Using Prolonged Exposure Therapy to Help Veterans Work through PTSD Symptoms

Many veterans say they were happy-go-lucky before joining the military and serving overseas. Although some still maintain that outlook after being discharged, many others don’t fit back in well with their family or civilian life. Vigilance, guardedness, and fear dominate, which affects their interpersonal relationships. Many veterans unable to cope with this end up withdrawing from life.

One of the key features of post-traumatic stress disorder (PTSD) is avoidance of trauma memories, which only serves to maintain the symptoms. Prolonged exposure (PE) therapy is designed to counteract the avoidance. With PTSD, patients exhibit a fear structure that at times is irrational, panic-level fear. Fear is a normal emotion if one is in an isolated, dangerous situation (eg, swerving to avoid hitting a car). But if a patient can’t go to the mall or movies out of fear, when the fear response prevents them from participating in every life activities, they require effective intervention.

Prolonged exposure (PE) therapy is one option that can help vets get back to their old selves. PE consists of four main components: patient education, breathing and relaxation exercises, real-world practice, and talking through the trauma. Patricia Hentz, EdD, PMHNP-BC, CRNP, clinical associate professor at Rutgers School of Nursing, gave a presentation on prolonged exposure therapy at the American Psychiatric Nurses Association 28th Annual Conference, held October 22-25, 2014 in Indianapolis, IN.

In prolonged exposure therapy, the veteran is asked to recall the most traumatic experience in the military over and over again. Hentz said, “You ask ‘what do you see? What do you hear? What do you feel?’ The theory behind this is that these memories have been fragmented. They aren’t in a coherent package. By going through the memory over and over again, that actually brings coherence and allows for the emotional processing that did not fully occur after the trauma.”

“So it’s like reading a book. If I gave you a book, I wouldn’t say read page two, page 14, page 76, jump to page 156, and then you can read the last page. You might have an idea what this is about but this is a way to come back and say OK, we’re going to go through the whole book. We’re really going to give it the time that your brain wants to process this,” said Hentz.

She said that when you think about people having flashbacks and nightmares and really working hard to avoid thinking about this, all their energy is going into avoidance. And their brain is basically saying “I need to process this. I need this to get some closure and some understanding and some meaning.”

Veterans get blocked when they have PTSD from military experiences and they tend to avoid at all costs. The way out is to do the painful, time-consuming work that they didn’t do when they first had the trauma. Hentz said that if you can allow somebody to go through the normal emotional processing when they have a trauma or shortly thereafter, you won’t see some of the long-term effects.

But PE is not for everyone. It is a very intense, emotionally charged experience for the veteran and, sometimes, the provider because “you’re actually taking people through their memories and really focusing on that full memory, emotional, physical and all the sensations. And you’re doing that over and over again,” said Hentz.

PE is not appropriate for people who are suicidal or homicidal, self-injurious, psychotic, in danger of being assaulted (ie, domestic violence), lack a clear memory of the traumatic event, or feel it will be too difficult or traumatic.