To Expose or Not to Expose: A Comprehensive Perspective on Treatment for Posttraumatic Stress Disorder

Trauma-focused psychotherapies, in particular prolonged exposure (PE) therapy, have been recognized as the “gold standard” for the treatment of posttraumatic stress disorder (PTSD). But effectiveness and implementation data show that a large proportion of patients who undergo exposure therapy retain their PTSD diagnosis, and implementation studies have shown low engagement and high dropout rates. Meanwhile, non-trauma-focused therapies have shown promise in treating PTSD. In this review, we aim to answer the question of whether exposure is necessary to treat PTSDby integrating clinical and research literature from multiple perspectives. We review the roots of exposure therapy in both psychodynamic and behavioral paradigms and their proposed mechanisms. We then review non-trauma-focused treatments and their proposed mechanisms. We conclude that the specific form of exposure required by PE is not necessary for symptom remission. Finally, common psychotherapy factors may facilitate patient self-directed exposure outside of the therapy context. These findings should alter the direction of clinical research to identify the therapy processes that most effectively promote the processing of trauma memories. With respect to clinical practice, shared decision-making should allow for increased patient autonomy in choosing either trauma-focused or non-trauma-focused treatments.