After you survive or someone you care about goes through a traumatic life event, it can be hard to find the right types of support, including informally through family and friends or professionally in the form of psychotherapy and medication. Often it is not clear what type of therapy psychologists, counselors, social workers, or other mental health providers will provide or what will be the most helpful for recovery.
It is very important for consumers of mental health care to know what the research shows are the current and most effective forms of treatment. This can be thought of as your mental health literacy1. Just as you would want to know if the medication you receive for medical conditions is the most researched and effective available, it is also important to know this about psychotherapies provided by mental health providers.
Review of Treatment Options for Trauma
Specifically regarding trauma, the psychologist Dr. Paula Schnurr recently published a review about different forms of treatments; she summarized their effectiveness and made recommendations for the treatment of post-traumatic stress disorder, or PTSD2. Here, we will review the treatments and their basic components. Then we will discuss what the research shows about which treatments seem to be the most effective. We hope that this review will enhance your trauma-specific mental health literacy, and that it will help you or a loved one receive quality evidence-based care as part of the recovery process.
Trauma-Focused vs. Non-Trauma-Focused Treatments
The main divide in psychological non-medication treatments for trauma-related disorders such as PTSD is whether they are trauma-focused or non-trauma-focused. To be considered trauma-focused, a treatment must focus on processing the traumatic event through cognitive, behavioral, or/and emotional strategies, or a combination of the three3. A trauma-focused treatment involves willingly exposing oneself to reminders of the trauma and to related memories.
Non-trauma-focused treatments rely more on cultivating support, warmth, empathy, and insight in the present moment, but they do not deal explicitly with processing the traumatic event in a systematic way.
PTSD did not become an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders until 19804. The aftermath of the Vietnam War and the women's liberation movement resulted in the societal acknowledgement of the psychological and personal impact of war, sexual violence, and other traumatic events. Given its relatively recent entry as a diagnosis into the world of mental health, it is impressive that so much research has gone into developing treatments for the disorder.
Evidence-Based Treatments for PTSD
Two of the most well-known trauma-focused treatments are prolonged exposure (PE) and cognitive processing therapy (CPT). Trauma-focused cognitive behavioral therapy (TF-CBT) for children is a very well-recognized option for children.
For a summary and list of evidence-based PTSD treatments for adults, visit the American Psychological Association to read more details: http://www.div12.org/psychological-treatments/disorders/post-traumatic-stress-disorder/.
One thing all these treatments have in common is psychoeducation. Each treatment begins with an orientation to PTSD, including what common symptoms may be like and why they occur. This early phase of treatment helps the survivor understand their experience better, give it a name, and let them know they are not alone in their reactions or struggles. However, these treatments also have some significant differences.
Prolonged Exposure Therapy
Prolonged exposure, or PE, is a type of cognitive behavioral therapy that works with people so they can face their fears5,6. With the support of a highly trained clinician, PE teaches survivors to gradually approach trauma-related memories, feelings, and situations that they have been avoiding either intentionally or unintentionally. This is called exposure. It may seem counterintuitive, but confronting fear directly can actually reduce it in the long run. PE typically takes between 8 to 15 sessions depending on an individual's goals and symptom severity.
In vivo and imaginal are two types of exposure conducted with individual survivors. In vivo exposure involves confronting situations, places, people, or activities that a survivor has been avoiding since the trauma. Typically, this is done at the individual's own pace, and after doing a series of in vivo exposures over time, survivors often feel much more comfortable in these situations.
Imaginal exposure involves talking in detail about the trauma and the emotions that arise from remembering it. Survivors often find that after doing a series of imaginal exposures, they are better able to cope with memories and feelings that come up about the trauma.
Cognitive Processing Therapy
Another popular form of trauma-focused treatment is cognitive processing therapy, or CPT7,8. Whereas PE focuses on behaviors like in vivo exposures, CPT focuses much more in-depth on the thoughts that arise in the aftermath of a trauma, as well as on the connections between those thoughts and the emotions and behavioral urges in response to those thoughts. Survivors can deal with many painful thoughts, particularly regarding self-blame, guilt, shame, safety, and trust. But when experienced as truths, they can become debilitating and stop a person from engaging in meaningful activities.
Over the course of CPT, survivors write about their trauma and talk in detail to their mental health provider about the negative, unhelpful thoughts that arise. Then survivors and their providers work together to learn new strategies to challenge those thoughts, in hope of generating more compassionate, balanced, and flexible thinking habits that allow them to re-engage with their lives. This process is called cognitive restructuring.
Trauma-Focused Cognitive Behavioral Therapy
Another form of evidence-based treatment, trauma-focused cognitive behavioral therapy, or TF-CBT, is specifically for children9 and adolescents. It typically takes 12 to 16 sessions, but length depends on the individual's needs and symptom severity.
The components of TF-CBT are similar to PE and CPT. They include exposure and teaching skills to manage trauma-related thoughts and feeling in new, more helpful ways. However, TF-CBT also includes parent-specific sessions and parent-child sessions that address the unique needs of child survivors of trauma. In the parent-specific sessions, strategies to support children and reduce parental distress concerning the trauma are discussed. In the parent-child sessions, many of the skills practiced in the parent-specific sessions are practiced with the support of a highly trained clinician.
Non-Trauma-Focused Treatments: Supportive Counseling and PCT
Doing trauma-focused psychotherapy is emotionally taxing, and there may be many valid reasons a person decides to hold off on it until they feel they have enough stability and safety to engage with it. So it is important to have alternative options for treatment that do not include exposures.
Some people may prefer ongoing supportive counseling if they are unable or unwilling to confront their fears through exposure. This type of treatment tends to focus on the present and cultivate general emotional support for coping with stressors and life events.
