Prolonged Exposure (PE)

Core Components

Prolonged Exposure (PE) therapy is an exposure-based intervention used in adolescents (aged 13-17 years) and adults for the treatment of PTSD and related conditions that could develop after a traumatic event. This targeted intervention is a type of Cognitive Behavioural Therapy (CBT) that focuses on modifying the pathological fear/emotional structure that could develop following a trauma event. This is achieved by gradual exposure to the stimuli or cues that trigger memories of the trauma and emotional processing of the trauma event in order to prevent the elicitation of extreme negative responses. This approach therefore helps patients overcome the fear and emotional response triggered by the trauma memory, minimise avoidance behaviours and reduce symptoms of PTSD.  

PE is a manualised intervention, delivered in an individualised format over 8-15 sessions (dependent on patient’s response). Sessions are delivered weekly and typically last about 90 minutes. PE content delivered during sessions consists of four main components; 1) Psychoeducation- education about the most common responses to trauma, and rationale behind the treatment provided; 2) Breathing retraining- equipping patients with skills needed to minimise physiological arousal and promote relaxation; 3) In vivo exposure- repeated engagement with triggers associated with the traumatic fear in order to address avoidance behaviour; 4) Imaginal exposure- systematic, repeated exposure to the trauma memory. Patients are encouraged to explicitly describe details of the traumatic event, discuss the emotions raised with the therapist, and emotionally process the trauma event. PE has a substantial homework component (including in vivo exposure) as this provides opportunities for patients to continue to process trauma memories and to challenge avoidance behaviour between sessions. 

Fidelity 

NICE recommends that trauma focused CBT interventions should be delivered by trained practitioner(s) with ongoing supervision, typically over 8-12 sessions (or more if clinically indicated). It is necessary that PE is delivered as per validated manual, and that stipulated content and structure are adhered to in order to ensure safe and consistent delivery of intervention. 

Fidelity measures for PE determine adherence to PE therapy components, and assess practitioner behaviours that could affect treatment outcomes https://pubmed.ncbi.nlm.nih.gov/30516797/. A sample PE fidelity checklist is available online at  https://deploymentpsych.org/system/files/member_resource/9-PE%20Fidelity%20Checklist_8_19_13_FINAL.pdf. The programme representative can also be contacted for fidelity measure 

Modifiable Components  

The individualised approach of PE allows modification of PE procedures to provide tailored treatment based on patient’s response to exposure. The individualised approach of the standard protocol also enables incorporation of issues associated with race motivated traumas and bias violence, facilitating PE delivery across diverse populations. Separate PE treatment protocols are available for adults and adolescents, with the adolescent treatment protocol also used in school aged children (https://www.sciencedirect.com/science/article/pii/S107772291400008X; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3144550/). There is evidence that PE improves symptoms of comorbidities associated with PTSD, including depression, dissociation, and substance use disorders (when offered along-side substance use treatments) https://www.tandfonline.com/doi/pdf/10.3402/ejpt.v3i0.18805?needAccess=true.  

PE can be delivered face-to-face (e.g. outpatient clinic setting, residential treatment programmes, community setting, or at patient’s home [for older patients]) or via video-teleconferencing (see Hagerty et al. 2020 for guidance). PE can also be  supported via mobile app (PE coach) while patients are receiving face-to-face or virtual therapy.  

Support for Organisation / Practice

Implementation Support 

Implementation support is provided by Dr. Edna Foa, Dr. Sandy Capaldi, and other faculty staff from Centre for the Treatment and Study of Anxiety’s (CTSA), University of Pennsylvania. Implementation support provided include practitioner training, post-training consultation, as well as links to purchase programme resources (including PE Therapist Guide and Patient Workbook).  

Start-up Costs 

There are no start-up costs associated with training provided within university training programmes (if training is through an NHS place) or by NES.  

