For many people living with the aftermath of trauma, avoidance becomes a way of life. You stop going to certain places. You push memories away. You stay busy so you don't have to feel. And for a while, it works — until it doesn't.

Prolonged Exposure (PE) therapy is one of the most extensively studied treatments for post-traumatic stress disorder. Developed by the late Dr. Edna Foa at the University of Pennsylvania, it has been shown to significantly reduce PTSD symptoms in the majority of people who complete it. I had the privilege of training in PE and participating in Dr. Foa's research at Penn — and I saw firsthand how transformative this approach can be. Her passing in March 2026 was a profound loss to the field, but her legacy lives on in every clinician she trained and every patient whose life was changed by her work.

So how does it actually work?

PE is built on a straightforward idea: avoidance keeps trauma alive. When we avoid reminders of what happened — whether those are places, people, memories, or feelings — we never get the chance to learn that those things are no longer dangerous. The fear stays frozen in time.

PE involves two core components. The first is imaginal exposure, where you recount the traumatic memory aloud in a safe therapeutic setting, repeatedly, until the memory loses its overwhelming emotional charge. The second is in vivo exposure, where you gradually re-engage with real-world situations you've been avoiding — not dangerous situations, but safe ones that trauma has made feel threatening.

What PE is not

PE is not about "reliving" your trauma for the sake of it. It's not about being re-traumatized. It's a structured, guided process where your therapist helps you approach difficult material at a pace that's manageable. You're always in control.

It's also not a quick fix. PE typically involves 8 to 15 sessions, and the work between sessions matters. But the research consistently shows that people who engage in PE experience meaningful, lasting reduction in PTSD symptoms — including people with complex trauma histories.

Who is PE right for?

PE has been used successfully with survivors of sexual assault, combat veterans, survivors of childhood abuse, accident survivors, and people who've experienced domestic violence. It works across ages, genders, and cultural backgrounds. In 2007, the Department of Veterans Affairs adopted PE as a first-line treatment for PTSD — a testament to the strength of the evidence behind it.

My own published research with Dr. Foa examined trauma exposure and PTSD rates in Philadelphia's community mental health system, and found that the need for evidence-based trauma treatment far exceeds what most people realize.

If you've been struggling with nightmares, flashbacks, hypervigilance, or emotional numbness — and if avoidance has become your primary coping strategy — PE may be worth exploring.

The hardest part is starting

Most people who seek trauma therapy have been living with their symptoms for years. The idea of talking about what happened can feel impossible. That's completely understandable. A good therapist will never push you faster than you're ready to go.

How I work with trauma

Intensive PE protocol is demanding — for both client and therapist — and delivering it well requires a clinical infrastructure that goes beyond what a solo practice can provide. I take that standard seriously because I helped build it.

In my practice, I provide evidence-based trauma therapy grounded in CBT, exposure principles, and emotional processing theory — the same body of knowledge that underpins PE. For clients who would benefit from the full intensive PE protocol, I offer thorough assessment and direct referrals to specialized providers, including colleagues at the University of Pennsylvania's Center for the Treatment and Study of Anxiety — the center Dr. Foa founded.

If you're curious about what approach might be right for you, a consultation is a good first step. You don't need to have the right words — just reaching out is enough.

You wake up exhausted. Not the kind of tired that sleep fixes — the kind that sits in your bones. You go through the motions: care for the kids, check on your aging parent, show up for work, hold it together for everyone who needs you. And at the end of the day, there's nothing left.

This is caregiver burnout. And it's not a weakness — it's what happens when a deeply caring person gives more than they have, for longer than anyone should.

What caregiver burnout actually looks like

Burnout doesn't always look dramatic. Sometimes it shows up as irritability that surprises you — snapping at someone you love over something small. Sometimes it's a creeping numbness, a feeling of going through the motions without being present. Sometimes it's resentment toward the very people you're caring for, followed immediately by guilt for feeling that way.

Other signs include difficulty sleeping even when you're exhausted, withdrawing from friends and activities you used to enjoy, feeling like nothing you do is ever enough, and physical symptoms like headaches, muscle tension, or getting sick more often than usual.

Why caregivers resist getting help

If you're a caregiver, chances are you've internalized a belief that your needs come last. You might tell yourself that other people have it worse. That you should be able to handle this. That taking time for yourself is selfish.

These beliefs are understandable — they often come from a lifetime of being the responsible one, the strong one, the person others turn to. But they're also the beliefs that keep you stuck.

Here's the truth: you cannot pour from an empty cup, and that's not a motivational poster — it's a clinical reality. Chronic stress without recovery leads to emotional depletion, compassion fatigue, and eventually, a breakdown in your ability to care for anyone, including yourself.

What therapy for burnout looks like

Therapy for caregiver burnout isn't about adding one more thing to your list. It's about creating a space — maybe the only space in your life — where someone is focused entirely on you.

In therapy, we work on identifying the patterns that got you here. We challenge the beliefs that tell you your needs don't matter. We build practical strategies for setting boundaries, asking for help, and reconnecting with the parts of yourself that got lost in the caregiving.

Cognitive Behavioral Therapy can help you recognize and restructure the thought patterns that keep you trapped in the cycle of over-giving. A trauma-informed approach can address any underlying experiences that shaped your relationship with caregiving in the first place.

