Sandy Capaldi, PsyD - Center for the Treatment and Study of Anxiety
Excerpted
and adapted from Capaldi, S., & Foa, E. B. (2025). Prolonged exposure
therapy for adolescents with PTSD: emotional processing of traumatic
experiences. In Evidence-Based Treatments for Trauma-Related Disorders
in Children and Adolescents (pp. 271-290). Cham: Springer Nature
Switzerland.
Prolonged Exposure therapy for
adolescents with PTSD (PE-A; Foa et al. 2008) is an adaptation of the widely
studied, empirically validated adult Prolonged Exposure (PE) protocol (Foa et
al. 2019). Developed for and tested with adolescents ages 12-18, PE-A is a
manualized, symptom-focused treatment designed to target PTSD symptoms in the
aftermath of all types of trauma. The treatment consists of four key phases:
pretreatment preparation, psychoeducation and treatment planning, exposures,
and relapse prevention/treatment termination. Each phase is comprised of
several modules that emphasize a specific therapeutic task or goal. While PE-A
is delivered in an individual format, it remains flexible, allowing for the
inclusion of parents or caregivers in portions of sessions. The structure
accommodates varying session lengths and pacing, ensuring adaptability to the
developmental needs of each adolescent. The typical course of treatment occurs
over 10–15 weekly sessions lasting 60-90 minutes each.
Emotional Processing Theory
The treatment is grounded in
cognitive-behavioral therapy and learning theory. Drawing from classical and
operant conditioning paradigms, the theory behind PE was influenced by Mowrer's
two-factor model of avoidance (Mowrer, 1960). In Mowrer’s model, fear is
initially acquired through classical conditioning, reinforced through avoidance,
and maintained through operant conditioning. Expanding on these ideas, Foa and
Kozak (1986; Foa et al. 2006) integrated Lang’s (Lang, 1977) concept of fear
structures, developing what has become known as emotional processing theory
(EPT). EPT provides a framework for understanding the factors that contribute
to the development and maintenance of post-traumatic stress symptoms, the
mechanisms underlying natural recovery from these symptoms, and the
amelioration of these symptoms via exposure treatments. EPT proposes that
emotions like fear are represented in memory as an emotional structure which
serves as a blueprint for action. This structure consists of three core
elements: representations of the feared stimuli, corresponding fear responses,
and the meanings associated with the stimuli and the responses. A fear
structure becomes maladaptive when it incorporates inaccurate or exaggerated
associations between the meanings associated with the stimuli and responses,
leading to fear responses to harmless stimuli. For example, an adolescent who
was bitten by a dog might generalize this fear to all dogs, avoiding them
completely—even friendly ones—because they believe any dog poses a threat.
According to EPT, traumatic memories
are structured emotional representations that encode the stimuli present during
the trauma, the individual's emotional and physiological responses (e.g., fear,
guilt, shame, freezing), and the meanings attributed to those experiences. In
PTSD, the trauma memory contains an excessive number of stimuli erroneously
linked to danger. For example, an adolescent who was sexually assaulted may
associate related but harmless stimuli, such as men with similar builds as the
perpetrator or small, enclosed spaces, with the meaning of danger. As a result,
individuals with PTSD are likely to perceive the world as entirely dangerous.
In addition, representations of the individuals’ responses during and following
the trauma often become associated with the meaning of incompetence (e.g., “I
failed to protect my friend”; “My PTSD symptoms mean I am weak”). These two
perceptions – that the world is entirely dangerous and the person is very
incompetent – serve to maintain PTSD symptoms.
PTSD symptoms often emerge
immediately after a traumatic event, but for many individuals, these symptoms
naturally diminish over time without intervention. EPT suggests that natural
recovery occurs through repeated exposure to trauma-related memories, emotions,
and situations in daily life. Engaging with these reminders—whether by
discussing the trauma, reflecting on associated emotions, or encountering
related environments—provide information that disconfirms the perception that
the feared stimulus is dangerous. For individuals who develop PTSD, however, avoidance
of trauma-related thoughts, feelings, and situations impedes activation of the
trauma memory and integration of disconfirming information that would alter the
pathological elements in the fear structure. To counteract this, treatment is
designed to approach the safe but feared situations to allow the opportunity to
experience the absence of negative consequences, which reduces or eliminates
the two perceptions that help to maintain PTSD symptoms – that the world is
entirely dangerous and the person is very incompetent.
