PROLONGED EXPOSURE COUNTERCONDITIONING (PEC)
Definition:
A behavioral-cognitive treatment in which learned emotional experiences of pleasure
and mastery are identified and imaginally relived in order to (a) strengthen the exposure
tolerance to learned painful emotional experiences, (b) counter depressive symptoms of
diminished interest in valued activities, social isolation and distancing from other people, and
a dampening of valued emotions such as joy or happiness, and (c) weaken learned painful
emotional experiences.
Elements:
Targets (a) dampened pleasurable and mastery experiencing, and (b) learned painful
emotional experiences.
Includes:
-Identification of the most valued pleasurable and mastery experiences in a clients life.
-Identification of the most central details of the highly valued pleasurable and mastery
experiences.
-Imaginal reliving of the most central pleasurable and mastery experiential details for a
prolonged time.
-Exposure to central trauma details for a short period of time.
-An immediate prolonged imaginal reliving of the most valued pleasurable and mastery
experiences after the trauma exposure.
-Daily listening to an audiotaped cassette of the session.
Related procedures:
As in covert reinforcement pleasurable activities are imaginally relived. However,
PEC utilizes idiosyncratically most pleasurable or strongest mastery experiences. Also, these
experiences are relived for a prolonged time in PEC.
The pleasurable and mastery reliving that is utilized in PEC in order to weaken a
traumatic experience can be conceptualized as a counterconditioning procedure similar to
systematic desensitization (SD). But contrary to SD that uses physiological relaxation
responses to counter anxiety and fear, in PEC incompatible emotional experiences of pleasure
and mastery are applied. Furthermore, the fear exposure in PEC is more thorough and intense
than in SD.
The prolonged pleasurable and mastery reliving can function as a behavioral
experiment that can be used in order to counter dysfunctional beliefs such as (a) a view of
oneself as unable to experience pleasure and mastery, (b) a belief that oneself is a worthless
individual, (c) a conviction that other people are malevolent or untrustworthy, and (d) a view
of the future as hopeless.
PEC is similar in its structure to implosive therapy for PTSD. In implosive therapy for
PTSD trauma exposure is preceded and succeeded by muscular and mental relaxation
exercises.
Application: Individual therapy.
First use:
Paunovic, N. (2003). Prolonged exposure counterconditioning as a treatment for chronic
posttraumatic stress disorder. Journal of Anxiety Disorders, 17, 479-499.
Other reference:
Paunović, N. (2002). Prolonged exposure counterconditioning (PEC) as a treatment for
chronic post-traumatic stress disorder and major depression in an adult survivor of
repeated child sexual and physical abuse. Clinical Case Studies, 1, 148-169.
Brief case illustration of PEC
The client was a 29-year-old woman that had developed PTSD as a result of three
sexual assaults committed by her uncle when she was 14 yrs old and a sexual assault by a
stranger at 19 yrs of age. She also suffered from severe depression and guilt. In PEC treatment
the client was first asked to identify self-relived life events during which she had felt most
happy/glad/well in her entire lifetime. The client was asked to identify three life events in
each of the following life areas: 1. Achieved goals or activities, 2. Events with her best
friends, 3. Most valued activities, 4. Appreciation, praise or affection from other people, and
5. Other life events. She was then asked to choose one life event from each category that had
made her feel most happy/glad/well. Second, the client was asked to specify details of each
event during the moments when she had felt most happy/glad/well. The client was asked to
describe details of what had happened, what she had seen, heard, felt, done, and what other
people did when she felt most happy/glad/well. The therapist wrote down all relevant details
that were stated by the client.
PEC was conducted in three steps. First, the following life events were imaginally
relived for a prolonged time: 1. She drives a chopper during her birthday, 2. She is on
barbecue with her friends, 3. She picks mushrooms with her boyfriend in a forest, 4. She
lights a fire with her family at their countryside, and 5. She gives a present to her mother-in-
law. The therapist repeated aloud each central detail of the pleasurable/ mastery life events on
a continuous basis at the same time as the client imaginally relived these details with her eyes
shut. For example, the following details were relived from event 2: “You build a fireplace
with your friends (naming each person); you pick branches and logs to sit on; you arrange
stones; you collect wood; your dog is with you and you play together; you see your friends
(naming each person); you hear the fire crackle; you hear your dog whining; you grill pork
fillet and marshmallows; you feel the taste; you see your dog and all the others sitting beside
you; you feel your dogs head on your back and how he pushes you down; you feel satisfied
and happy”.
During sessions 1-4 the client was imaginally exposed to the most central details of
her traumatic experiences for 5 minutes. During sessions 5 and 6 she was first exposed to
violent video movie scenes for 1-2 minutes and then imaginally exposed to the central trauma
details for 5 minutes. During imaginal reliving of the trauma she was asked to describe details
of what had happened, what she had seen, heard, done, and what the perpetrator did when she
felt most afraid/distressed during the event. The following details were repeated aloud by the
therapist while the client imaginally relived them with her eyes shut: “You hear him say, ‘you
want to’, but your whole body says ‘no’; you hear him blame you, he says ‘you want to’”.
During the peak of her trauma-related distress the client switched back to an imaginal reliving
of her most pleasurable life moments for a prolonged time by therapist prompting in the same
way as before the trauma exposure. During sessions 1-2 she imaginally relived pleasurable
life moments for 45 min. before the trauma exposure and 40 min. after the exposure. During
sessions 3-4 she imaginally relived pleasurable events 30 min. before the first trauma
exposure and 25 min. after two trauma exposures. During session 5-6 she imaginally relived
pleasurable life events 20 min. before the first trauma exposure and 15 min. after three trauma
exposures. From pre- to posttreatment her PTSD, depression and guilt had decreased to a non-
clinical level and she no longer suffered from her traumatic experience after the treatment.
