TIRCIA · EMDR
EMDR and exposure therapy
What they have in common, what sets them apart, and how to bring them together
By Marie-Agnès Thulliez · Author · Publishing Director13-minute read
EMDR and exposure therapy are often presented as two separate worlds, even as rivals. Yet they have a great deal in common: both ask the patient to move closer to what they avoid. For practitioners, the value lies in understanding what distinguishes them, how to choose between them, and how to bring the findings of exposure research into EMDR practice. Here is an overview for therapists.
In brief
- Prolonged exposure and EMDR are among the most effective treatments for PTSD, with similar results in the trials that compare them head to head.
- They differ mainly in how they engage the memory: at length and repeatedly in exposure, in short sets combined with bilateral stimulation in EMDR.
- The inhibitory learning model has renewed our understanding of exposure and offers principles that are useful to any clinician, including in EMDR.
- Combinations (the phobia protocol, Flashforward, intensive programmes) are promising, but have so far been little evaluated in controlled trials.
1. Exposure therapy
Rooted in cognitive behavioural therapy, exposure involves facing, in a prepared and repeated way, what a person fears and avoids: a memory, a situation, a sensation. It is at the heart of the treatment of phobias, panic disorder and obsessive-compulsive disorder.
In PTSD, its most widely studied form is the prolonged exposure developed by Edna Foa (Foa et al., 2007). The protocol usually comprises 8 to 15 sessions of 90 minutes: psychoeducation and breathing, then imaginal exposure (the patient recounts the traumatic memory aloud, in the present tense, several times per session, with a recording to listen to again at home) and in vivo exposure (gradually confronting, between sessions, situations that are safe but avoided). A meta-analysis showed large effects compared with control groups (Powers et al., 2010). The American Psychological Association places it at the highest level of recommendation for PTSD, above EMDR (APA, 2025).
Why exposure works: from habituation to inhibitory learning
Foa and Kozak’s emotional processing theory explained the effect of exposure through the activation of the “fear structure” followed by the integration of information incompatible with it, with the reduction in anxiety within and between sessions serving as an indicator (Foa and Kozak, 1986). More recent research has shown that the reduction in anxiety during a session is a poor predictor of long-term outcome. The inhibitory learning model offers another reading: the original fear is left in place, while a new learning (“this is no longer dangerous”) comes to compete with it, and it is the strength of this new learning that protects against relapse (Craske et al., 2014).
This model has direct practical implications that are of interest to every clinician:
The principles of inhibitory learning
- Aim for expectancy violation: before the exercise, put into words what the patient fears, then check what actually happened, rather than waiting for the anxiety to go down.
- Vary the contexts: different places, times and intensities, so that the new learning generalises.
- Reduce safety behaviours: what the patient does to reassure themselves (avoiding eye contact, keeping their phone in hand) prevents them from discovering that the danger does not materialise.
- Label emotions: putting words to what one feels during exposure appears to strengthen its effect.
2. EMDR
In EMDR, the patient brings the memory to mind for only a few dozen seconds at a time, while following bilateral stimulation, and then simply notes what comes up. They do not recount the memory in detail and have no mandatory exercises between sessions. According to Francine Shapiro’s clinical model, the aim is less to habituate to the memory than to “reprocess” it so that it is integrated differently (see our article The AIP model).
Is EMDR exposure in disguise? The question long divided researchers. An early meta-analysis found no specific effect of eye movements (Davidson and Parker, 2001); a more recent meta-analysis concludes that they have a moderate additional effect compared with simply recalling the memory (Lee and Cuijpers, 2013). The best-supported explanation today is the working memory account: the dual task is thought to make the memory less vivid and less emotionally charged. The two methods therefore share an element of exposure, but EMDR involves more than that.
