Brian Klassen, PhD: What the Early Stages of Prolonged Exposure Therapy for PTSD Look Like

Starting in the first few therapy sessions in Road Home's two-week immersive program, veterans and service members with PTSD work with a clinician to share the narratives of their traumatic experiences. They repeat the story, letting it unfold, adding more context and details, feeling the associated emotions and memories. They also work with their therapist on "in vivo exposure," such as taking steps to ride public transportation or eat in a restaurant, activities that may have been impossible pre-therapy.

Brian Klassen, PhD, is the Clinical Director of the Road Home Program, part of the Wounded Warrior Project's Warrior Care Network.

For information about treatments for PTSD please visit The Treatment Hub.

In the beginning it’s kind of like setting the stage. It’s providing a lot of education, providing the rationale of kind of setting expectations, and kind of letting that veteran know like “here’s the arc of treatment, here’s the outline that we’re following.“ You would collaboratively agree on a certain moment in time during the trauma that you would focus on. And so I think that’s another benefit that’s lost in a lot of how trauma is approached in general, like outside of these treatments, is that you know, there are many traumatic experiences that people have. And I think helping them sort of focus on one is, in itself, therapeutic. It just helps a person organize their memories, organize their experiences a little more. So, in the beginning it’s a lot of kind of setting the stage, getting things organized, providing a rationale. Within the first couple sessions, you know, you’re really into it. You know, you don't, there’s not a lot of lead time, there’s not a lot of beating around the bush. I mean, you decide on an experience, and you have the person kind of give the narrative repeatedly, right? Sometimes you might do it three, four or five times in session, depending on how long the story is. Sessions are 90 minutes, so it leaves plenty of time, that you don't feel rushed, you feel that the story has time to develop and that you have time to kind of get in touch with maybe feelings or memories that you had been avoiding up to this point. The other thing in prolonged exposure that we do that is effective is that there’s a fair amount of work for the veteran outside of session and so that takes place in a couple of ways. One is we always like to make recordings of the prolonged exposure sessions so that the veteran can listen to it outside of session, right? We have found that this is a more effective way of like accelerating the course of therapy so that you’re taking therapy home with you. And that it’s not that you get 90 minutes once a week, but that you’re kind of spending a little time on it each day, just like learning anything new, just like learning a new skill. The other thing that happens in prolonged exposure is what we call en vivo exposures, which is a collaborative, again, discussion with the veteran about things in their life that they might be avoiding. Now this might be like eating in a crowded restaurant, taking public transportation, those kinds of things. But what’s interesting about prolonged exposure is if you have a practioner who’s really good, is they got to know you. And the things on this list that you might do outside of session could get very specific. It might include having conversations with family members, it might mean leaving your door unlocked at night. It might mean things that kind of push the envelope to give you just enough anxiety so that you kind of recalibrate and habituate to it, but not so much that it’s counterproductive. If we decide that eating in a crowded restaurant is an appropriate homework assignment, that would be thoroughly discussed with the veteran beforehand. There would be buy-in and motivation from the veteran because if I have this great idea and I think it’s worthwhile for them to do in treatment, but they’re not willing to do it, or practically can’t do it, you know, that’s on me to find something else. 

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Posted on BrainLine October 8, 2021. Reviewed October 8, 2021.

About the author: Brian Klassen, PhD

Brian Klassen, Ph.D., is the Associate Clinical Director for The Road Home Program: The National Center of Excellence for Veterans and Their Families at Rush University in Chicago, Illinois. Brian spent his formative years training at the Jesse Brown VA Medical Center, completing rotations in chronic pain management, residential substance use disorder treatment, and PTSD. Brian has special expertise in providing front-line treatments for PTSD, including Prolonged Exposure and Cognitive Processing Therapy.

Headshot of Dr. Brian Klassen wearing glasses and a charcoal sweater over a white shirt and navy blue tie, smiling at the camera