To learn or to unlearn. Whether through exposure therapy one learns not to respond to behaviors previously learned by exposure to trauma OR one unlearns the behaviors one has learned through that exposure. That is the question. Apologies to Shakespeare. Also, apologies to those who suffer from PTSD and are simply no good at learning things or otherwise don't respond to the treatment.
Let's start by considering why the question of learning or unlearning makes no sense. What is learning? You can learn facts in school and you can learn to recite the Gettysburg address. You can learn how not to cross the street on a red light by being instructed by a parent or by crossing on red and narrowly avoided getting hit by a car or maybe you were hit and survived. Still, there are those who survive being hit, but nevertheless respond by crossing on red with greater awareness to traffic flow or at least think they are more aware. This doesn't even begin to address the issue of how one learns, but should illustrate how much more complex learning is than the model "I teach, you learn," which seems to dominate most education nowadays and also therapy.
The issues are these. Learning Theory, which still survives in modern psychological practice, somehow assumes that what we learn is linear. Prime motive for learning: you don't want to have flashbacks or moments of fear or terror. Treatment: The therapist will continue to expose you to the aversive experience until you learn (or unlearn) to not respond (or unlearn your response set), either/or doesn't matter. You want it. We'll give it to you. Eventually, you will learn through repeated exposure.
But, what happens if you don't learn what you and I both want you to learn?
The answer would appear to be that, if you don't learn it the first time, then you will learn better through repetition, that is, by over-learning. If you're such a dolt that you don't get it the first time (and don't feel bad because almost [and possibly] nobody gets it the first time and therefore you should not think badly of yourself), we will have to repeat the exposure multiple times until you do get it. And I would have to add that I have heard more than once of sufferers of PTSD who complain of the therapist going to sleep from the repetition. But, who can blame them? It's your trauma that the therapist is listening to again and again. I feel compelled to add that there is no textbook that has ever informed the trained therapist when to stop repeating the exposure technique or what else is available if it doesn't have the desired effect or even still simply doesn't work.
It needs to be stated and cannot be stated enough that exposure therapy is based on theory. Given the complexity of learning, as briefly illustrated above, it is hard to imagine that repeated exposure will work for most people or even for some, especially if the originating trauma was repeated, severe, and occurred over a long period of time. Further, given the diversity of trauma that people with PTSD may have suffered, it would be hard to imagine that a single treatment would work for all. No wonder why those with the most severe cases of PTSD would prefer to run from the room when it is time for another exposure session. It also makes it particularly hard to convince them there are other ways to approach treating their symptoms because everyone in the world, clinicians and sufferers alike, seem to agree that the only way to overcome the symptoms is by suffering through them again and again and again.
You don't need to be an Einstein to recognize that insanity is doing the same thing over and over again and expecting different results. But somehow in psychotherapy the expectation of different, more adaptive results through re-exposure has become the rule. And strangely, most everyone agrees that something else will eventually happen if you expose the traumatized person often enough.
If I hadn't seen so many failures and such resistance to re-exposure, I would not be writing this. What I am describing is not research in a test-tube, but in practice.