Prolonged Exposure Therapy (PE)

A comprehensive guide to Prolonged Exposure Therapy: how confronting traumatic memories and avoided situations helps you recover from PTSD and trauma.

8 min readLast reviewed: March 24, 2026

What Is Prolonged Exposure Therapy?

Prolonged Exposure Therapy (PE) is a highly effective, evidence-based treatment for Post-Traumatic Stress Disorder (PTSD) and trauma-related difficulties. Developed by psychologist Edna Foa at the University of Pennsylvania in the 1990s, PE is based on emotional processing theory — the idea that PTSD symptoms are maintained by avoidance of trauma-related memories, thoughts, feelings, and situations. By systematically confronting these avoided experiences in a safe, therapeutic context, PE helps you process the trauma and reduce PTSD symptoms.

PE is one of the most extensively studied treatments for PTSD in existence and is strongly recommended by the American Psychological Association, the VA/DoD Clinical Practice Guidelines, the International Society for Traumatic Stress Studies, and NICE.

PE has been validated across diverse trauma populations, including combat veterans, sexual assault survivors, survivors of childhood abuse, motor vehicle accident survivors, and refugees. It is effective regardless of the type of trauma or how long ago it occurred.

How It Works

PE follows a structured protocol typically delivered over 8 to 15 weekly sessions, each lasting 90 minutes. The treatment has four main components.

Psychoeducation

In the first session, your therapist explains how PTSD works, why avoidance maintains symptoms, and how PE addresses this. You learn about the rationale for exposure and what to expect throughout treatment.

Breathing Retraining

You learn a simple breathing technique to manage acute anxiety. This is a coping tool, not the primary mechanism of change — the exposure work is what drives recovery.

In Vivo Exposure

You and your therapist create a hierarchy of situations, places, and activities that you have been avoiding because they are associated with the trauma (even though they are objectively safe). You then systematically and gradually approach these situations between sessions. For example, if you have been avoiding driving since a car accident, your hierarchy might progress from sitting in a parked car to driving in a quiet neighborhood to driving on a highway.

Imaginal Exposure

This is the central component of PE. During sessions, you close your eyes and recount the traumatic memory aloud, in the present tense, with as much sensory and emotional detail as possible. Your therapist guides you through this process, and the recounting is typically repeated multiple times across sessions. Between sessions, you listen to audio recordings of the imaginal exposure.

The mechanism is not simply desensitization. Through repeated engagement with the memory, you process emotions that were not fully processed at the time of the trauma, correct unhelpful beliefs ("The memory is dangerous," "I cannot handle remembering"), and integrate the traumatic experience into your broader life narrative.

53-80%

of patients no longer meet PTSD diagnostic criteria after completing Prolonged Exposure, based on clinical trial data

What to Expect

PE sessions are 90 minutes long, held weekly. The first two sessions focus on psychoeducation, treatment planning, and building the in vivo hierarchy. Imaginal exposure begins in session 3 and continues through the end of treatment.

Imaginal exposure sessions follow a predictable structure: a brief check-in, 30 to 45 minutes of imaginal exposure (recounting the trauma), and 15 to 20 minutes of processing — discussing what you noticed, what emotions came up, and what you learned.

The first few imaginal exposure sessions are typically the most difficult. It is normal to experience temporary increases in distress as you begin confronting what you have been avoiding. However, most people find that distress decreases significantly across sessions as the memory is processed. Your therapist will monitor your distress levels throughout and ensure you feel safe and supported.

Between sessions, you will listen to the recording of your imaginal exposure daily and continue working through your in vivo hierarchy. These homework assignments are essential to the treatment's effectiveness.

Conditions It Treats

PE was developed specifically for PTSD and has its strongest evidence there. It is effective for PTSD resulting from:

Combat and military trauma
Sexual assault and abuse
Physical assault
Childhood abuse and neglect
Motor vehicle accidents
Natural disasters
Terrorist attacks
Any traumatic event

PE also reduces co-occurring depression, anxiety, guilt, anger, and general distress that accompany PTSD.

Effectiveness

PE has been evaluated in more than 20 randomized controlled trials and is one of the most rigorously tested treatments for any psychological condition. Meta-analyses consistently show large effect sizes, with 53-80% of patients no longer meeting PTSD diagnostic criteria after treatment.

PE is effective across trauma types, populations, and settings. It works for recent and distant traumas, single-incident and multiple-incident traumas, and has been validated in diverse cultural contexts. The VA has trained thousands of clinicians in PE as part of its national rollout of evidence-based PTSD treatments.

Compared to EMDR, both are strongly recommended first-line treatments for PTSD. PE involves more direct, extended engagement with the trauma memory, while EMDR uses shorter memory activations combined with bilateral stimulation. Research generally shows equivalent outcomes, and choice often depends on client preference. Compared to CPT, PE relies more on emotional processing through exposure, while CPT focuses more on cognitive restructuring of stuck points. Again, outcomes are comparable, and PE may be preferred for people whose avoidance is a dominant maintaining factor.

PE can be emotionally challenging, especially in the early sessions. However, research consistently shows that dropout rates for PE are comparable to other PTSD treatments, and the temporary distress is a normal part of recovery. Your therapist will pace the work carefully and ensure you have coping tools. Most people find that the distress decreases significantly as treatment progresses.

No. Imaginal exposure is not the same as reliving the trauma. You are recounting the memory in a safe therapeutic environment, with full awareness that you are in your therapist's office and that the trauma is not happening now. Research shows that PE reduces — not increases — PTSD symptoms.

PE involves a specific, structured process of recounting the trauma in the present tense with sensory detail, repeated across sessions, with audio recordings for between-session practice. This systematic approach to the memory is fundamentally different from unstructured discussion and is what drives the therapeutic change.

PE can be effective for people with multiple traumas. Your therapist will help you identify the 'index trauma' — the event most closely connected to your current symptoms — and treatment typically focuses on this memory. Often, processing the index trauma leads to improvement in symptoms related to other traumas as well.

Yes. Research supports the effectiveness of PE delivered via video telehealth. This has expanded access significantly, particularly for veterans and people in rural areas.