Following a personal or witnessed traumatic experience, finding appropriate support can be a challenge. Whether seeking comfort from loved ones or professional help such as psychotherapy or medication, the road to recovery is often uncertain. Understanding the types of therapy offered by psychologists, counsellors, social workers and mental health providers, and identifying the most beneficial options, can greatly impact one’s journey towards healing.
Mental health literacy, a crucial facet for consumers of mental health services, includes awareness of current research-supported treatment approaches. Just as one would want well-researched and effective medications for physical ailments, it is equally important to be aware of the evidence-based psychotherapeutic interventions offered by mental health professionals.
Analysing trauma treatment
Dr Paula Schnurr, a respected psychologist, has recently conducted a comprehensive review of various treatment modalities, focusing specifically on their effectiveness in treating post-traumatic stress disorder (PTSD) and providing valuable recommendations for therapy. In this review, we will look at the components of these treatments and evaluate the research to identify the most effective approaches. Our aim is to improve your understanding of trauma-specific mental health literacy and enable you or your loved one to access high-quality, evidence-based care during the recovery process..
Trauma-focused versus non-trauma-focused treatments
Within the field of psychological interventions for trauma-related disorders, such as PTSD, there is an important distinction between trauma-focused and non-trauma-focused treatments. To be considered trauma-focused, a treatment must prioritise processing the traumatic event through cognitive, behavioural and/or emotional strategies, often combining these approaches. Such therapies involve willingly confronting reminders of the trauma and dealing with associated memories.
Non-trauma-focused treatments, on the other hand, emphasise the cultivation of present support, empathy, warmth, and insight, but do not explicitly address the systematic processing of the traumatic event.
It is worth noting that PTSD was not officially recognised as a diagnosable condition until 19804, when it was included in the Diagnostic and Statistical Manual of Mental Disorders. It was the aftermath of events such as the Vietnam War and the women’s liberation movement that led to societal recognition of the profound psychological and personal impact of war, sexual violence and other traumatic experiences.
Given the relatively recent emergence of PTSD as a recognised diagnosis within the mental health field, it is remarkable to witness the considerable research effort devoted to developing effective treatments for this disorder.
Evidence-Based Treatments for PTSD
Among the most widely accepted trauma-focused treatments for post-traumatic stress disorder (PTSD), prolonged exposure (PE), cognitive processing therapy (CPT), and trauma-focused cognitive behavioural therapy (TF-CBT) for children stand out as prominent options.
A comprehensive overview and list of evidence-based treatments specifically designed for adults with PTSD can be found on the American Psychological Association website: https://www.div12.org/psychological-treatments/disorders/post-traumatic-stress-disorder/.
A common thread running through these treatments is the inclusion of psychoeducation. Each approach begins the therapeutic journey with an introduction to PTSD, providing insight into typical symptoms and their underlying causes. This initial phase serves to increase survivors’ understanding of their experiences, provides a vocabulary to articulate their struggles, and reassures them that their reactions and challenges are not uncommon. However, there are also notable differences between these treatments.
Prolonged exposure therapy
Prolonged exposure (PE) is a form of cognitive behavioural therapy that empowers people to confront their fears. Under the guidance of highly trained clinicians, PE gradually helps survivors to confront trauma-related memories, emotions, and situations that they have avoided, either intentionally or unintentionally. This therapeutic technique, known as exposure, may seem counterintuitive at first, but the direct confrontation of fear can ultimately lead to its reduction over time. The duration of PE typically ranges from 8 to 15 sessions, depending on the individual’s treatment goals and the severity of their symptoms.
Two types of exposure are commonly used in PE: in vivo exposure and imaginal exposure. In vivo exposure involves confronting the situations, places, people or activities that survivors have avoided since the traumatic event. This process unfolds at the survivor’s own pace, and as they gradually engage in a series of in vivo exposures, they often experience increasing comfort in such circumstances.
Imaginal exposure involves engaging in detailed discussions about the traumatic event and exploring the associated emotions that arise when remembered. Through a series of imaginal exposures, survivors often acquire improved coping mechanisms for dealing with the memories and emotions associated with the trauma.