3. What they have in common, what sets them apart
| Prolonged exposure | EMDR | |
|---|---|---|
| Contact with the memory | Long and repeated (full account, several times per session) | Brief (sets of a few dozen seconds) |
| Attention | Entirely focused on the memory | Divided between the memory and bilateral stimulation |
| Detailed account | Yes, aloud | Not required |
| Between sessions | In vivo exercises and listening to recordings | No mandatory exercises |
| Session length | Often 90 minutes | Often 60 to 90 minutes |
| Proposed explanation | Inhibitory learning | Reprocessing (AIP model) or working memory load |
| Common ground | Reducing avoidance | Reducing avoidance |
4. Which is more effective?
Both. In one of the trials that compared them directly, in women who had been raped, prolonged exposure and EMDR were both superior to a waiting list, with no significant difference between them, either at the end of treatment or at six months (Rothbaum et al., 2005). On a larger scale, a network meta-analysis of 98 randomised trials found that prolonged exposure, EMDR and cognitive processing therapy all markedly reduce PTSD symptoms, with none clearly standing out from the others (Yunitri et al., 2023). The APA nevertheless ranks prolonged exposure one notch above EMDR, according to its own weighting of the evidence; the trials that compare the two methods directly show no difference in effectiveness.
One finding is of particular interest to clinicians who hesitate to offer trauma-focused work to patients considered fragile. In 155 patients with both a psychotic disorder and PTSD, prolonged exposure and EMDR, delivered without a prior stabilisation phase, were effective and did not worsen symptoms; adverse events were in fact less frequent than in the waiting-list group (van den Berg et al., 2015).
5. How to choose together with the patient
Since neither has been shown to be superior to the other, the choice rests on clinical criteria and on the patient’s preference:
- The patient’s preferences and fears: some dread recounting the memory in detail and prefer EMDR; others appreciate the explicit structure of exposure.
- The capacity to do exercises between sessions, which is essential in prolonged exposure.
- The nature of the fear: fear centred on a memory, on avoided present-day situations, or on a future catastrophe.
- The risk of dropout: a meta-analysis found an average dropout rate of 16% in psychotherapy trials for PTSD, higher for trauma-focused therapies (Lewis et al., 2020). Explaining the rationale clearly and tailoring it to the patient matters as much as the technique.
- The therapist’s training: a well-mastered method serves the patient better than one applied approximately.
A long-standing finding is worth recalling: a survey of American psychologists showed that the great majority of them did not use exposure to treat PTSD, often for fear of worsening symptoms or for lack of training (Becker et al., 2004). The available evidence encourages clinicians to move beyond this reluctance, within a well-prepared framework.
6. Combining the two
Combinations are being explored more and more:
- In phobias: the EMDR protocol for specific phobias ends with real-life exposure exercises, to check and consolidate progress (de Jongh et al., 1999).
- When facing fear of the future: the Flashforward procedure (in French) targets, within EMDR, the dreaded catastrophic image, when the fear concerns what might happen rather than a memory (Logie and de Jongh, 2014).
- In intensive treatment: in the Netherlands, programmes lasting a few days alternate prolonged exposure and EMDR, with large reductions in symptoms. These studies, however, have no control group (Matthijssen et al., 2024; Rentinck et al., 2025).
- After reprocessing: when the memory is no longer disturbing but avoidance persists out of habit, in vivo exercises built on inhibitory learning principles help the patient to reclaim the situations they have been avoiding.
In every case, exposure should be prepared with the patient, explained and agreed to: a person is always told in advance before facing what they fear.
7. Photos, videos, virtual reality: what role do they play?
When a patient finds it hard to picture the feared situation, a photo or video can help to activate the fear in a measured way. Virtual reality exposure has proved effective in anxiety disorders, with results comparable to conventional exposure (Carl et al., 2019). The value of these aids within an EMDR session, on the other hand, has yet to be evaluated in studies: it is a reasonable clinical practice, though not yet a validated method.
Clinical vignette
A fictional case, drawn from common clinical situations.
Julien, 41, was involved in a serious motorway accident two years ago. He has PTSD and has not driven since. He says straight away that he does not feel “able to tell the story of the accident in detail over and over again”. After discussing it with him, the therapist suggests EMDR. In four reprocessing sessions, the memories of the accident no longer disturb him (0 out of 10) and the nightmares have stopped.