For example, if an adolescent girl
who experienced a vicious dog attack avoids all dogs, she never learns that
most dogs she might encounter are actually safe. Additionally, by avoiding
thinking about what happened, this adolescent’s memory will often remain
fragmented and poorly articulated, and the erroneous perception that she may
have been responsible for the attack will remain unquestioned. The adolescent’s
avoidance behaviors are negatively reinforced because they temporarily reduce
distress and so become habitual in similar circumstances. If she sees a dog
approaching her on the street and quickly crosses to the other side, she
experiences immediate relief. If she begins to think about the attack, becoming
highly distressed, and immediately pushes those thoughts away or tries to
distract herself, she may also experience relatively quick relief. However,
while avoidance reduces distress in the short term, it perpetuates PTSD by
blocking experiences that would otherwise modify the pathological elements in
the fear structure. In our example, this adolescent girl does not get the
opportunity to learn that the dog could have been safe (because she avoided it)
or to learn that she is not to blame for the attack (because she does not allow
herself to think about it).
Learning about the relative safety
of trauma-related situations and memories and the relative competence of the
individual who experienced the trauma is achieved for many individuals who do
not develop PTSD through natural recovery. In essence, natural recovery
includes approaching trauma-related triggers in daily life so that learning can
occur. Effective PTSD treatment modifies the pathological elements of the fear
structure and reduces pathological reactions by simulating natural recovery. In
order to achieve this, two conditions are necessary. First, the fear structure
must be activated (i.e., feared stimuli must be approached). Second, new
information that is incompatible with the unrealistic elements (i.e., the
feared stimuli is not dangerous) must be available and incorporated. When this
new learning (or emotional processing) takes place, stimuli that used to evoke
pathological responses will no longer do so.
PE-A aims to promote emotional
processing by encouraging adolescents to talk about the trauma, referred to as
revisiting and recounting the trauma memory (imaginal exposure), and to
approach objectively safe situations that are trauma reminders, referred to as
real-life experiments (in vivo exposure). By deliberately confronting safe but
avoided trauma-related thoughts, feelings, and situations, the pathological
fear structure is activated, and erroneous elements are modified through
corrective experiences. Repeatedly recounting the traumatic memory reduces the
anxiety associated with thinking about the trauma, provides opportunities to
organize and better understand what happened, and helps the adolescent to
explore and disconfirm other erroneous perceptions (e.g., that the adolescent’s
actions mean he/she is incompetent or at fault for the trauma). Confronting
trauma reminders and situations that are erroneously perceived as dangerous via
real-life experiments reduces PTSD symptoms by breaking the habit of avoidance,
promoting recognition that these situations are not harmful, and increasing the
adolescent’s confidence in his or her ability to cope.
Research Evidence
Research on Prolonged Exposure
Therapy for Adolescents (PE-A) has demonstrated its effectiveness in treating
PTSD and superiority to active comparison treatments in multiple randomized controlled
trails (RCTs).
- PE-A
vs. Time-Limited Dynamic Psychotherapy (TLDP): In Gilboa-Schechtman et al.’s
(2010) RCT, adolescents (ages 12–18) with PTSD stemming from a single-event
trauma (n = 38) were randomized to receive either PE-A or TLDP. Results showed
that 73.7% of PE-A participants achieved good end-state functioning compared to
31.6% in TLDP. Furthermore, 68.4% of adolescents in the PE-A group no longer
met criteria for PTSD post-treatment, compared to 36.8% in TLDP. These
improvements were sustained at 6- and 17-month follow-ups.
- PE-A
vs. Client-Centered Therapy (CCT): This RCT (Foa et al., 2013) assessed
adolescent females (ages 13–18) with PTSD related to sexual abuse (n = 61) who
sought treatment in a community mental health setting. PE-A led to greater
reductions in PTSD and depression symptoms, as well as enhanced global functioning
compared to CCT. At post-treatment, 83.3% of adolescents receiving PE-A no
longer met PTSD criteria, versus 54% in the CCT group. These gains persisted at
12-month follow-up.
- PE-A
vs. Supportive Counseling (Delivered by Psychotherapy-Naïve Nurses): In this
RCT, Roussouw et al. (2018) examined PE-A’s effectiveness among adolescents
(ages 13–18) with chronic PTSD due to interpersonal trauma (n = 63) in South
African schools. The PE-A group showed more significant PTSD and depression
symptom reductions and improved global functioning compared to those receiving
supportive counseling. By post-treatment, 80% of PE-A participants no longer
met PTSD criteria, compared to 48% in the counseling group. These results
remained stable at 12- and 24-month follow-ups (Roussouw et al., 2022).