Present-centered therapy, or PCT, is a form of evidence-based non-trauma-focused treatment for PTSD10,11. It provides psychoeducation about the impact of trauma on the survivor and teaches problem-solving strategies that focus on current life issues and improving relationship behaviors. The treatment does not include exposures or a focus on altering thinking habits directly.
Trauma-Focused or Non-Trauma Focused Treatments?
So, which treatments work best? This question invites lingering controversy, and it remains an empirical one that should be continually examined with sophisticated research methods and diverse communities of trauma survivors. In a 2008 systematic review of 17 studies that compared exposure-based trauma-focused treatment to non-trauma-focused treatments, a team of researchers concluded that both types of treatments do not significantly differ in their potential benefit to clients who have PTSD12.
However, more recent work has countered this claim, citing that the 2008 study was biased in its selection of studies reviewed, and that it did not include relevant studies that demonstrated the superiority of trauma-focused treatment. Researchers encouraged further inquiry into testing the specific components of PTSD treatments, such as exposure and cognitive restructuring, to determine which are truly mechanisms of therapeutic change in PTSD13.
In addition, a 2016 systematic review, which analyzed 55 studies comparing types of trauma-focused and non-trauma focused psychotherapy and pharmacotherapy or PTSD, concluded differently14. The results showed that trauma-focused psychotherapies were more effective than non-trauma-focused psychotherapies, and that they had longer-lasting effects than medications on individuals' well-being. To date, this is the most recent systematic review on this topic. Its findings strongly support the use of trauma-focused psychotherapy as the first choice for PTSD treatment, assuming the survivor is willing.
Which Treatment Is Best for You?
The literature appears to show that trauma-focused treatments that include some form of exposure and cognitive restructuring have the strongest evidence to support their use as a front-line treatment for PTSD.
Not all trauma-focused treatments have equal levels of research support. The field is evolving rapidly, and new treatments continue to be developed and tested. It is likely that one treatment will not be the best-suited or most effective for everyone. People are extremely diverse with regard to their cultures, developmental stages, identities, and trauma exposures. Some types of trauma-focused treatments will be more effective and some will be less effective for specific cultural groups and individuals, and researchers should continue to investigate these moderators of treatment outcome.
As a consumer of mental health resources, be aware of and honor your own preferences for treatment and find a provider who allows you to feel comfortable engaging in any type of therapy.
Recommended For You
1. Jorm, A. F. (2015). Why we need the concept of "mental health literacy." Health Communication, 30(12), 1166-1168. doi:10.1080/10410236.2015.1037423
2. Schnurr, P. P. (2017). Focusing on trauma-focused psychotherapy for posttraumatic stress disorder. Current Opinion in Psychology, 1456-60. doi:10.1016/j.copsyc.2016.11.005
3. Department of Veterans Affairs and Department of Defense: Management of Post-Traumatic Stress. Department of Veterans Affairs and Deportment of Defense; 2010.
4. van der Kolk, B., & Najavits, L. M. (2013). Interview: What is PTSD really? Surprises, twists of history, and the politics of diagnosis and treatment. Journal of Clinical Psychology, 69(5), 516-522. doi:10.1002/jclp.21992
5. 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. doi:10.1016/j.cpr.2010.04.007
6. Foa, E. B., McLean, C. P., Capaldi, S., & Rosenfield, D. (2013). Prolonged exposure vs supportive counseling for sexual abuse-related PTSD in adolescent girls: A randomized clinical trial. JAMA: Journal of the American Medical Association, 310(24), 2650-2657. doi:10.1001/jama.2013.282829
7. Resick, P.A., Monson, C.M., & Chard, K.M. (2008). Cognitive processing therapy: Veteran/military version. Washington, DC: Department of Veterans' Affairs.
8. Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965-971. doi:10.1037/0022-006X.73.5.965
9. Sachser, C., Keller, F., & Goldbeck, L. (2017). Complex PTSD as proposed for ICD-11: Validation of a new disorder in children and adolescents and their response to Trauma-Focused Cognitive Behavioral Therapy. Journal of Child Psychology and Psychiatry, 58(2), 160-168. doi:10.1111/jcpp.12640
10. Classen, C., Butler, L. D., & Spiegel, D. (2001). A Treatment manual of present-focused and trauma-focused group therapies for sexual abuse survivors at risk for HIV infection. Stanford, CA: Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.
11. Classen, C., Cavanaugh, C., Kaupp, J., Aggarwal, R., Palesh, O., Koopman, C., Kraemer, H., Spiegel, D. (2011). A Comparison of Trauma-Focused and Present-Focused Group Therapy for Survivors of Childhood Sexual Abuse: A Randomized Controlled Trial. Psychological Trauma: Theory, Research, Practice and Policy, 3(1) 84-93.
12. Benish, S. G., Imel, Z. E., & Wampold, B. E. (2008). The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28(5), 746-758. doi:10.1016/j.cpr.2007.10.005
13. Ehlers, A., Bisson, J., Clark, D. M., Creamer, M., Pilling, S., Richards, D., & ... Yule, W. (2010). Do all psychological treatments really work the same in posttraumatic stress disorder?. Clinical Psychology Review, 30(2), 269-276. doi:10.1016/j.cpr.2009.12.001
14. Lee, D. J., Schnitzlein, C. W., Wolf, J. P., Vythilingam, M., Rasmusson, A. M., & Hoge, C. W. (2016). Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: Systemic review and meta‐analyses to determine first‐line treatments. Depression and Anxiety, 33(9), 792-806. doi:10.1002/da.22511
Date of original publication: August 10, 2017