Delayed Exposure: 
A Proposed Tweak to VA Treatment Flows for PTSD

Tony Clark and David Mosely, September 22, 2025

By delaying trauma-focused discussion, non-pharmacological adjunctive therapies like that provided by the 2-Dooz DSM App and Resilience Smart Ring offer a more conservative and effective way to manage PTSD symptoms at the opening stage of treatment. Prolonged-avoidance for PTSD is a non-pharmacological treatment flow, which delays trauma re-exposure; allowing a veteran additional time to stabilize prior to exposure therapy.  

Prolonged-avoidance purposely increases the mental distance from a trauma, which can improve a veteran's tolerance for subsequent trauma-focused psychotherapies, such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) Therapy; reducing treatment drop-out rates, while avoiding the suicide risks sometimes associated with PTSD medication.  Delayed exposure is a proposed tweak to de-facto treatment flows and is consistent with existing VA Treatment Guidelines for PTSD.

The Challenge of Exposure Therapy

Exposure therapy has two sides: while 50% to 70% of patients who complete the therapy respond to treatment, exposure to trauma-related stimuli can be highly distressing, potentially leading to a worsening of symptoms. Research suggests that an aversion to these stimuli fuels an exposure therapy dropout rate as high as 50%.  So, on one hand exposure therapy can be quite effective, but on the other hand getting a veteran through a full course of exposure therapy is problematic.

Fortunately, delaying the start of exposure therapy can be beneficial. Research finds that a meditative (conscious or paced) breathing intervention for PTSD should precede trauma exposure therapy when severely traumatized individuals are unable, or unwilling to endure reliving traumatic experiences.  Case studies show that when breathing interventions preceded exposure therapy, clients were better able to tolerate and benefit from the therapy.

A More Conservative Starting Point

Medication use for PTSD in veterans falls within the VA's treatment guidelines, but can be a double-edged sword.  While SSRIs like Zoloft and Paxil are proven to reduce debilitating symptoms, a serious question remains: Are we inadvertently increasing the risk of suicide in an already vulnerable population? 

Achieving a delicate balance between the benefits of medication and the potential for increased suicidal thoughts—particularly during the initial and final stages of treatment—can be challenging.  Based on such considerations, a more conservative, non-pharmacological initial treatment phase appears warranted.

The Role of Stabilization

The concept of establishing sufficient "mental distance" from a trauma before exposure therapy is formally referred to as stabilization, or emotional regulation skills training. The core idea is that a person needs to be in a psychologically stable and safe state before they can effectively engage in trauma-focused therapies. Attempting to confront or "re-expose" a person to their trauma before they have developed adequate coping skills can be overwhelming, potentially leading to further distress or treatment dropout.

Many evidence-based therapy protocols, including the VA’s own guidelines, allow for a stabilization phase during the initial stages of treatment. During stabilization, a therapist helps the veteran develop skills to manage emotional and physiological distress. These skills are a form of "mental distance" and include breathing retraining and relaxation techniques to help patients gain control over physical stress responses, such as a racing heart or shortness of breath.  A tool-box of non-pharmacological stabilization techniques includes the following.

• Breathing Retraining: Techniques like deep, controlled breathing help regulate the body's stress response.

• Grounding Techniques: These skills help a person stay connected to the present moment, which is critical when intrusive thoughts or flashbacks occur.

• Affect Tolerance: This involves learning to identify and tolerate difficult emotions without being overwhelmed by them.
  
  

The Clinical Rationale

Trauma disrupts the brain's ability to regulate emotion and process information. When a person is in a constant state of hyperarousal (the "fight-or-flight" response), their prefrontal cortex—the part of the brain responsible for logical thought and self-control—is less active.

Mastering stabilization skills, e.g., tactical breathing, can help a veteran to reactivate downregulated areas of the brain during periods of distress. Mastering such skills also prepares a veteran for the difficult work of trauma processing, allowing the person to revisit the traumatic memory from a place of relative calm, focus and control. This process is a key part of healing.

The 2-Dooz Approach for Delayed Exposure

The Distress Symptoms Mitigation (DSM) App and the Resilience Smart Ring are ideally suited to help with symptoms stabilization. The smart ring picks up on small physiological changes that often appear before a person is consciously aware of a stress response. The DSM app then guides the user through a meditative deep-breathing session to help short-circuit symptoms before they escalate.

An apt car analogy is that the DSM App and Resilience Smart Ring act like a "check engine" light for PTSD triggering.  They provide an early warning, giving a veteran a crucial window to act before things escalate into a panic attack, a flashback, or an overwhelming wave of anxiety.

Clinical research confirms that the conscious, deep breathing, guided by the DSM App and Resilience Smart Ring, decreases sympathetic nervous system (SNS) activity while increasing parasympathetic nervous system (PNS) activity. This facilitates a quicker return to a pre-distress state, provided the intervention is used early in the progression of symptoms.

Thus, the DSM App and Resilience Smart Ring can be used to help stabilize PTSD symptoms prior to exposure therapy, making it easier for a veteran to engage in and benefit from follow-on intensive trauma therapy after they have developed sufficient confidence in their coping abilities.

2-Dooz is conducting ongoing PTSD Clinical Studies, which examine the efficacy of using DSM App and Resilience Smart Ring to reduce PTSD symptoms severity.  Veterans interested in participating can learn more here.

Fit of Delayed Exposure Within Existing VA Treatment Guidelines

Current VA PTSD Treatment Guidelines already recognize the importance of non-exposure therapy options. The guidelines specifically cite the importance of Mindfulness-Based Stress Reduction (MBSR) practices for treating PTSD symptoms.

In particular, the VA presently teaches focused, conscious breathing to help veterans detach from distressing thoughts and feelings.  The 2-Dooz DSM App and Resilience Smart Ring provide a biofeedback-triggered meditative breathing intervention which falls within this category of MBSR practices.

While the exact timing for when to use non-exposure treatments relative to exposure therapy is not explicitly stated in the VA Treatment Guidelines for PTSD, the guidelines are supportive of Delayed Exposure, defined here as the use of conservative, non-exposure, non-pharmacological treatment modalities during the initial treatment phase to stabilize PTSD symptoms prior to exposure therapy.  Once a veteran is sufficiently stable to tolerate exposure therapy, they would move into a second, more intensive phase of treatment involving trauma re-exposure.

Again, the benefit of prolonged avoidance—pursuing PTSD symptoms stabilization before exposure therapy—is that it affords greater mental distance from the seminal trauma.  Research corroborates that this extra time improves the tolerance of a subsequent exposure therapy; possibly allowing more veterans to benefit from exposure-based treatments.

(Disclaimer: This article provides general information and does not constitute medical advice. Treatment decisions for PTSD and related conditions should always be made in consultation with a qualified healthcare professional.  If you are a veteran or you know of a veteran who is in crisis, please seek immediate help by calling or texting the Veterans Crisis Line at 988 and pressing 1.)