Prolonged Exposure Therapy: Why It’s Common to Feel Worse Before Feeling Better
Prolonged Exposure (PE) therapy is one of the most effective treatments for trauma-related disorders, particularly Post-Traumatic Stress Disorder (PTSD). As a psychotherapist, I have seen firsthand how this evidence-based approach can lead to significant healing. However, it is also common for clients to feel worse before they start feeling better during the course of PE therapy. This temporary discomfort is a natural part of the therapeutic process and, ultimately, the benefits far outweigh the initial pain.
The Nature of Prolonged Exposure Therapy
Prolonged Exposure therapy is grounded in the principles of cognitive-behavioural therapy (CBT) and is specifically designed to help individuals confront and process traumatic memories in a safe, controlled environment. The core components of PE therapy include in vivo exposure, where clients gradually face situations they have been avoiding due to trauma-related fear, and imaginal exposure, where clients recount the traumatic memory in detail during therapy sessions (Foa et al., 2019).
The goal of PE therapy is to reduce the power that the traumatic memory holds over the client. By repeatedly confronting these memories and the associated emotions, clients can begin to reframe their trauma, reducing symptoms of PTSD such as hypervigilance, nightmares, and intrusive thoughts.
Why Clients May Feel Worse Before Feeling Better
The initial phases of PE therapy can be challenging, as clients are asked to engage directly with their trauma—something they have likely been avoiding for a significant period of time. This process can lead to an increase in distressing symptoms, including heightened anxiety, emotional pain, and even a temporary intensification of PTSD symptoms (Bryant et al., 2003).
This phenomenon occurs because the client is revisiting the traumatic event in a detailed and deliberate way, which can bring up intense emotions that were previously suppressed or avoided. For many clients, this can feel overwhelming, and they may question whether the therapy is working or if they are making progress.
The Importance of Persevering Through the Discomfort
Despite the initial increase in distress, it is crucial for clients to persevere through the discomfort. The temporary exacerbation of symptoms is a sign that the therapy is addressing the core of the trauma, rather than simply treating the surface symptoms. This is a necessary step toward long-term healing (Foa et al., 2019).
As clients continue with PE therapy, they gradually become desensitized to the traumatic memories and the emotions they evoke. The repeated exposure helps to break the association between the trauma and the intense fear or distress that accompanies it. Over time, clients begin to notice a decrease in symptoms, an increase in emotional regulation, and an overall improvement in their quality of life (Powers et al., 2010).
The Long-Term Benefits of Prolonged Exposure Therapy
The benefits of Prolonged Exposure therapy are well-documented and extend beyond the reduction of PTSD symptoms. Clients who complete PE therapy often report an enhanced sense of empowerment, as they regain control over their lives and no longer feel defined by their trauma (Resick et al., 2002). Additionally, they are better able to engage in relationships and daily activities that they may have avoided due to trauma-related fears.
Furthermore, the skills learned during PE therapy—such as emotional regulation, coping strategies, and resilience—can have lasting positive effects. Clients are often better equipped to handle future stressors, reducing the likelihood of retraumatization or the development of additional mental health issues (Foa et al., 2019).
Supporting Clients Through the Process
As a psychotherapist, my role is to support clients through the challenging phases of PE therapy, providing them with the tools and encouragement they need to continue with the process. It is essential to maintain open communication, allowing clients to express their fears and concerns, and validating their experiences while reminding them of the long-term benefits they are working toward.
Additionally, integrating other therapeutic modalities, such as mindfulness or grounding techniques, can help clients manage the distress they may feel during the initial stages of PE therapy (Boden et al., 2012). This holistic approach ensures that clients feel supported and equipped to handle the discomfort that is a natural part of the healing process.
Conclusion
While it is common for clients to feel worse before feeling better during Prolonged Exposure therapy, this is a temporary phase that ultimately leads to significant healing and recovery. The process of confronting and processing trauma is not easy, but it is a crucial step toward reclaiming one’s life from the grip of PTSD. With perseverance and the right therapeutic support, the benefits of PE therapy far outweigh the initial discomfort, leading to lasting improvements in mental health and overall well-being.
References
Boden, M. T., Kimerling, R., Kulkarni, M., & Bonn-Miller, M. O. (2012). Coping among
military veterans with PTSD in substance use disorder treatment. Journal of Substance
Abuse Treatment, 43(4), 451-460.
Bryant, R. A., Moulds, M. L., Guthrie, R. M., & Nixon, R. D. (2003). Treating acute stress
disorder following mild traumatic brain injury. American Journal of Psychiatry, 160(3),
585-587.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2019). Prolonged exposure therapy for PTSD:
Emotional processing of traumatic experiences (2nd ed.). Oxford University Press.
Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-
analytic review of prolonged exposure for posttraumatic stress disorder. Clinical
Psychology Review, 30(6), 635-641.
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of
cognitive-processing therapy with prolonged exposure and a waiting condition for the
treatment of chronic posttraumatic stress disorder in female rape victims. Journal of
Consulting and Clinical Psychology, 70(4), 867-879.
