To expose or not to expose: A comprehensive perspective on treatment for posttraumatic stress disorder.

Summary & key facts

This paper reviews research on trauma-focused therapy, especially prolonged exposure (PE), and on treatments that do not focus directly on the trauma. The authors find that PE has long been called the best treatment for posttraumatic stress disorder (PTSD), but many people who try it keep their diagnosis and many drop out or do not engage with it. Studies of non-trauma-focused therapies show they can also help. The authors conclude that the exact kind of exposure used in PE does not have to happen for symptoms to get better. They suggest researchers should study which therapy processes really help people process trauma, and clinicians should let patients choose between trauma-focused and non-trauma-focused options.

Key facts:

• Prolonged exposure (PE) is widely called the "gold standard" for treating PTSD, but real-world data show many people who get PE still meet criteria for PTSD afterward.
• Studies of how PE is used in clinics show low engagement and high dropout rates, meaning many people stop or do not start the therapy.
• Other therapies that do not focus directly on the traumatic memory have shown promise for treating PTSD.
• The authors conclude that the specific kind of exposure used in PE is not necessary for symptoms to improve.
• Common factors in therapy, such as the relationship with the therapist or gradual facing of fears, might help people do their own exposure outside of formal PE sessions.
• The paper recommends changing research goals to identify which therapy processes best help people process trauma, rather than assuming PE exposure is the only effective route.
• For clinical care, the authors recommend shared decision-making so patients can choose either trauma-focused or non-trauma-focused treatments according to their preferences.

Abstract

Trauma-focused psychotherapies, in particular prolonged exposure (PE) therapy, have been recognized as the "gold standard" for the treatment of posttraumatic stress disorder (PTSD). But effectiveness and implementation data show that a large proportion of patients who undergo exposure therapy retain their PTSD diagnosis, and implementation studies have shown low engagement and high dropout rates. Meanwhile, non-trauma-focused therapies have shown promise in treating PTSD. In this review, we aim to answer the question of whether exposure is necessary to treat PTSD by integrating clinical and research literature from multiple perspectives. We review the roots of exposure therapy in both psychodynamic and behavioral paradigms and their proposed mechanisms. We then review non-trauma-focused treatments and their proposed mechanisms. We conclude that the specific form of exposure required by PE is not necessary for symptom remission. Finally, common psychotherapy factors may facilitate patient self-directed exposure outside of the therapy context. These findings should alter the direction of clinical research to identify the therapy processes that most effectively promote the processing of trauma memories. With respect to clinical practice, shared decision-making should allow for increased patient autonomy in choosing either trauma-focused or non-trauma-focused treatments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Topics

Posttraumatic Stress Disorder Research Resilience and Mental Health

Categories

Clinical Psychology Psychology Social Sciences

Tags

Artificial intelligence Astronomy Clinical psychology Computer science EXPOSE Perspective (graphical) Physics Posttraumatic stress Psychology

Conditions & symptoms

PTSD