Edna Foa on Prolonged Exposure

Edna Foa on Prolonged Exposure

Dr. Edna Foa, the extremely influential anxiety disorder researcher and University of Pennsylvania professor, authored a brief article in the December issue of Depression and Anxiety. For those who don’t recognize her name, Foa is an enormously influential psychologist who developed the emotional processing theory as a unifying theory to guide exposure therapy, and is perhaps best known for her pioneering work in developing Prolonged Exposure Therapy, a gold standard treatment for posttraumatic stress disorder. In 201, Time magazine include her in 2010 in their list the 100 Most Influential People in the World.

In “Prolonged Exposure Therapy: Past, Present, and Future,” Foa offers a brief summation of the work on prolonged exposure. Foa doesn’t address the recent criticisms directed at the emotional processing theory, particularly newer research that suggests habituation is not necessary in exposure therapy. However, the brief article provides a concise summary of the research on prolonged exposure. I learned that it has been adapted for use with complication grief, which I didn’t know before.

An Overview of Emotional Processing Theory

An Overview of Emotional Processing Theory

NOTE: This post is part of a larger series of on the theory, practice, and research on exposure therapy. If you are interested in other posts in this series, you can find them here.

Twenty-five years ago, in an attempt to create a unifying theory that would explain the processes of and guide the use of exposure in the treatment of anxiety disorders, Foa and Kozak (1986) developed the emotional processing theory (aka, information processing theory). The emotional processing theory has since guided an enormous amount of research, particularly for posttraumatic stress disorder (PTSD). Dr. Foa drew from the theory in developing prolonged exposure, a landmark PTSD treatment and the gold standard approach to PTSD treatment.

Much of my experience with the emotional processing theory comes from my training in prolonged exposure. When I was originally trained in prolonged exposure, I had the impression that it was more on the behavioral side of cognitive behavioral therapy. However, in reading about the emotional processing theory in greater depth, I realized that, although prolonged exposure looks procedurally like behavior therapy, the theory behind it is more of a product of the cognitive revolution with its emphasis on the computer as a metaphor for the human mind.

According to the emotional processing theory, fear is activated through associative networks that include information about the feared stimulus, escape or avoidance responses to the feared stimulus, and the meaning of the fear (e.g., threat or danger). Fear becomes problematic when it is intense to a degree that it gets in the way of functioning, or when it persists even when there are no clear indications of danger. In these instances, there may be maladaptive or pathological fear structures. The theory holds that chronic avoidance (e.g., escape behavior, avoidance, dissociation) often leaves these maladaptive schemas in place, as people do not remain in a situation long enough for new learning to occur.

Emotional processing theory proposes that exposure can alter the relationships between the fear stimulus and these networks. For this to happen, the network must first be activated, and then new information must be encoded that is incompatible with what is in the fear network. This is accomplished through habituation. Staying in contact with a fear stimulus until there’s a reduction in anxiety allows for the encoding of new information that is incompatible with the fear stimulus (e.g., it’s not dangerous). For example, in someone with OCD, repeated exposure to an obsession while refraining from engaging in a particular ritual serves to disconfirm maladaptive beliefs about the importance of the ritual in keeping harm away.

I break this process down with greater detail below.

Fear Structures

We’ll start with fear structures. Originally proposed by Lang (1977), fear structures are cognitive networks of maladaptive thinking that become activated through fear or anxiety. For people with anxiety-related problems, there are two common maladaptive beliefs about the fear stimulus: 1. That anxiety or distress will escalate to the degree it becomes unmanageable (e.g., “I can’t handle this”); 2. The feared stimulus or their experience of anxiety will cause harm (e.g., “I’ll lose control” or “I’ll go crazy”). For example, someone with panic disorder might think, “I’m going to die” when they start to notice panic cues like shortness of breath.

The major problem, according to emotional processing theory, is that people with anxiety disorders usually engage in some form of escape or avoidance behaviors when they feel anxious. As a result, they don’t remain in contact with their anxiety long enough to disconfirm the fear structure. Over time, people continue to engage in disruptive behaviors (e.g., escape) whenever they experience fear. An unfortunate side effect of continued avoidance behavior is that people’s lives begin to constrict in order to avoid things that trigger the fear structures. Their lives become narrower and more confined (e.g., they stop leaving the house).

