Description of PE

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PE is described in detail in Foa and Rothbaum (1998), so here we provide only a shorter overview. PE is delivered in an individual format and typically consists of 9-12 sessions, each lasting about 90 minutes. The treatment incorporates four procedures: (1) psychoeducation about trauma, reactions to trauma, and PTSD; (2) breathing retraining; (3) in vivo exposure to the feared (but now safe) trauma-related situations that the client avoids; and (4) imaginal exposure that consists of repeatedly recounting memories of the traumatic event. At the end of each imaginal exposure session the client and therapist process the thoughts and feelings that emerged during the imaginal exposure or as a result of recounting the trauma. Finally, each session ends with a homework assignment that includes in vivo exercises and listening to tape recordings of the imaginal exposure exercise conducted in that session.

The first session of PE is devoted to laying the groundwork for the program. The therapist provides a description of the treatment and each of the procedures that will be used. The therapist also provides the client with a model for understanding the persistence of PTSD symptoms. The model emphasizes the role of avoidance and negative beliefs about the world and the self in impeding recovery and thus maintaining PTSD symptoms (Foa & Riggs, 1993; Foa & Rothbuam, 1998). Following the overall rationale for the treatment and a general description of the PE procedures, the therapist collects information about the patient's traumatic experience, using a semistructured interview format to elicit details about the trauma and the patient's reactions during and after the trauma. (This information may also be collected in a less structured format.) At the end of the session, the patients is trained to use controlled breathing to manage anxiety. Setting a pattern for all sessions, this session ends with homework assignment. For the first session, the homework consists of practicing controlled breathing (3 x 10 minutes each day), reading a handout that outlines the rationale for PE, and listening to an audiotape of the session.

The second PE session focuses on two treatment components. First, the therapist continues to educate the client about trauma and PTSD by discussing reactions that are commonly reported by people who have experienced trauma. Second, the therapist introduces in vivo exposure. In addition to providing a framework for understanding the patient's symptoms and normalizing the reaction to the trauma, the discussion of common reactions provides an opportunity for the patient to identify specific difficulties that he or she has experienced. Once this discussion is completed, the therapist provides a detailed rationale and description of the in vivo exposure procedure. Together the client and therapist construct the hierarchy by identifying situations that the patient avoids and rating each situation on a subjective distress scale. This hierarchy will guide the in vivo exercises through the balance of the program. Homework assignments for the second session consist of (1) reading a handout that describes the common reactions to trauma discussed in the session; (2) listening to the tape of the treatment session; (3) continuing the breathing exercises; and (4) completing one or more in vivo exposure exercises. Typically the in vivo exposure assignments in this session involve confronting situations or objects that will elicit anxiety but will not overwhelm the patient—that is, items on the hierarchy that the patient rated as moderately distressing. The therapist also reviews the instructions for in vivo exposure and explains in detail how the particular exercise will be conducted.

The third session introduces imaginal exposure, in which the patient is asked to recount the identified index trauma. The session begins with a review of the client's homework and continues with the therapist's expansion of the rationale for the imaginal exposure exercises. The patient is then guided through approximately 45 minutes of imaginal exposure to a single traumatic event (when the client has experienced multiple traumas, he or she is asked to recount the event that causes the most distress at the time of treatment). The patient is asked to close his or her eyes, imagine the traumatic event as vividly as possible, and recount it aloud in the present tense. If recounting of the trauma does not fill the allotted 45 minutes (as is usually the case), the client is asked to return to the beginning of the memory and repeat the procedure until 45 minutes has elapsed. Following the recounting, the therapist and patient spend time discussing the patient's reactions to the exposure exercise, with particular emphasis on thoughts and emotions that arose during the recounting. We refer to this as "processing" the trauma memory. The time allotted to processing also helps the patient to calm any distress remaining from the exposure. Homework assigned for this session includes (1) daily in vivo exercises; (2) listening to the imaginal exposure audiotape daily while imagining the trauma as vividly as possible; (3) listening to the audiotape of the session at least one time; and (4) continuing the breathing practice.

With the exception of the last session, the rest of the PE sessions follow the same format. First the therapist reviews the previous week's homework, and then the client completes an imaginal exposure exercise lasting 30-45

minutes. This is followed by a 15- to 20-minute processing of the imaginal exposure and homework assignment. Homework for these sessions includes daily in vivo exercises selected from the hierarchy and daily listening to the imaginal exposure audiotape from the preceding session. Beginning around session six or seven, the focus of the imaginal exposure exercise is shifted from the entire traumatic event to the particular aspects that are associated with the greatest distress during the recounting. Patients are asked to focus their recounting on these "hot spots," one at a time, describing the event and their thoughts and emotions is as much detail as possible. Patients are asked to repeat this "hot spot" as many times as necessary to fill the 30- to 45-min-ute imaginal exposure.

The format of the final session is similar to the previous sessions, except that the imaginal exposure exercise is usually shortened to 20-30 minutes, and the discussion of the client's reactions is focused on progress achieved during treatment and the application of what the client has learned to other aspects of his or her life. In the course of this discussion, the therapist asks the client to re-rate the items on the in vivo hierarchy to identify progress and any items that remain problematic. The therapist briefly discusses issues related to relapse prevention, such as the potential for PTSD symptoms to increase temporarily and the utility of the techniques used in treatment to address stressful situations that arise in the future.

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