Notably, this study demonstrated that psychotherapy-naïve nurses could
successfully deliver PE-A with fidelity, reinforcing its potential for broad
implementation, particularly in low- and middle-income countries.
- Impact
on behavioral symptoms & suicidal ideation: Utilizing data from Foa et al.
(2013), Zandberg et al. (2016) found that adolescents treated with PE-A
exhibited greater reductions in externalizing symptoms, including
rule-breaking, aggression, and conduct problems, compared to those receiving
Client-Centered Therapy (CCT). Additionally, Brown et al. (2020) observed that
suicidal ideation decreased more rapidly in adolescents who underwent PE-A than
in those randomized to CCT.
- Therapeutic
alliance and treatment outcomes in PE-A: Process-focused research has
highlighted the importance of therapeutic alliance in PTSD recovery. Capaldi et
al. (2016) analyzed data from Foa et al. (2013) and found that adolescent-rated
alliance improved more in PE-A than in CCT, with stronger alliance associated
with better treatment outcomes across both therapies. These findings challenge
concerns that exposure-based interventions might disrupt therapeutic
relationships, demonstrating that symptom-focused trauma work can enhance
alliance rather than hinder it.
- Mechanisms
of change in PE-A: Studies examining the underlying processes in PE-A suggest
that modifications in trauma-related cognitions play a central role in symptom
relief. McLean et al. (2015) found that changes in negative trauma-related
beliefs mediated reductions in both PTSD and depression symptoms. Later
research (McLean et al., 2017) reinforced this connection, showing that PTSD
symptom reductions during PE-A led to subsequent decreases in depressive
symptoms.
- Exploratory
research on “intensive” PE-A:
- Hendriks et al. (2017) examined a
five-day intensive PE-A program for adolescents (ages 12–18) with PTSD and
comorbid disorders stemming from multiple interpersonal traumas. The model
consisted of 15 PE-A sessions in five days, followed by three weekly booster
sessions. Findings indicated significant reductions in PTSD, depression,
anxiety, and dissociation symptoms from pre- to post-treatment, with no
dropouts or adverse events, suggesting potential benefits for treatment
retention.
- Tijsseling et al. (2024) conducted
a trial examining an intensive PE-A format that included four half days of
treatment per week for two weeks and included 90 minutes of PE-A and 90 minutes
of EMDR each day. Results indicated PTSD remission rates of 58%–62% and
decreases in PTSD severity compared with baseline, with treatment effects
maintained at 1-month and 3-month follow-ups and a dropout rate of 13%.
- Rentinck et al. (2025) investigated
an intensive treatment format that consisted of six treatment days, divided
into three treatment days per week, for two consecutive weeks and included 90
minutes of PE-A and 90 minutes of EMDR each day. Findings showed a significant
reduction in PTSD symptoms (Cohen’s d = 1.66) and depressive symptoms (Cohen’s
d = 1.02) from pre-treatment to one month after treatment, with 70% (n=52) showing
a clinically meaningful response, and 65% (n=48) no longer meet the PTSD
criteria one month after treatment. Dropout was 4% (N = 3) and no adverse events
or worsening of symptoms were observed.
These findings underscore PE-A’s effectiveness
and adaptability across different populations and settings, making it a vital
evidence-based intervention for adolescents with PTSD. Research on PE-A has
expanded beyond its core effectiveness to examine secondary outcomes and
treatment processes as well.
While existing studies support PE-A as an effective
intervention, further research is warranted to refine its implementation.
Larger-scale randomized clinical trials comparing PE-A with other
evidence-based PTSD treatments in adolescents are needed. Future research
should also explore cultural adaptations, mechanisms driving symptom change,
and predictors of treatment success and failure to optimize outcomes. Although
additional studies are necessary, current evidence strongly supports PE-A as a
first-line treatment for adolescent PTSD
Brown LA, Belli G,
Suzuki N, Capaldi S, & Foa EB. (2020). Reduction in suicidal
ideation from prolonged exposure therapy for adolescents. Journal of
Clinical Child & Adolescent Psychology, 49(5), 651-659. https://doi.org/10.1080/15374416.2019.1614003
Foa EB, Chrestman K,
& Gilboa-Schechtman E. (2008) Prolonged exposure therapy for adolescents
with PTSD: Emotional processing of traumatic experiences. Oxford University
Press.