Disconfirming Fear Structures Through Habituation

The solution then, according to the emotional processing theory, is for people to stay with their anxiety long enough for it to reduce on its own. Research suggests that so long as we don’t actively feed anxiety through worry, it tends to go down on its own after about 45 minutes –what is called habituation to the feared stimulus. Through repeated habituation, they begin to learn that what they’re afraid will happen (e.g., “I’ll go crazy”) doesn’t occur, and/or that the feared consequences are less likely to occur or are milder than expected (e.g., “If people notice I’m anxious, they’ll laugh at me”).

Foa and Kozak (1986) suggested that exposure weakens associations and replaces maladaptive fear associations with more adaptive ones. However, this view was revised in Foa and McNally (1996), where the authors incorporated animal behavior models of exposure from the lab of Bouton. Bouton’s work suggests that exposure does not actually alter associations so much as creates new, competing associations. What this means is that following exposure, there may now be two associations: a pathological one and a non-pathological one. Ideally, the person begins engaging in behaviors that are more in accordance with the non-pathological association, strengthening it over time.

Here’s an example: A motor vehicle accident survivor develops a fear structure involving thoughts that all automobiles are extremely dangerous. As a consequence, he stops driving. The therapist might arrange a series of exposure exercises involving automobiles. The person might start by sitting in a parked car each day until his anxiety decreases. He may then drive very slowly on low traffic streets, working his way up to driving again. The man may retain the association that all automobiles are dangerous, but through exposure a competing association that harm is unlikely accompanies it. The man may then make choices in accordance with this second association (e.g., the choice to drive a car).

A Glimpse Into the Future of the Emotional Processing Theory

This is a brief sketch of the emotional processing theory. It has been hugely influential in guiding research on anxiety treatment, particular for posttraumatic stress disorder and obsessive-compulsive disorder. The application of the emotional processing theory to PTSD has led to a very successful treatment—prolonged exposure. However, treatments may be effective even if the theories guiding them are not entirely accurate.

As I’ve written in a previous post, the main area in which newer research has brought the emotional processing theory into question is its emphasis on habituation. There’s no reason to offer a complete retread of the post, but newer research suggests that it’s not necessary for someone’s anxiety to go down during exposure in order for him or her to benefit. Additionally, McNally (2007) argued that the concept of “fear structures” is vague, circular, and not supported by research. Dr. Craske at UCLA, in particular, has criticized the principles underlying the emotional processing theory (See Craske et al, 2008 for a summary of exposure research; Baker et al, 2010, for study from Craske’s lab questioning the usefulness of habituation in predicting treatment outcome).

In upcoming posts, I’ll be discussing newer research that challenges the emotional processing theory, and that offers glimpses into where our understanding of exposure may go.

For more information about Emotional Processing Theory

If you want to read more about emotional processing theory, here’s a good book:

 Pathological Anxiety, Emotional Processing in Etiology and Treatment (2005), by Barbara Rothbaum.

Or for the most widely used guide for Prolonged Exposure, the main therapy approach guided by emotional processing theory, see:

Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide (2007) by Edna Foa, et al.

Contextual Behavioral Exposure: An Acceptance and Commitment Therapy Approach to Exposure

Contextual Behavioral Exposure: An Acceptance and Commitment Therapy Approach to Exposure

For the past year, I’ve been interested in how to use exposure in the context of Acceptance and Commitment Therapy.

Even after a year, I feel I’m only ever so slowly developing my understanding.

At Portland Psychotherapy, we have a weekly lab meeting where we discuss ongoing research projects and brainstorm new ones. Every so often, one of us gives a presentation to about something we’ve been working or reflecting on. Not long ago, I presented some guidelines for using exposure from both an ACT perspective and, more broadly, a contextual behavioral science perspective. The presentation was an attempt to offer practical suggestions for guiding exposure treatment in ACT. At the encouragement of our clinic director, I created a screencast of it.