Yet Julien still does not drive. A Flashforward session targets the dreaded image of a lorry veering into his lane. Then, with the therapist, he builds a graded series of in vivo exercises: driving in a car park, then in town, then on a main road, and finally on the motorway. Before each step, he writes down what he fears (“I’m going to panic and lose control”), then what actually happened. Three months later, he is driving to work on his own. In this course of treatment, EMDR processed the memory of the accident, and exposure allowed him to reclaim his driving.
What is established, and what is still to be confirmed
- Established: prolonged exposure and EMDR are both effective in PTSD, with similar results.
- Established: exposure is a reference treatment for phobias and anxiety disorders.
- Established: in patients considered fragile, such as those with a psychotic disorder, these trauma-focused treatments have been delivered without worsening, within a suitable framework (one randomised trial, van den Berg et al., 2015).
- To be confirmed: the value of EMDR–exposure combinations and of digital aids in EMDR.
Frequently asked questions
Should an EMDR therapist train in exposure?
It is optional, but knowing the principles of inhibitory learning is very useful, particularly for phobias, residual avoidance after reprocessing, and patients for whom EMDR alone is not enough.
Can you switch from one to the other if the first does not work?
Yes. If improvement is insufficient, switching to another trauma-focused approach is a reasonable option, discussed with the patient and, if necessary, in supervision.
Is exposure dangerous for patients with complex trauma?
The available evidence shows no general worsening with trauma-focused treatments, including in patients considered fragile. Pace and preparation should nonetheless be tailored to each patient (see our article on stabilisation).
In one sentence
EMDR and exposure complement each other: they are two ways, both effective, of helping the patient stop avoiding what frightens them.
The right choice is the one that suits the patient and that the therapist has mastered; and the principles of inhibitory learning can enrich any practice.
References
- American Psychological Association (2025). New guidelines for treating PTSD and trauma. Monitor on Psychology, July-August 2025. Link
- Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42(3), 277-292. Link
- Carl, E., Stein, A. T., Levihn-Coon, A., et al. (2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 61, 27-36. Link
- Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23. Link
- Davidson, P. R., & Parker, K. C. H. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69(2), 305-316. Link
- de Jongh, A., ten Broeke, E., & Renssen, M. R. (1999). Treatment of specific phobias with EMDR: Protocol, empirical status, and conceptual issues. Journal of Anxiety Disorders, 13(1-2), 69-85. Link
- Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged Exposure Therapy for PTSD: Therapist Guide. New York: Oxford University Press.
- Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20-35.
- Lee, C. W., & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44(2), 231-239. Link
- Lewis, C., Roberts, N. P., Gibson, S., & Bisson, J. I. (2020). Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: Systematic review and meta-analysis. European Journal of Psychotraumatology, 11(1), 1709709. Link
- Logie, R., & de Jongh, A. (2014). The "Flashforward procedure": Confronting the catastrophe. Journal of EMDR Practice and Research, 8(1), 25-32. Link
- Matthijssen, S. J. M. A., et al. (2024). The effects of an intensive outpatient treatment for PTSD. European Journal of Psychotraumatology, 15(1). Link
- Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30(6), 635-641.
- Rentinck, E. M., van Mourik, R., de Jongh, A., & Matthijssen, S. J. M. A. (2025). Effectiveness of an intensive outpatient treatment programme combining prolonged exposure and EMDR therapy for adolescents and young adults with PTSD in a naturalistic setting. European Journal of Psychotraumatology, 16(1). Link
- Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18(6), 607-616. Link
- van den Berg, D. P. G., de Bont, P. A. J. M., van der Vleugel, B. M., et al. (2015). Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: A randomized clinical trial. JAMA Psychiatry, 72(3), 259-267. Link
- Yunitri, N., Chu, H., Kang, X. L., et al. (2023). Comparative effectiveness of psychotherapies in adults with posttraumatic stress disorder: A network meta-analysis of randomised controlled trials. Psychological Medicine, 53(13), 6376-6388. Link
This article summarises the scientific evidence available at the date of publication. It is no substitute for clinical training, supervision, or the advice of a health professional.
