The Broader Challenges of Traditional Therapies
While traditional therapies such as Cognitive Behavioral Therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR), and Exposure Therapy are well-established treatments for PTSD, they are not without significant limitations. Understanding these challenges is needed to recognize why alternative therapies are gaining attention.
Time-Intensive Nature of Psychotherapy: Psychotherapeutic interventions, particularly those aimed at treating trauma, are often long-term processes requiring multiple sessions over weeks or months. CBT, EMDR, and Exposure Therapy involve incremental progress, and patients may not experience significant symptom relief until much later in their treatment course. The time commitment can be overwhelming for individuals, especially those in acute distress, contributing to high dropout rates. Moreover, many patients in crisis require more immediate symptom alleviation, which traditional therapies cannot always provide.
Emotional Readiness and Stability Requirements: Traditional therapies often demand a certain level of emotional stability and readiness from patients. PTSD patients, especially those with severe symptoms, may not be emotionally prepared to engage fully in intensive treatments. For instance, revisiting traumatic memories through exposure or EMDR can initially exacerbate distress, leading to overwhelming emotional responses. This emotional intensity can make it difficult for some patients to remain engaged in treatment, further complicating their healing process.
Potential for Re-Traumatization: Exposure-based therapies can be particularly challenging because they require patients to confront trauma-related stimuli. Without careful pacing and therapeutic support, patients may experience re-traumatization—where they feel as though they are reliving their trauma. This can heighten anxiety, avoidance, and overall distress, making the therapeutic process counterproductive for some. Clinicians must be highly skilled in managing these risks, but even under the best circumstances, re-traumatization remains a potential pitfall of trauma-focused interventions.
Limited Efficacy in Complex Trauma Cases: For individuals with complex PTSD, which often results from prolonged exposure to traumatic events (e.g., childhood abuse or combat), traditional therapies may not provide adequate relief. Complex trauma typically involves deeper emotional and relational wounds that are not as easily addressed through cognitive restructuring or exposure to specific triggers. These patients often need more holistic and integrative approaches that can address the multifaceted nature of their trauma, including dissociation, emotional dysregulation, and interpersonal difficulties.
Efficacy of Traditional Therapies
While CBT, EMDR, and Exposure Therapy are considered gold-standard treatments for PTSD, their efficacy varies significantly among different populations, and these therapies do not work for everyone. Many patients, especially those with complex or treatment-resistant PTSD, experience limited symptom reduction, and in some cases, no improvement at all.
- CBT Efficacy: Cognitive Behavioral Therapy (CBT) has a robust evidence base and is often cited as one of the most effective treatments for PTSD. Research consistently shows that CBT can lead to a 40-60% reduction in PTSD symptoms for many individuals. However, despite its strengths, CBT does not achieve full remission for all patients, with approximately one-third of individuals showing limited improvement or experiencing residual symptoms. This limitation is especially pronounced in cases involving complex trauma, where patients often have a history of prolonged or repeated traumatic experiences, leading to more extensive disruptions in emotional regulation, cognitive function, and interpersonal relationships. For these individuals, the structured, cognitive focus of CBT may not fully address the depth of their emotional and relational needs, suggesting the necessity of alternative or supplementary therapeutic approaches.
- EMDR Efficacy: EMDR is similarly effective for many patients, with meta-analyses showing that it can reduce PTSD symptoms significantly, often in fewer sessions than CBT. Studies have demonstrated that EMDR can lead to full remission in up to 50-60% of cases . However, like CBT, its effectiveness is reduced with complex PTSD or co-occurring conditions, such as depression or substance abuse. Research by Van der Kolk et al. (2007) showed that while EMDR significantly reduced PTSD symptoms, patients with more complex trauma profiles often required additional support beyond the initial treatment phase .
- Exposure Therapy Efficacy:
Exposure Therapy has been shown to effectively reduce PTSD symptoms, particularly for individuals who experience significant avoidance behaviors and hypervigilance. Studies indicate that 50-70% of patients report meaningful symptom reduction following exposure-based interventions, underscoring its efficacy in addressing trauma-related anxiety. However, as with other traditional therapies like CBT and EMDR, Exposure Therapy’s effectiveness may be limited in cases of complex trauma or in individuals with dissociative symptoms. Patients with complex trauma often find it challenging to engage fully with exposure processes due to the intensity of the emotional responses that arise, which can complicate treatment outcomes and necessitate additional therapeutic support..
Relapse and Symptom Recurrence
Even for patients who complete therapy, relapse remains a major concern, particularly in the absence of ongoing support or booster sessions. Follow-up studies suggest that a significant proportion of individuals experience a return of PTSD symptoms after completing treatment, often within months or years.