Some Caveats About the Screencast


My presentation is a work in progress. It presumes a basic familiarity with ACT and exposure. I shied away from getting bogged down in research citations and focused on suggestions and decision points. I don’t consider it definitive or even fully fleshed out; rather, it’s a snapshot of my thoughts at the moment, a work in process.

Please keep these things in mind if you decide to watch it. It’s more of a sketch than a finished work. Hopefully, you may find something of value in it.

There are two parts:

Contextual Behavioral Exposure, Part 1

Contextual Behavioral Exposure, Part 2

Watch both of them via this playlist.

The Problems with Habituation as an Explanation for Exposure Treatment

The Problems with Habituation as an Explanation for Exposure Treatment

NOTE: This post is part of a larger series of on the theory, practice, and research on exposure therapy. If you are interested in other posts in this series, you can find them here.


As discussed in a previous post, it is clear that exposure, or the systematic confrontation with feared stimuli, seems to be a critical component of most therapies, particularly for the treatment of anxiety. However, the way in which exposure is conducted and theories about it why it works vary widely. For decades, one of the dominant concepts used to guide the conduct of exposure therapy was habituation.

In the context of exposure, habituation refers to reductions in fear over time as a person encounters fear-inducing stimuli. While it was originally a term that emerged from behaviorism, it seems to more recently be used to refer to any sort of a decrease in response to a stimulus. For example, you’ve probably had the experience of putting on sunglasses and eventually forgetting that you’re wearing them until you walk indoors and notice how dark everything looks. In these instances, you’ve habituated to feel of the glasses against your skin and the darkened tint of the lenses.

As a more personal example, after getting in a car accident, I remember feeling a sense of anxiety the first few of times I drove again. However, this subsided over time and now I rarely think about the accident when I’m driving. I wasn’t in therapy and didn’t approach this in a systematic way, but I recognized my reactions as minor posttraumatic stress symptoms that would eventually recede as I habituated to driving again. This is basically the same thing that happens in exposure therapy.

In a research context, habituation is often measured through objective physiological measures such as heart rate and skin conductance or through questionnaire measures of fear, such as the Subjective Units of Distress Scale (SUDS). (Instead of “distress,” I’ve also heard “discomfort” and “disturbance” used for the “D” in SUDS.)

Within-Session and Between-Session Habituation

There are two types of habituation in exposure therapy. Within-session habituation occurs when fear decreases during a therapy session as exposure is conducted. Between-session habituation occurs when fear decreases between therapy sessions.

Habituation doesn’t mean that fear goes away completely. Many people continue to experience a fear response when they encounter certain situations. For example, professional public speakers often say that they always feel at least a little nervous before a speaking engagement. However, they generally are often less nervous than they were when they first started (which is similar to between-session habituation) or they find their nervousness goes down more quickly when they begin speaking and become involved in what they’re doing (which is similar to within-session habituation).

The Old Guideline: Within-Session Habituation is Important

It used to be that habituation was used a primary guide for exposure treatment, particularly for treatment of PTSD and obsessive-compulsive disorder. Typical guidelines would be that the person should stay in contact with the feared stimulus until his or her fear went down. At that point, exposure might be discontinued. For example, here’s a diagram of the heart rate of a person doing exposure who is afraid of cats.

Often this happens naturally. If we don’t feed our anxiety by leaving the situation, it will often decrease on it’s own within about 45 minutes. Consequently, some exposure therapies specified that a person remain in an anxiety provoking situation for 30-60 minutes, or until anxiety decreased.

The New Guideline: Within-Session Habituation Doesn’t Matter

Although habituation has supplied thousands of clinicians with a measurable marker for beginning and ending exposure treatment, research hasn’t provided a lot of support for its reliability and validity. Using habituation isn’t necessarily a bad thing—it does provide a decent marker—but researchers haven’t found much of a relationship between within-session habituation and treatment success. There’s even some question whether between-session habituation matters, but that’s a little more controversial.

