EMDR versus Prolonged Exposure For the Treatment of Trauma

When it comes to effective treatment for trauma, two psychotherapy approaches consistently stand out: Eye Movement Desensitization and Reprocessing (EMDR) and Prolonged Exposure (PE). 

In fact, they are two of the three psychotherapies that are recommended as first-line treatments for Post-Traumatic Stress Disorder in the updated 2023 VA/DoD Clinical Practice Guideline for Management of PTSD as well as in the 2019 treatment guidelines by the International Society for Traumatic Stress Studies. Both have been extensively researched and shown to be effective in reducing PTSD symptoms, but they differ significantly in philosophy, process, and overall client experience. This blog will dive into each therapy, how they compare, and recommendations for treatment.

What is Prolonged Exposure (PE)?

Prolonged Exposure (PE) therapy is a cognitive-behavioral approach developed by Dr. Edna Foa. The core principle behind PE is that avoidance keeps trauma symptoms alive. By having clients repeatedly and methodically bring up traumatic material, their nervous system gradually learns through habituation that these memories and triggers are no longer dangerous or scary. This process can be done through imagination (imaginal exposure) or real-world experiences (in vivo exposure). Over time, the nervous system gradually becomes less reactive.

For imaginal exposure, a typical PE process may involve systematically recounting the traumatic memory in detail across multiple sessions. For in vivo exposure, the client may be asked to confront real-life triggers; that is, situations, people, or places that are safe, of course, but associated with trauma-related fear. These experiences, including one’s emotional reactions, meanings, and interpretations, are then discussed verbally in therapy to be processed.

Research shows PE can significantly reduce trauma symptoms such as avoidance, hypervigilance, and intrusions. However, if you can imagine, the process can feel emotionally demanding, as clients are asked to repeatedly confront painful material head-on. For some, this intensity can be re-traumatizing if not carefully paced and supported. In many studies, the dropout rate is higher as a result than with other forms of psychotherapy, such as EMDR.

What is EMDR Therapy?

EMDR Therapy, developed by Dr. Francine Shapiro in the 1980s, approaches trauma from a TOTALLY different angle. EMDR is based on the idea that trauma symptoms are the result of insufficiently processed, maladaptively stored memories from the past. So, when an overwhelming event occurs, some of the experience gets "stuck" so to speak and stored in the brain indefinitely, causing a host of significant trauma-related issues. In EMDR therapy, these specific negative experiences are identified and then reprocessed using various forms of bilateral stimulation. As the memory becomes neutral and adaptive, the related symptoms subsequently decrease.

Mangrove Therapy Group is known for being experts in the South Florida community in EMDR Therapy. Check out our various blogs written on the subject!

EMDR versus PE, Head-to-Head

Multiple studies have been done comparing each approach in a head-to-head fashion. Check out this page compiled by the EMDR Institute detailing the findings of each study along with references for each article. Generally-speaking, no statistically-significant differences have been found between each modality for the treatment of PTSD, though there are some clear qualitative differences between the two. 

One of the differences is that EMDR does not require any homework, while cognitive-behavior approaches such as PE require many hours of homework that is usually quite uncomfortable.

Clients often find EMDR less overwhelming than exposure-based methods, since they don’t have to provide full verbal accounts of their traumatic experiences if they don’t want to. Bessel van der Kolk, one of the top researchers in the field of trauma, said this in his book, The Body Keeps the Score, about how EMDR is superior to exposure therapy:

“If [patients] manage to stay with the treatment and keep reliving their trauma, they slowly become less reactive and less prone to disintegrate when they recall the event…  However, as far as we know, simply exposing someone to the old trauma does not integrate the memory into the overall context of their lives, and it rarely restores them to the level of joyful engagement with people and pursuits they had prior to the trauma.  In contrast, EMDR […] focuses not only on regulating the intense memories activated by trauma but also on restoring a sense of agency, engagement, and commitment through ownership of body and mind.” (p. 256)

EMDR + Prolonged Exposure: A Combined Approach

While EMDR and PE are often presented as separate treatment options, emerging research shows that they don’t have to be mutually exclusive. In fact, some clinicians integrate principles of both approaches in their treatment of traumatized clients.

This study, done in the Netherlands, examined the effectiveness of an intensive treatment program where participants received a session of PE in the morning and then a session of EMDR in the afternoon. This was done for 5 straight working days and included daily sessions of physical exercise. Results showed a significant decrease in post-traumatic stress symptoms.

This study was a follow-up to the Netherlands study, but this time investigating whether the sequence mattered regarding whether patients received PE or EMDR first. As before, participants received daily sessions of both PE and EMDR, but half did PE first, and the other half did EMDR first. This was done for eight days, while also having daily physical exercise. Both groups showed significant improvements in PTSD symptoms, though the group that did PE first, followed by EMDR, showed significantly better results than the other group.

This third study was a case report of a patient who had intensive online trauma treatment using both PT and EMDR 2.0. EMDR 2.0 is a modified EMDR protocol that relies on taxing working memory (click here to see a blog by Mangrove therapist, Amber Zalman, who is an expert on the protocol). After six days of treatment, the study's patient, Mary, achieved full remission of PTSD.

A colleague of ours, Aleighsha Webber, LMHC of Still I Rise Counseling, who is a Certified EMDR therapist near Fort Walton Beach, shared an innovative approach to treating one of her client's blood draw phobia. To treat this, Aleighsha combined basic exposure therapy concepts with EMDR. She had the client bring in the blood draw kit to session, first starting off with it lying on the table next to the therapist so it was in the peripheral vision, then bringing it closer and closer as the session progressed. All the while, they engaged in EMDR reprocessing as they targeted negative memories from the past of scary blood draws and passing out. This particular client had tried exposure and response prevention (ERP) therapy in the past but to no avail as she still kept passing out due to extreme fear. However, by the end of this single combined EMDR + exposure session, the client actually felt excited to go and get her blood drawn! 

Final Thoughts

Both EMDR and Prolonged Exposure are powerful, evidence-based approaches to trauma therapy. Neither has been shown in research to be more effective than the other in the treatment of PTSD, though more head-to-head studies need to be conducted on this topic.

Start Working With an EMDR Therapist in Palm Beach County, FL

At Mangrove Therapy Group, we specialize in trauma-focused therapies, including EMDR and exposure-based approaches. We will tailor treatment to each of our clients’ unique preferences and needs. If you’re considering therapy for trauma and want to learn more about these methods, we’re here to help guide you toward the path of recovery that fits you best! Start your therapy journey with us by following your simple steps:

1. Contact Mangrove Therapy Group 

2. Meet with a caring therapist 

3. Start finding lasting recovery from trauma!

Other Services Offered with Mangrove Therapy Group

EMDR therapy is just one piece of the healing puzzle, and our therapists are trained to support you through so much more. Our Delray Beach, FL office, also offers care for:

• Trauma, EMDR intensives, PTSD, and Complex PTSD
• Substance use and process addictions
• Eating disorders and body image concerns
• Grief, loss, anxiety, depression, and self-esteem challenges
• Anger, shame, emotional dysregulation
• “Failure to Launch” issues and life transitions
• CBT and DBT-based support

If you’re ready, we’re here. Let’s help you build a life where your nervous system doesn’t have to brace for impact—and where love starts to feel like a soft place to land. You can learn more from our blog or FAQs page.