Is My Client Ready for Prolonged Exposure (PE) Therapy?

An Occupational Therapy Perspective 

Prolonged Exposure (PE) therapy is a highly effective, evidence-based treatment for post-traumatic stress disorder (PTSD). It involves gradually and repeatedly approaching trauma-related memories, feelings, and situations that have been avoided. While PE can be transformative, it is not the right starting point for every client. As Occupational Therapists (OTs), our role includes assessing readiness, supporting nervous system regulation, and ensuring the foundations for safe and effective trauma processing are in place. 

Why Readiness Matters 

Research consistently shows that trauma-focused therapies such as PE yield strong outcomes for PTSD. However, initiating exposure work without sufficient stabilization can lead to overwhelm and disengagement. Readiness is not about “toughness” - it is about whether a client has the internal and external resources to remain engaged, regulated, and supported throughout the process. 

The Window of Tolerance: A Core Framework 

A central concept in determining readiness is the window of tolerance, a term coined by Dr. Dan Siegel. It describes the optimal zone of arousal where a person can effectively process information, regulate emotions, and stay present. 

• Within the window: The client can experience distress while maintaining a sense of safety and control. 

• Hyperarousal (above the window): Fight-or-flight responses dominate - anxiety, panic, irritability, racing thoughts. 

• Hypoarousal (below the window): Shutdown responses - numbness, dissociation, fatigue, disconnection. 

PE requires clients to intentionally approach trauma-related distress. If a client is frequently outside their window - either overwhelmed (hyperaroused) or shut down (hypoaroused) - they may not yet be ready for exposure work. Instead, widening and stabilizing the window becomes the immediate therapeutic priority. 

Nervous System Regulation: The Foundation of Readiness 

From an OT lens, functional engagement in therapy depends on the ability to regulate one’s nervous system. Clients ready for PE generally demonstrate: 

• The ability to recognize early signs of dysregulation 

• Access to effective self-regulation strategies (e.g., grounding, paced breathing, sensory modulation) 

• The capacity to return to baseline after distress 

• Tolerance of moderate emotional activation without dissociation or panic 

If a client becomes quickly overwhelmed, dissociates, or cannot recover after emotional activation, PE may be premature. In these cases, interventions should focus on building regulation skills through bottom-up (body-based) and top-down (cognitive) strategies. 

Trauma-Informed Care: Safety First 

A trauma-informed approach is essential when considering PE readiness. This includes principles of: 

• Safety (physical and emotional) 

• Choice and collaboration

• Trustworthiness and transparency

• Empowerment and skill-building

Clients should have a clear understanding of what PE involves and actively consent to this type of work. They should feel a sense of control over pacing and be able to communicate boundaries. If a client feels pressured, uncertain, or unsafe, proceeding with PE may undermine therapeutic trust and outcomes. 

The Role of Stabilization 

Stabilization is not a delay - it is an active and necessary phase of trauma therapy. Evidence-based trauma models (including phase-oriented treatment approaches) emphasize that building safety and regulation precedes trauma processing. 

Key stabilization targets include: 

• Establishing consistent daily routines and occupational balance 

• Strengthening coping strategies and distress tolerance 

• Addressing immediate safety concerns (e.g., suicidality, substance misuse, unstable living situations) 

• Improving sleep, nutrition, and physical health 

• Building social supports 

As OTs, we uniquely contribute by helping clients develop meaningful routines, structure, and engagement in daily life - all of which support nervous system stability. 

Indicators of Readiness for PE 

While readiness is individualized, the following indicators suggest a client may be prepared to begin PE: 

• They can remain within or return to their window of tolerance during moderate distress 

• They understand the rationale for exposure and are motivated to engage 

• They demonstrate consistent use of coping and regulation strategies 

• Their environment is relatively stable and safe 

• They can tolerate discussing trauma-related topics without extreme dysregulation 

• There is a strong therapeutic alliance and sense of trust 

When to Pause or Reconsider 

It may be important to delay PE if a client: 

• Frequently dissociates or becomes overwhelmed during sessions 

• Has active safety concerns (e.g., ongoing trauma exposure, suicidal crisis) 

• Lacks reliable coping or grounding strategies 

• Is experiencing severe instability in housing, relationships, or health 

• Expresses reluctance or fear about engaging in exposure work 

In these cases, continuing with stabilization and capacity-building is both clinically appropriate and evidence-based. 

The Occupational Therapy Perspective 

Occupational Therapists play a critical role in preparing clients for PE. Our focus on daily functioning, sensory processing, and meaningful activity provides a practical and embodied pathway toward readiness. We help clients: 

• Build routines that support regulation 

• Develop sensory and grounding strategies tailored to their needs 

• Increase participation in valued activities to strengthen resilience 

• Translate therapy skills into real-world contexts 

Final Thoughts 

Prolonged Exposure therapy can be life-changing - but timing matters. Readiness is less about symptom severity and more about regulation, safety, and capacity. By grounding our clinical reasoning in the window of tolerance, trauma-informed care, and nervous system regulation, we can better support clients in engaging with PE safely and effectively. In many cases, slowing down to stabilize is what ultimately allows us to move forward with confidence. 

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Oxford University Press.

Edgelow, M. M., MacPherson, M. M., Arnaly, F., Tam-Seto, L., & Cramm, H. A. (2019). Occupational therapy and posttraumatic stress disorder: A scoping review. Canadian Journal of Occupational Therapy, 86(2), 134–148.

McLean, C. P., & Foa, E. B. (2024). State of the science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder. Journal of Traumatic Stress.