I’ll be going into this issue in more depth on subsequent posts, but for now, I’ll summarize. There’s evidence that clients may show physiological decreases in anxiety but continue to report high levels of fear, and vice versa. Put simply, it may not matter much whether people experience reductions in fear through exposure. The usefulness of exposure appears to be more about people getting used to their fear than changes in how strong it is. In sum, the research evidence for habituation doesn’t support its use in exposure therapy.

Look for future posts that go into greater detail on the problems with habituation.

What is Exposure Therapy and Why Does It Matter?

What is Exposure Therapy and Why Does It Matter?

A few months ago, I received a call from a casting director looking for exposure therapists to conduct on-camera exposure for a reality TV show by the people who made Hoarders. I turned it down, of course—the ethics of it made me uncomfortable. However, the encounter suggested that exposure is becoming more widely known outside of professional circles.

Exposure has been hailed as one of the greatest success stories in cognitive behavioral treatment, and it’s currently going through a fertile period as clinicians and researchers are redefining what makes exposure work. There’s an enormous body of research on the use of exposure for things such as a panic disorder, worry, phobias, obsessive-compulsive disorder, and posttraumatic stress disorder. I intend to devote time to exploring exposure research in greater depth across future posts.

What Is Exposure?

This is a good place to start: what is exposure? In a book chapter on exposure, Moscovitch, Antony, and Swinson (2009), offer a wonderfully succinct definition: “the repeated and systematic confrontation of feared stimuli.” But what does that mean? In essence, exposure involves having someone deliberately be with an experience that he or she would normally avoid. For example, having someone afraid of heights safely stand near the edge of a building. Often we think of exposure as a component in structured cognitive behavioral treatments. However, exposure doesn’t have to be so structured. Whether they realize it are not, therapists who ask their clients to sit with painful thoughts and feelings, as they come up in session, are using exposure too.

You’ll notice that the discussion of exposure in the paragraph above focuses on the procedure of exposure. It doesn’t tell us anything about how and why exposure works. The reason for this is that decades of research have proven exposure to be an extraordinarily effective treatment, but there is no consensus on its mechanisms of change.

Research on exposure began decades ago and was rooted in the early behaviorist perspective—classical conditioning (think, Pavlov’s dogs). Exposure was a way to undo a condition association between a neutral object or experience and a fear response. Several years later, cognitive therapists began using exposure as a way to challenge or disconfirm negative thoughts about feared outcomes. There is even a variant of exposure called implosive therapy in which therapists encouraged clients to imagine scenes with psychodynamic imagery as a way to facilitate exposure.

None of these theories used to explain exposure have been entirely satisfying. In addition, adding other interventions to exposure therapy  (e.g., relaxation, psychodynamic imagery) doesn’t appear to make it any more effective. Exposure seems to work on it’s own; however, without a theory to guide it, structuring exposure sessions can be tricky.

Who Uses Exposure?

Exposure is most often used by cognitive behavioral therapists, particularly those who specialize in anxiety disorders treatment. That said, there’s a lot of therapists who think exposure is a good idea, but who don’t use it in their own practices. Barriers include lack of training, fear that clients won’t tolerate it, and general discomfort with it. Exposure can be intense—for the therapists as well as the client! For example, the blog Psychotherapy Brown Bag has a nice post on the ethics of exposure therapy.

Clinicians seem especially reluctant to use exposure for posttraumatic stress disorder. Even though exposure is a gold standard treatment for PTSD, a survey of 207 licensed psychologists found that 83% never used exposure to treat people with PTSD (Becker et al., 2004). Another survey found that 84% of women with trauma would be willing to engage in exposure treatment after the rationale was explained to them. This suggests that clients are more willing to engage in exposure than therapists.

Why Am I Writing About Exposure?

For me, this series gives me an opportunity to delve into the exposure literature. My experience with exposure is that it can be a very potent intervention, but it requires thoughtful planning to successfully implement. There’s been some fascinating new research about exposure within the past 5 years. We seem to be going through a sea change in our understanding of it. My goal through these posts is increasing understanding of how we might better use exposure as therapists in clinical practice.


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.

Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.

Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.

Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.

Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 11, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.

The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. Read More.

Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD

May 13th, 2022Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div, M.S.