- CBT Relapse Rates: While CBT often provides substantial symptom relief for PTSD patients, studies indicate that relapse rates can be as high as 30% within the first year after treatment. This suggests that although CBT equips patients with valuable coping strategies for addressing cognitive distortions, it may not consistently result in long-term changes in emotional and behavioral patterns, particularly in the absence of follow-up care. These findings highlight the importance of incorporating maintenance sessions or booster therapy to reinforce cognitive and emotional resilience over time, minimizing the risk of symptom recurrence.
. - EMDR Relapse Rates: Research on the long-term efficacy of Eye Movement Desensitization and Reprocessing (EMDR) suggests that many patients achieve lasting symptom relief. However, relapse remains a concern, especially among individuals with complex trauma. Studies indicate that approximately 20-30% of patients experience a recurrence of PTSD symptoms within the first year post-treatment, often triggered by new stressors or unresolved aspects of their trauma history. These findings highlight the need for ongoing support and potential booster sessions to help patients maintain their progress, particularly in the face of future life challenges.
- Exposure Therapy Relapse Rates: Relapse rates for Exposure Therapy are a notable concern, with studies indicating that up to 35% of patients experience a return of PTSD symptoms within two years after completing treatment. This recurrence is especially common among individuals who continue to avoid trauma-related stimuli or who lack ongoing support to reinforce the therapeutic progress made during treatment. These findings suggest that long-term maintenance strategies, including booster sessions or supportive follow-up, may be necessary to sustain the benefits of Exposure Therapy and prevent symptom recurrence..
Conclusion
The statistical evidence on dropout rates and efficacy highlights the limitations of traditional PTSD therapies. While CBT, EMDR, and Exposure Therapy are effective for many patients, a substantial proportion either drop out of therapy or fail to achieve full remission. For those who do complete therapy, relapse remains a risk, particularly in the absence of ongoing support. These findings underscore the need for alternative treatment options that can offer faster relief, lower dropout rates, and better long-term outcomes for individuals with PTSD.
The Need for Alternative Therapies
As discussed, while traditional therapies like CBT, EMDR, and Exposure Therapy have provided significant benefits for many individuals with PTSD, there are key issues. High dropout rates, the time-intensive nature of therapy, and the emotional toll it can take on patients highlight the limitations of these methods. Furthermore, some individuals—particularly those with treatment-resistant or complex PTSD—may not achieve adequate symptom relief through conventional approaches alone.
The emergence of alternative therapies offers new hope for those who have not responded to traditional treatments. In the following Chapters, we will demonstrate that these novel approaches, including ketamine, psilocybin, and MDMA-assisted therapies, have the potential to provide faster relief and potentially more comprehensive healing by addressing the neurobiological, emotional, and cognitive dimensions of trauma. As research continues to grow, these therapies are becoming an increasingly viable option for many individuals struggling with PTSD.
In Chapter 3, we introduce ketamine, a promising alternative therapy emerging in PTSD treatment. Unlike traditional therapies, we will present evidence that ketamine works rapidly to reduce symptoms and enhance neuroplasticity, offering new hope for those who have not found success with standard treatments.
Chapter 2: References
Time-intensive nature of psychotherapy for PTSD
- Hoge, C. W., Grossman, S. H., Auchterlonie, J. L., Riviere, L. A., Milliken, C. S., & Wilk, J. E. (2014). “PTSD treatment for soldiers after combat deployment: Low utilization of mental health care and reasons for dropout.” Psychiatric Services, 65(8), 997-1004.
Examines dropout rates in PTSD treatment among soldiers, highlighting how the lengthy nature of psychotherapy, including CBT and EMDR, contributes to high attrition rates, particularly among individuals seeking immediate relief. - Swift, J. K., & Greenberg, R. P. (2012). “Premature discontinuation in adult psychotherapy: A meta-analysis.” Journal of Consulting and Clinical Psychology, 80(4), 547-559.
Conducts a meta-analysis on dropout rates in psychotherapy, finding that time commitment and delayed symptom relief are primary reasons for attrition, especially among patients in acute distress. - Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). “Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults.” Cochrane Database of Systematic Reviews, (12).
Reviews the time-intensive nature of CBT, EMDR, and Exposure Therapy, noting that these therapies often require a long-term commitment, which may not meet the immediate symptom relief needs of all PTSD patients. - Rauch, S. A. M., Eftekhari, A., & Ruzek, J. I. (2012). “Review of exposure therapy: A gold standard for PTSD treatment.” Depression and Anxiety, 29(7), 587-593.