Costs apply when training is provided by private organisations and may include a 4-day virtual workshop charged at $1500 per practitioner (includes training and supporting materials). There is also 1-day Prolonged Exposure for Adolescents Webinar at $400 per practitioner (includes training and supporting materials).  

Other costs can include guidebooks: Prolonged Exposure Therapy for PTSD Therapist Guide at $44.19, Prolonged Exposure Therapy for Adolescents with PTSD Therapist Guide at $29.99; Prolonged Exposure Treatment Program Workbook at $27.62; Prolonged Exposure Therapy for PTSD: Teen Workbook at $19.46; and Post-Workshop Online PE Group Consultation at $600 USD per practitioner. 

Building Staff Competency 

Qualifications Required 

PE is typically delivered by mental health professionals and practitioners that work under supervision. Practitioners applying for NES training should have had training in CBT (to Certificate level or above) and prior experience managing people who have experienced trauma(s).  

Training Requirements 

Practitioners attending NES commissioned training in Scotland typically attend 3 training days (2 workshops and a follow up day) covering the components of PE, skills practice and support with implementing PE in practice.   It is recommended that practitioners access post-training supervision for support, consultation and feedback from a PE expert in addition to practice being supported through local supervision arrangements. 

When accessing training through private providers, training typically involves 4 training days and post-training consultations which can involve 12 sessions, with each session lasting about 90 minutes. These sessions can be delivered via videoconferencing. 

Private training providers may offer an additional 1-day training for practitioners delivering PE to adolescents. This is not currently available via NES. 

Supervision Requirements 

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). 

Practitioners accessing training through private providers can receive consultation from PE experts on submission of PE session recordings for two PE training cases. Consultation includes a review of the PE training cases and provision of feedback on the reviewed sessions. Consultation is delivered over 12 week  in weekly 1.5hr Zoom meetings.

Evidence 

PE is a type of Trauma-Focused Cognitive Behavioural Therapy (CBT-T). Evidence of clinical effectiveness for PE and other interventions within the CBT-T class have been explicitly detailed in the National Institute for Health and Care Excellence (NICE) evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the prevention and treatment of PTSD in adults. 

Theory of Change  

Prolonged Exposure (PE) is founded on emotional processing theory of PTSD. This theory poises that PTSD emerges from the development of a fear network in memory of the traumatic event, which in turn elicit avoidance and escape behaviours on exposure to reminders of the trauma. It proposes that enabling patients face their traumatic memory/ stimuli would result in desensitisation of their fear  and alteration of their fear/emotional structure. PE therefore aims to modify the pathological fear/emotional structure that could develop following a trauma event. The process involves graded exposure of the patient to stimuli or cues that trigger memories of the trauma and encouraging emotional processing of the trauma event in order to prevent the elicitation of extreme negative responses. PE delivery is expected to help patients overcome the fear response triggered by the trauma memory, minimise avoidance behaviours, and reduce symptoms of PTSD. 

Values  

Prolonged Exposure (PE) therapy is an exposure-based intervention used in adolescents and adults for the treatment of PTSD and related conditions that could develop after a traumatic event. PE is a specific type of Cognitive Behavioural Therapy (CBT) that is founded on emotional processing theory of PTSD.    

• Do the target patients, underpinning theory, and the underlying mental health condition addressed by the intervention align with the requirements of your organisation?

Priorities

PE is a trauma-focused psychological intervention that aims to treat PTSD and related conditions. It focuses on modifying the pathological fear/emotional structure that could develop following a trauma event by applying techniques including imaginal exposure and in vivo exposure. PE helps patients overcome the fear/emotional response triggered by the trauma memory, minimise avoidance behaviours, and reduce symptoms of PTSD.

• Is your service looking to deliver a targeted intervention for the treatment of PTSD and related conditions?
• Should the proposed intervention be psychological, psychosocial or pharmacological?