You don't need to earn the right to get help

If any of this resonates, I want you to know something: you don't need to be in crisis to deserve support. You don't need to justify it. You just need to reach out.

A brief consultation — 15 minutes, no pressure — is a good first step. It's a chance to talk about what's going on and see if therapy feels like the right next move.

When people first consider therapy, one of the first questions is usually: "Does my insurance cover this?" It's a reasonable question. Therapy is a financial commitment, and insurance exists to help with healthcare costs.

But there's something most people don't realize about how insurance works with mental health care — and understanding it can change how you think about the investment.

What insurance requires

To use insurance for therapy, your therapist has to give you a mental health diagnosis. That diagnosis goes on your permanent medical record. Insurance companies then dictate how many sessions you're approved for, what kind of treatment is covered, and when you need to stop.

Your therapist also has to submit notes and treatment plans to the insurance company, which means a third party has access to details about your care. For many people, that level of outside involvement doesn't feel compatible with the kind of open, private space therapy is supposed to be.

What private pay offers

Private pay — also called out-of-pocket or self-pay — means you pay your therapist directly. There's no diagnosis requirement, no session limits, and no insurance company reviewing your treatment.

This creates several meaningful advantages. Your therapist can tailor your treatment entirely to your needs, not to what an insurance company will approve. There are no arbitrary limits on how many sessions you can have. Your therapy stays completely private — no diagnosis on your record, no notes sent to a third party. And you have the freedom to choose the therapist who's the best fit for you, not just whoever is in your network.

The cost question

Private pay therapy in Pennsylvania typically ranges from $125 to $200+ per session for a licensed therapist. That's real money, and it's worth being honest about that. But consider what you're getting: an hour each week with a highly trained professional, focused entirely on helping you live a better life.

The superbill option

Even with private pay, you may be able to get partial reimbursement from your insurance company. Many therapists provide what's called a superbill — a detailed receipt you can submit to your insurer for out-of-network reimbursement. Depending on your plan, you may get back 40-80% of the session cost.

It's worth calling your insurance company and asking about your out-of-network mental health benefits before ruling out private pay. Under the No Surprises Act, you also have the right to receive a Good Faith Estimate of costs before starting treatment.

The bottom line

Insurance-based therapy works well for some people. But if you value privacy, flexibility, and a therapeutic relationship that isn't shaped by a corporation's coverage policies, private pay is worth serious consideration.

The best way to figure out what's right for you is to talk to a therapist directly. A brief phone or video consultation can help you understand your options and decide what feels right.

Dr. Edna Foa, the developer of Prolonged Exposure (PE) therapy, died this spring at the age of 88. Her passing has prompted me to revisit the years I spent practicing the treatment she developed, and to reflect on what that work taught me about trauma, healing, and the kind of clinician I wanted to become.

What the work was

For five years early in my career, I delivered PE as a primary therapist on a research study at the University of Pennsylvania's Center for the Treatment and Study of Anxiety. The study compared PE to client-centered therapy in survivors of sexual violence. I sat with the same group of clients week after week, under two hours of weekly supervision from the Penn team. It was the most rigorous clinical training I have ever received.

PE itself is built on a counterintuitive idea: avoidance keeps trauma alive, and the path through is to approach what happened in a careful, systematic, supported way. Before this approach was widely accepted, much of the field believed direct engagement with traumatic memories would harm patients. PE challenged that. Study after study has shown it significantly reduces PTSD symptoms in the majority of patients who complete it. By 2007, the Department of Veterans Affairs adopted PE as a first-line treatment for PTSD, training over a thousand therapists nationwide.

What the work taught me

Doing this work for five years taught me three things I carry into every session.

Trust the evidence. PE works because it has been tested. It is studied, measured, refined. The discipline of working inside that kind of rigor taught me to be skeptical of clinical intuition unmoored from data. The treatments we offer to people in pain should be backed by the strongest possible evidence, not just clinical comfort. That conviction has shaped my entire career.

People are more resilient than we think. PE asks patients to approach what they have spent years avoiding. Many clinicians resist this because they worry about causing harm. The work showed me, over and over, that people can face extraordinarily difficult material and come through it stronger. I carry that belief into every client relationship now: the person across from me has more capacity than they know.

Access matters. PE was developed in a research environment, but its purpose was always broader: to make effective treatment available where it is needed most. I spent a decade in Philadelphia's public behavioral health system, building initiatives to expand access to effective mental health treatment. For the past four years I've continued that work at the state level across Pennsylvania. This is what I do every day, alongside my clinical practice. The need for effective, accessible trauma treatment in under-resourced communities is enormous, and the gap between what works and what's available remains one of the central problems in the field.

How this shows up in my practice today

The lessons of those five years are the foundation of how I work with every person who comes to me. Trust the evidence. Believe in resilience. Prioritize access. Whether I'm doing trauma work, helping someone through burnout, or sitting with anxiety, those principles guide the way I show up.

Dr. Foa's contribution to the field was extraordinary. Her work made effective treatment for PTSD possible for millions of people. The clinicians who trained in the environment she built will carry that work forward for decades to come.

Resources

If you're interested in learning more about Prolonged Exposure Therapy:

• Center for the Treatment and Study of Anxiety, University of Pennsylvania
• APA Clinical Practice Guideline: Prolonged Exposure
• National Center for PTSD: About Prolonged Exposure
• NIMH: Post-Traumatic Stress Disorder