Discusses the gradual nature of exposure therapy and its effects on PTSD symptom reduction over time, emphasizing the challenges faced by patients who require faster symptom alleviation. - Karlin, B. E., & Cross, G. (2014). “From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs health care system.” American Psychologist, 69(1), 19-33.
Highlights the time-intensive commitment required for evidence-based therapies like CBT and EMDR, particularly within veteran populations, and discusses the implications of lengthy treatment protocols on patient retention
Emotional Readiness and Stability
- Resick, P. A., Monson, C. M., & Rizvi, S. L. (2008). “Posttraumatic stress disorder.” In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual, 65-122.
Describes the emotional demands of trauma-focused therapies, such as CBT and EMDR, noting that some patients may struggle with treatment engagement due to emotional intensity and readiness challenges. - Hembree, E. A., Foa, E. B., Dorfan, N. M., Street, G. P., Kowalski, J., & Tu, X. (2003). “Do patients drop out prematurely from exposure therapy for PTSD?” Journal of Traumatic Stress, 16(6), 555-562.
Examines dropout rates in exposure therapy, particularly among PTSD patients with severe symptoms, emphasizing that revisiting trauma can intensify distress and make treatment engagement challenging for those lacking emotional readiness.
Potential for Re-Traumatization
- van der Kolk, B. A. (2006). “Clinical implications of neuroscience research in PTSD.” Annals of the New York Academy of Sciences, 1071(1), 277-293.
Discusses the risk of re-traumatization in trauma-focused therapies, particularly exposure-based treatments, emphasizing the need for skilled clinicians to manage patients’ responses and avoid triggering intense distress. - Foa, E. B., & Meadows, E. A. (1997). “Psychosocial treatments for posttraumatic stress disorder: A critical review.” Annual Review of Psychology, 48(1), 449-480.
Critically examines the potential challenges of exposure therapy, including re-traumatization risks, and highlights the need for therapeutic pacing to ensure that revisiting trauma does not exacerbate symptoms. - Jaycox, L. H., & Foa, E. B. (1996). “Obstacles in implementing exposure therapy for PTSD: Case discussions and practical guidance.” Journal of Traumatic Stress, 9(2), 389-404.
Provides insight into the practical challenges clinicians face when using exposure therapy, noting that improper pacing or lack of preparation can lead to re-traumatization and increased distress in PTSD patients. - Zoellner, L. A., Feeny, N. C., Cochran, B., & Pruitt, L. (2003). “Treatment choice for PTSD.” Behavior Therapy, 34(2), 221-231.
Explores how exposure therapy’s intensity can trigger re-traumatization in some patients, leading to heightened avoidance and dropout rates, particularly among individuals unprepared for trauma processing. - Kehle-Forbes, S. M., Meis, L. A., Spoont, M., & Polusny, M. A. (2016). “Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic.” Psychological Trauma: Theory, Research, Practice, and Policy, 8(1), 107-114.
Examines dropout rates in trauma-focused therapies within veteran populations, noting that re-traumatization risks in exposure therapies contribute to high attrition, especially among patients with severe PTSD symptoms.
Limited Efficacy in Complex Trauma Cases
- Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). “Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices.” Journal of Traumatic Stress, 24(6), 615-627.
Explores the challenges of treating complex PTSD with traditional therapies, suggesting that more integrative approaches may be necessary to address symptoms like emotional dysregulation and interpersonal issues that arise from prolonged trauma exposure. - Ford, J. D., & Courtois, C. A. (2009). “Defining and understanding complex trauma and complex traumatic stress disorders.” In J. D. Ford & C. A. Courtois (Eds.), Treating complex traumatic stress disorders: An evidence-based guide, 13-30.
Defines complex PTSD and discusses why traditional PTSD treatments, like CBT and exposure therapy, may fall short in addressing the relational and emotional difficulties characteristic of complex trauma. - van der Kolk, B. A. (2005). “Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories.” Psychiatric Annals, 35(5), 401-408.
Proposes a new framework for understanding and treating complex trauma, arguing that therapies targeting simple traumatic memories or cognitive distortions are insufficient for individuals with developmental and relational trauma histories.
CBT Efficacy
- Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). “A multidimensional meta-analysis of psychotherapy for PTSD.” American Journal of Psychiatry, 162(2), 214-227.
Presents a meta-analysis on the efficacy of CBT for PTSD, showing an average reduction of 40-60% in symptoms, while noting that a significant portion of patients do not achieve full remission, especially those with complex trauma histories. - Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). “Psychotherapy for military-related PTSD: A review of randomized clinical trials.” JAMA, 314(5), 489-500.