Existing Initiatives

• Does your service use trauma-focused interventions or other interventions to treat PTSD in adults and adolescents?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

PE is typically delivered by registered mental health professionals. Practitioners should have prior experience managing people who have experienced trauma(s). PE is delivered weekly or twice weekly, over 8-15 sessions (dependent on patient’s response). To support PE delivery, practitioners receive at least 3 days of workshops. An additional 1-day training is available to practitioners delivering PE to adolescents. Practitioners can access post-training consultation (this may be through video) to get support, consultation and feedback from a PE expert.

• Does your service have qualified and experienced practitioners who are available and interested in learning and delivering PE?
• Can your service support the time commitment required by practitioners for training, supervision, and PE delivery?

Technology Support

Practitioner training and consultation/supervision may be delivered virtually. PE delivery to patients could be face-to-face or virtually (via tele-videoconferencing). PE sessions should be recorded on a suitable device. PE support can also be accessed via mobile app (e.g. PE coach) while patients are receiving face-to-face or virtual therapy.

• Does your service have the technology to support practitioner training and consultation?
• In what form will PE be offered? Can your service support delivery of PE in the chosen form?
• Do people using the service have access to a suitable device to record sessions?

Administrative Support

PE is delivered bi/weekly, over 8-15 sessions. Face-to-face therapy sessions can be held in several settings including outpatient clinic setting, residential treatment programmes, community setting, or at patient’s home (for older patients)

• In what setting will PE be delivered?
• Does your service have a venue where the PE sessions can be delivered?

Financial Support

There are financial supports covering training costs and follow up consultation for NHS or partnership staff when accessing training though NES.

Costs apply when accessing training, consultation or supervision through private providers.  Costs can include costs of 4-day virtual workshop charged at $1500 per practitioner (includes training and supporting materials); 1-day Prolonged Exposure for Adolescents Webinar at $400 per practitioner (includes training and supporting materials); costs of guidebooks (Prolonged Exposure Therapy for PTSD Therapist Guide at $44.19, Prolonged Exposure Therapy for Adolescents with PTSD Therapist Guide at $29.99; Prolonged Exposure Treatment Program Workbook at $27.62; Prolonged Exposure Therapy for PTSD: Teen Workbook at $19.46); and Post-Workshop Online PE Group Consultation at $600 USD per practitioner.

• How many practitioners will receive PE training?
• Will PE be delivered to adolescents? How many practitioners will receive the additional training to deliver PE to adolescents?
• Can practitioner training costs and book costs be financially supported?
• Will practitioners in your service attend post-training consultation? Can consultation costs be financially supported?

Comparable Population

Prolonged Exposure (PE) therapy is an exposure-based intervention used in adolescents (aged 13-17 years) and adults for the treatment of PTSD and related conditions that could develop after a traumatic event. Effectiveness of PE was assessed within the wider trauma-focused CBT (CBT-T) class. CBT-T interventions were shown to be effective in the early prevention (initiated ≤ 1 month) of PTSD in adults; in the delayed treatment (>3 months) of non-significant PTSD symptoms in adults; as well as in the early and delayed treatment of PTSD in adults. Effectiveness has also been shown in the prevention of PTSD in children and young people with ongoing exposure to trauma; in the delayed treatment (>3 months) of non-significant PTSD symptoms in children and young people; as well as in the delayed treatment (>3months) of PTSD in children and young people.

• Is this comparable to the population your service would like to serve?

Desired Outcome

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) interventions have been shown to effectively reduce acute stress disorder diagnosis, PTSD diagnosis, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following early initiation of intervention (≤1 month). TF-CBT interventions have also been shown to reduce PTSD symptoms, reduce symptoms of comorbidities associated with PTSD (including depression and anxiety), and reverse PTSD diagnosis following early (1-3 months) and delayed treatment (≤ 3months).  Effects have been sustained at follow-up.

• Is delivering trauma-focus psychotherapy for the treatment of PTSD and related conditions in adults a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?