Foa EB, Hembree EA,
Rothbaum BO, & Rauch, S. (2019). Prolonged exposure therapy for PTSD:
Emotional processing of traumatic experiences - therapist guide, 2nd edition.
Oxford University Press.
Foa EB, Huppert JD,
& Cahill SP. (2006). Emotional processing theory: an update. In: Rothbaum
BO (ed) Pathological anxiety: emotional processing in etiology and treatment
(pp. 3–24). Guilford Press.
Foa EB & Kozak MJ.
(1986). Emotional processing of fear: exposure of corrective information.
Psychological Bulletin, 99, 20–35. https://doi.org/10.1037/0033-2909.99.1.20
Foa EB, McLean CP,
Capaldi S, & Rosenfield D. (2013). Prolonged exposure vs. supportive
counseling for sexual abuse-related PTSD in adolescent girls: a randomized
controlled trial. JAMA, 310, 2650–2657. https://doi.org/10.1001/jama.2013.282829
Gilboa-Schechtman E,
Foa EB, Shafran N, Aderka IM, Powers MB, Rachamim L, Rosenbach L, Yadin E,
& Apter A. (2010). Prolonged exposure versus dynamic therapy for adolescent
PTSD: a pilot randomized controlled trial. Journal of the American Academy of Child
and Adolescent Psychiatry, 49, 1034–1042. https://doi.org/10.1016/j.jaac.2010.07.014
Hendriks, de Kleine,
RA, Heyvaert, M, Becker, ES, Hendriks, GJ, & van Minnen, A. (2017).
Intensive prolonged exposure treatment for adolescent complex posttraumatic
stress disorder: a single-trial design. Journal of Child Psychology and
Psychiatry and Allied Disciplines., 58(11), 1229–1238. https://doi.org/10.1111/jcpp.12756
Lang, P. J. (1977).
Imagery in therapy: An information processing analysis of fear. Behavior
Therapy, 8(5), 862–886. https://doi.org/10.1016/S0005-7894(77)80157-3
McLean, CP, Su, Y,
Carpenter, JK, & Foa, EB. (2017). Changes in PTSD and depression during
prolonged exposure and client-centered therapy for PTSD in adolescents. Journal
of Clinical Child & Adolescent Psychology, 46(4), 500-510, https://doi.org/10.1080/15374416.2015.1012722
McLean, CP, Yeh, R,
Rosenfield, D, & Foa, EB, Changes in negative cognitions mediate PTSD
symptom reductions during client-centered therapy and prolonged exposure for
adolescents, Behaviour Research and Therapy, 68, 64-69.
https://doi.org/10.1016/j.brat.2015.03.008
Mowrer, OH. (1960). Learning
theory and behavior. John Wiley & Sons Inc. https://doi.org/10.1037/10802-000
Rentinck, E. M., van
Mourik, R., de Jongh, A., & Matthijssen, S. J. M. A. (2025). Effectiveness
of an intensive outpatient treatment programme combining prolonged exposure and
EMDR therapy for adolescents and young adults with PTSD in a naturalistic setting.
European Journal of Psychotraumatology, 16(1).
https://doi.org/10.1080/20008066.2025.2451478
Rossouw, J., Yadin, E.,
Alexander, D., & Seedat, S. (2018). Prolonged exposure therapy and
supportive counselling for post-traumatic stress disorder in adolescents:
Task-shifting randomised controlled trial. The British Journal of Psychiatry,
213(4), 587-594. https://doi.org/10.1192/bjp.2018.130
Rossouw, Yadin, E.,
Alexander, D., & Seedat, S. (2022). Long-term follow-up of a randomised
controlled trial of prolonged exposure therapy and supportive counselling for
post-traumatic stress disorder in adolescents: a task-shifted intervention. Psychological
Medicine., 52(6), 1022–1030. https://doi.org/10.1017/S0033291720002731
Tijsseling, I.,
Noordende, A. T. V. T., Zijlstra, B. J., Merbis, M., & Veen, S. C. V.
(2024). The Effectiveness and Tolerability of an Intensive Outpatient Trauma
Treatment Program for Adolescents With PTSD. Journal of EMDR Practice and
Research, 18(2), 68-81.
Zandberg, L,
Kaczkurkin, AN, McLean, CP, Rescorla, L, Yadin, E, & Foa, EB. (2016).
Treatment of adolescent PTSD: The impact of prolonged exposure versus
client-centered therapy on co-occurring emotional and behavioral problems.
Journal of Traumatic Stress, 29(6), 507–514. https://doi.org/10.1002/jts.22138