Reviews CBT efficacy for military-related PTSD, finding that while effective for many, CBT shows reduced success rates in cases of complex trauma, where patients often struggle with lasting emotional and cognitive impairments. - Resick, P. A., & Monson, C. M. (2008). “Cognitive processing therapy for PTSD.” Journal of Traumatic Stress, 21(5), 481-489.
Describes the mechanisms of CBT, acknowledging that while it effectively reduces PTSD symptoms in a majority, it may be less effective for those with pervasive emotional dysregulation and cognitive difficulties associated with complex trauma. - Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray, S. H. (2008). “Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations.” Psychiatry: Interpersonal and Biological Processes, 71(2), 134-168.
Analyzes nonresponse and dropout rates in PTSD treatments, finding that around one-third of patients do not respond fully to CBT, with complex trauma often cited as a complicating factor for treatment effectiveness. - Cloitre, M., Stovall-McClough, K. C., Miranda, R., & Chemtob, C. M. (2004). “Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder.” Journal of Consulting and Clinical Psychology, 72(3), 411-416.
Highlights the reduced efficacy of CBT in complex trauma cases, particularly among individuals with histories of prolonged trauma exposure, and discusses the need for trauma-specific adaptations to address these challenges.
EMDR Efficacy
- Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). “Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults.” Cochrane Database of Systematic Reviews, (12).
Summarizes the effectiveness of EMDR in treating PTSD, showing that it can lead to significant symptom reduction and remission in up to 50-60% of cases, often in fewer sessions than CBT. - van der Kolk, B. A., Spinazzola, J., Blaustein, M., Hopper, J. W., Hopper, E. K., Korn, D. L., & Simpson, W. B. (2007). “A randomized clinical trial of EMDR, fluoxetine, and placebo in the treatment of PTSD: Treatment effects and long-term maintenance.” Journal of Clinical Psychiatry, 68(1), 37-46.
Evaluates the efficacy of EMDR, finding that while it significantly reduces PTSD symptoms, patients with complex trauma or co-occurring conditions often benefit from additional, prolonged support beyond standard EMDR sessions. - 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.
Analyzes the effectiveness of EMDR, concluding that it reduces PTSD symptoms effectively and efficiently, although complex cases may require more extensive treatment. - Maxfield, L., & Hyer, L. (2002). “The relationship between efficacy and methodology in studies investigating EMDR treatment of PTSD.” Journal of Clinical Psychology, 58(1), 23-41.
Discusses EMDR’s overall effectiveness in PTSD treatment, showing how symptom reduction is achieved efficiently for many patients, with limitations noted for those with complex trauma or concurrent mental health conditions. - Rodenburg, R., Benjamin, A., de Roos, C., Meijer, A. M., & Stams, G. J. J. M. (2009). “Efficacy of EMDR in children: A meta-analysis.” Clinical Psychology Review, 29(7), 599-606.
Examines the efficacy of EMDR across populations, including complex cases, suggesting that additional support may be needed for more severe trauma profiles to achieve lasting results.
Exposure Therapy Efficacy
- 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.
Presents a meta-analysis showing that 50-70% of PTSD patients report meaningful symptom reduction with Exposure Therapy, with specific efficacy noted in reducing avoidance behaviors and hypervigilance. - Rauch, S. A. M., Eftekhari, A., & Ruzek, J. I. (2012). “Review of exposure therapy: A gold standard for PTSD treatment.” Depression and Anxiety, 29(7), 587-593.
Reviews Exposure Therapy’s success in PTSD, highlighting its effectiveness for patients with anxiety and avoidance symptoms, while noting reduced efficacy in those with complex trauma or dissociative symptoms. - Hembree, E. A., & Foa, E. B. (2000). “Exposure therapy for PTSD.” In J. R. T. Davidson & E. B. Foa (Eds.), Posttraumatic stress disorder: DSM-IV and beyond, 51-66.
Discusses the limitations of Exposure Therapy, particularly for complex trauma patients who may struggle with emotional intensity, emphasizing the need for additional therapeutic support. - Foa, E. B., & Meadows, E. A. (1997). “Psychosocial treatments for posttraumatic stress disorder: A critical review.” Annual Review of Psychology, 48(1), 449-480.
Examines the efficacy of exposure-based interventions in PTSD, underscoring its success in symptom reduction and noting challenges in cases of dissociation or complex trauma where engagement may be limited. - van Minnen, A., & Foa, E. B. (2006). “The effect of imaginal exposure length on outcome of treatment for PTSD.” Journal of Traumatic Stress, 19(4), 427-438.
