy. That’s followed—the most important thing in session 3 is the patient’s first imaginal revisiting of the trauma memory.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

During this imaginal exposure, instruct the patient to recount the trauma memory for 40 to 45—up to 60 minutes. And this is followed by about 15 to 20 minutes of discussion aimed at helping the patient to continue processing the thoughts and feelings associated with the trauma. In general, we recommend that PE be administered in sessions that are 90 minutes long to allow enough time for this.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

And as always, the end of session 3 is assignment of homework. And in this case, listen to the recording of the imaginal exposure daily. Listen to the recording of the entire session at least one time. Continue with in vivo exposure, and continuing practicing the breathing retraining. And in general, that’s going to be the homework after every other session now.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

The intermediate sessions, sessions 4 up until when treatment ends, follow the same format. You start with reviewing homework, followed by anywhere from 30 to 45—up to 60—minutes of imaginal exposure, approximately 15 to 20 minutes of the post-exposure processing of the thoughts and feelings, and about 15 minutes of in-depth discussion of the homework, in vivo homework assignments that are going to be prescribed for homework.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

As treatment advances, we want to encourage the patient to describe the trauma in greater detail during the imaginal revisiting and recounting, and then to focus progressively more on the most distressing aspects of the memory or hotspots. And we’ll talk about that in the future. In later sessions as the patient improves, imaginal exposure may become shorter to about 30 minutes.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

The final session, as always, starts with homework review and then recounting the entire trauma memory only once, and that will take anywhere say, from 15 to 25 minutes. Discussion or processing of this exposure with a lot of emphasis on how that experience has changed over the course of therapy and a detailed review of the patient’s progress and treatment.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

The final part of the session is devoted to discussing continued application of all that the patient has learned in treatment, relapse prevention, and treatment termination.

Reference

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

The key points from this video are that session 1 includes presenting the patient with an overview of the treatment program and a general rationale for PE, collecting information about the trauma and ends with the introduction of breathing retraining. Imaginal exposure to the trauma memory and processing begins in session 3 and continues each session for the remainder of therapy. The hierarchy for in vivo exposure is constructed in session 2 and in vivo exposure homework is assigned in session 2 and continues each session for the remainder of therapy.

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