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PTSD: National Center for PTSD

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In Vivo Exposures for Prolonged Exposure Therapy During a Pandemic


In Vivo Exposures for Prolonged Exposure Therapy During a Pandemic

Lisa Cuccurullo, PsyD, and Jennifer Joyce, PsyD

Prolonged Exposure (PE;1), is an evidence-based treatment for PTSD. A core component of PE is exposure. The purpose of exposure is to help patients overcome avoidance of memories and activities that cause trauma-related distress. In PE there are two types of exposure. During imaginal exposure, patients retell the trauma memory. During in vivo exposure, patients do activities where they gradually approach trauma-related memories, feelings and situations that are avoided because of the trauma. The therapist and patient develop a hierarchy of avoided activities that the patient practices through in vivo exposure between sessions.

Conducting PE during the coronavirus (COVID-19) pandemic may require creativity to identify in vivo exposures that are meaningful and effective for patients while also compliant with 'shelter-in-place,' physical distancing, and other safety recommendations. The good news is PE is a robust treatment and can be successful, even in these unique circumstances.

Avoidance and Exposure

During the COVID-19 pandemic, it may be appropriate for patients to avoid certain situations that they normally avoid because of their PTSD, such as being in a crowded place. Many patients will also have situations they are avoiding because of their PTSD that are still safe during the pandemic. It is important to look for both when developing the in vivo hierarchy.

It is important to remind patients about the rationale behind conducting exposures, specifically:

  • Exposure breaks the habit of avoidance
  • Exposure helps patients process their trauma
  • Doing avoided activities gets easier over time
  • Exposure provides patients the opportunity for new learning, such as "I can handle this" and "This situation is not dangerous"
  • Exposure promotes personal mastery

The three categories of in vivo exposures:

  1. Exposure to situations, activities, objects that are avoided because they are perceived as dangerous
  2. Exposure to situations or cues that are avoided because they are reminders of the trauma
  3. Behavioral activation


When creating an in vivo hierarchy with patients, it is important to talk about the function of their avoidance. Patients may avoid the same situation for different reasons.

  • Patient One avoids the grocery store because she feels vulnerable and uncomfortable in crowds.
  • Patient Two avoids the grocery store because the smell of the flowers when she enters the store reminds her of her trauma.
  • in vivo exposures during COVID-19 (as always) need to address the function of the avoidance. In the examples above, each patient's in vivo hierarchy may look very different even though the situation they avoid (going to the store) is the same.

    In Vivo Assignments During COVID-19

    Below are examples of in vivo assignments that can be compliant with COVID -19 restrictions. This is not an exhaustive list but is intended to help therapists be creative in planning in vivo exercises.

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    Expert clinicians from the PTSD Consultation Program are available to talk with therapists about how they might adapt these suggestions for a specific Veteran patient. We can be reached at or 866-948-7880

    The headings below are categories of avoidance. Under each heading are examples of in vivo exercises that may work well within pandemic-related restrictions.

    Exposure to situations, activities, objects that are avoided because they are perceived as dangerous.


    • Imaginal exposure to a crowded situation
    • Watch video clips of crowds
    • Sit in the car close to the entrance of a supermarket or other essential business

    People are dangerous

    • Sit at home with the windows and/or blinds open
    • Sit on porch with back to the street
    • Sit in backyard with gate open
    • Drive with the doors unlocked
    • Sit in car in a parking lot with the doors unlocked
    • Walk with headphones in ears
    • Listen to music at a high enough volume so that other noise would not be able to be heard
    • Close eyes while listening to music
    • Go for a walk while maintaining social distancing


    • Sit in the car in driveway or street
    • Sit in the car with the engine on outside
    • Drive alone in one's own neighborhood
    • Drive alone in an unknown neighborhood
    • Drive in traffic: there is typically traffic near hospitals or medical testing locations
    • Ride as a passenger while a housemate drives

    Exposure to situations or cues that are avoided because they are reminders of the trauma.

    Enclosed spaces (can be modified with lighting, opening doors, time of day, etc.)

    • Sit in the smallest area in the living space (e.g., closet)
    • Sit in the shower stall or bathtub
    • Sit in a car
    • Tuck oneself in blankets
    • Wear a face mask or covering

    Pictures or videos

  • Go through old pictures/videos from the time of the trauma
  • Go through old pictures/videos that include reminders of the trauma (example: military friends or in military uniform)
  • Movies/TV shows/YouTube

    • Watch a movie or TV show that was popular at the time of the trauma
    • Watch a movie or TV show that has a scene that is reminiscent of the trauma
    • Watch a movie or TV show that has a character or actor who is a reminder of a person associated with the trauma


    • Spend time in the room with an odor reminder
    • Keep the odor reminder on lap
    • Sounds

    • Have sounds that are reminders of the trauma playing in the room
    • Use headphones to listen to reminder sounds


    • Be in the room with clothing that is a reminder of the trauma (e.g., uniform)
    • Wear or touch clothing that is the trauma reminder Locations
    • Watch videos or online pictures of places that look like the trauma location
    • Go to locations and walk in environments that are reminders of the trauma

    Behavioral activation

    • Go for a bike ride
    • Watch a favorite movie
    • Listen to comedy
    • Engage in a favorite hobby
    • Call a friend or family member
    • Video chat with a group
    • Connect with a religious or other community group via a video meeting
    • Drive by to say hello to a loved one
    • Read a book or magazine
    • Exercise
    • Garden
    • Take a bath
    • Cook a meal
    • Write a gratitude list
    • Participate in an exercise class online

    Safety behaviors

    Safety behaviors prevent patients from learning that they can tolerate avoided situations successfully. Therapists may already be familiar with their patients' safety behaviors, but some new ones may emerge in light of the pandemic. Some safety behaviors that therapists may want to ask about are listed below:

    • Home lighting: Are lights consistently kept on or off?
    • Weapons in the home: Where are they stored? Can they be locked away?
    • Monitoring behaviors: Are you consistently sitting in certain locations to monitor the door, window or other parts of the home?
    • Doors: Are room doors consistently open or closed? If so why?
    • Volume: Does the TV or music always maintain a certain volume? If so why?
    • Clothes: Are there certain clothes or shoes that are always worn at home? If so why?
    • Pets: Are there ways in which they are used as protection? If so how? Are there ways in which they are used as a mechanism for self-soothing? If so how?

    Living in the Spirit of the Treatment

    A patient's routine is likely to be different during the pandemic. Patients may have more, or less, time for in vivo exposure assignments, may have to do homework at a different time than before, or may have to rethink when and how they do assignments because of privacy issues.

    It is important to work collaboratively with patients and be creative and flexible to help the patient find solutions. In addition to in vivo assignments, therapists may want to ask patients to continue to engage in behaviors that are in the spirit of the treatment. These can be activities that support their treatment goals but may not take as much time as an exposure or cannot be repeated or are difficult to repeat. These tasks can include:

    • Call customer service
    • Work on a household task
    • Ask for help on a task
    • Help someone with a task or goal
    • Reach out to a loved one via phone or video chat
    • Join a social media group
    • Initiate a hug with a loved one
    • Make a meal for yourself or a loved one
    • Learn something new
    • Eat a meal with a loved one


    • Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. A. M. (2019) Prolonged Exposure Therapy for PTSD: Emotional processing of Traumatic Experiences - Therapist Guide (2nd Edition). Oxford.

    PTSD Information Voice Mail: (802) 296-6300
    Also see: VA Mental Health