Investigates factors influencing outcomes in Exposure Therapy, indicating that prolonged exposure effectively reduces symptoms but may be less tolerable for patients with complex trauma or high emotional reactivity.
CBT Relapse Rates
- Cahill, S. P., Foa, E. B., Hembree, E. A., Marshall, R. D., & Nacash, N. (2006). “Dissemination of exposure therapy in the treatment of PTSD.” Journal of Traumatic Stress, 19(5), 597-610.
Examines relapse rates following CBT, indicating that up to 30% of patients experience symptom recurrence, emphasizing the role of follow-up care to maintain cognitive and emotional resilience. - Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., & Fennell, M. (2005). “Cognitive therapy for post-traumatic stress disorder: Development and evaluation.” Behaviour Research and Therapy, 43(4), 413-431.
Highlights the effectiveness of CBT in reducing PTSD symptoms, while noting relapse rates of up to 30% within a year, particularly in patients without ongoing maintenance therapy. - Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray, S. H. (2008). “Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations.” Psychiatry: Interpersonal and Biological Processes, 71(2), 134-168.
Analyzes dropout and relapse patterns in PTSD therapies, suggesting that follow-up support may reduce CBT relapse rates, which can reach 30% in cases lacking maintenance interventions. - Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive Processing Therapy for PTSD: A Comprehensive Manual. Guilford Press.
Discusses relapse in cognitive processing therapy, noting that continued care or booster sessions can help prevent symptom recurrence and support long-term outcomes. - Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). “Psychotherapy for military-related PTSD: A review of randomized clinical trials.” JAMA, 314(5), 489-500.
Reviews CBT efficacy for PTSD in veterans, acknowledging relapse rates of around 30% and highlighting the benefits of booster sessions to reinforce treatment effects.
EMDR Relapse Rates
- van der Kolk, B. A., Spinazzola, J., Blaustein, M., Hopper, J. W., Hopper, E. K., Korn, D. L., & Simpson, W. B. (2007). “A randomized clinical trial of EMDR, fluoxetine, and placebo in the treatment of PTSD: Treatment effects and long-term maintenance.” Journal of Clinical Psychiatry, 68(1), 37-46.
Evaluates EMDR’s long-term efficacy, noting that relapse rates of 20-30% within the first year are common, particularly in complex trauma cases where new stressors can trigger symptom recurrence. - van Emmerik, A. A. P., Kamphuis, J. H., & Emmelkamp, P. M. (2002). “Single session debriefing after psychological trauma: A meta-analysis.” Lancet, 360(9335), 766-771.
Assesses long-term outcomes for EMDR-treated PTSD, showing sustained relief for many patients but documenting relapse rates of up to 30% when exposed to subsequent stressors. - Nijdam, M. J., Baas, M. A., Olff, M., & Gersons, B. P. (2013). “Hotspots in trauma memories and their relationship to successful trauma-focused treatment of PTSD.” Behaviour Research and Therapy, 51(10), 523-530.
Explores EMDR efficacy in long-term PTSD symptom relief, finding that complex cases and subsequent life stressors can contribute to a relapse rate of 20-30%.
Exposure Therapy Relapse Rates
- 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.
Examines relapse rates in Exposure Therapy, indicating that up to 35% of patients may experience symptom recurrence within two years, particularly those who resume avoidance behaviors. - Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Oxford University Press.
Provides detailed insights into the efficacy and limitations of Exposure Therapy, including relapse rates of up to 35% in patients lacking follow-up support or continued reinforcement of therapeutic gains. - Hembree, E. A., & Foa, E. B. (2000). “Exposure therapy for PTSD.” In J. R. T. Davidson & E. B. Foa (Eds.), Posttraumatic stress disorder: DSM-IV and beyond, 51-66.
Discusses relapse trends in PTSD treatment with Exposure Therapy, noting that up to one-third of patients relapse if they return to avoidance patterns or lack post-treatment support. - Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray, S. H. (2008). “Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations.” Psychiatry: Interpersonal and Biological Processes, 71(2), 134-168.
Analyzes dropout and relapse patterns in PTSD therapies, including Exposure Therapy, finding that 30-35% of patients may relapse without ongoing support to manage avoidance behaviors.
Cahill, S. P., Foa, E. B., Hembree, E. A., Marshall, R. D., & Nacash, N. (2006). “Dissemination of exposure therapy in the treatment of PTSD.” Journal of Traumatic Stress, 19(5), 597-610.
Highlights the importance of long-term follow-up in Exposure Therapy, noting that up to 35% of patients experience symptom return, especially if avoidance behaviors persist post-treatment.