Theoretical rationale and practical limitations of exposure techniques in the psychotherapy treatment of posttraumatic stress (Mervin Smucker 2015)

Prolonged exposure is an exposure-based, behavioral treatment embedded in the theories of classical conditioning that relies primarily on the processes of repeated and prolonged exposure, desensitization, habituation, and extinction to facilitate change.  The primary focus of prolonged exposure is on significantly reducing trauma-related fear, anxiety, and avoidance.  Specifically, posttraumatic sufferers are taught that avoidance does not lead to long-term symptom relief, that traumatic memories are manageable and tolerable, and that the fear and anxiety provoked by these memories will eventually subside and extinguish as exposure continues.  As such, it is the repeated, prolonged exposure to the fear elements of the trauma that is thought to enhance emotional processing of the trauma memories by means of the processes of habituation and desensitization from which emerges critical “corrective information” (e.g., that the traumatic event is in the past, that the trauma-related fear and anxiety are not harmful and are manageable). Imaginal exposure -- a central component of PE -- is used as a means of exposing trauma sufferers to their fear-based memories and facilitating adaptive emotional processing.  However, considerable scientific evidence has emerged in the trauma literature indicating that exposure treatment alone is less effective when non-fear emotions are predominant and that non-fear emotions – such as anger, guilt and shame – are often more predominant than fear in traumatic memories. Such findings underscore the need for developing trauma treatments that go beyond exposure techniques, especially in the treatment of non-fear emotions relating to trauma.