Cognitive Processing Therapy
Cognitive Processing Therapy (CPT) is emerging as another prominent trauma-focused treatment. Unlike PE, which primarily targets behaviour through in vivo exposure, CPT delves deeper into post-trauma thought processes and their links to emotions and behavioural responses. Survivors often struggle with distressing thoughts related to self-blame, guilt, shame, safety and trust. When these thoughts become entrenched as absolute truths, they can become debilitating and prevent individuals from engaging in fulfilling activities.
During CPT, survivors engage in writing exercises about their trauma and have in-depth conversations with their mental health providers, shedding light on the negative and unhelpful thoughts that surface. Together, survivors and their providers work to develop new strategies to challenge these thoughts, with the aim of fostering compassionate, balanced and flexible thinking patterns that enable individuals to re-engage with their lives. This process is called cognitive restructuring.
Trauma-focused cognitive behavioural therapy
Trauma-focused cognitive behavioural therapy (TF-CBT) is tailored to the needs of children and adolescents. Treatment typically lasts 12 to 16 sessions, although the length of treatment varies according to individual needs and symptom severity.
TF-CBT has similar components to PE and CPT, including exposure techniques and teaching skills to manage trauma-related thoughts and feelings more effectively. However, TF-CBT also includes specialised sessions for parents and joint parent-child sessions that address the specific needs of child trauma survivors. Parent-specific sessions focus on strategies to support children and reduce parental distress resulting from trauma, while parent-child sessions provide a supportive environment for practising skills under the guidance of a trained clinician.
Non-Trauma-Focused Treatments: Supportive Counseling and PCT
Recognising that trauma-focused psychotherapy can be emotionally taxing, it is important to consider alternative treatment options for individuals who may be unwilling or unable to engage in exposure-based therapies.
Supportive counselling provides ongoing guidance and emphasises present-centred support to help individuals cope with stressors and life events without directly confronting their fears.
Present-centred therapy (PCT) is an evidence-based, non-trauma-focused treatment approach for PTSD. PCT provides psychoeducation about the impact of trauma on survivors and equips them with problem-solving strategies that focus on current challenges and improving interpersonal behaviours. It does not involve exposure techniques or direct modification of thought patterns.
Trauma-Focused or Non-Trauma Focused Treatments?
The question of which treatments provide the best outcomes is an area of ongoing debate and requires ongoing investigation using sophisticated research methods involving diverse communities of trauma survivors. In a 2008 systematic review of 17 studies comparing trauma-focused and non-trauma-focused treatments, researchers concluded that both types of therapy had similar potential benefits for clients with PTSD.
However, more recent research has questioned this claim, claiming that the 2008 study showed bias in the selection of studies reviewed and overlooked relevant research demonstrating the superiority of trauma-focused treatments. These researchers argue for further research into the specific components of PTSD treatments, such as exposure techniques and cognitive restructuring, to determine their role as genuine mechanisms of therapeutic change in PTSD.
In addition, a comprehensive systematic review conducted in 2016 analysed 55 studies comparing different trauma-focused and non-trauma-focused psychotherapies and pharmacotherapies for PTSD, and came to different conclusions. The results showed that trauma-focused psychotherapies outperformed non-trauma-focused psychotherapies in terms of efficacy, and had longer-lasting effects on individuals’ well-being compared to medication-based interventions.
To date, this remains the most recent systematic review on the subject and provides strong support for trauma-focused psychotherapy as the preferred choice for the treatment of PTSD, provided the survivor is willing to engage in such therapy.
Which Treatment Is Best for You?
The available literature suggests that trauma-focused treatments using exposure techniques and cognitive restructuring have the strongest evidence to support their use as primary treatments for PTSD.
However, it is important to note that not all trauma-focused treatments have the same level of research support. Given the rapid development of the field, new treatments are constantly being developed and tested. It is likely that no single treatment will be universally appropriate or most effective for everyone, given the enormous diversity among individuals in terms of culture, developmental stage, identity and experience of trauma. Specific cultural groups and individuals may experience varying degrees of treatment efficacy with different trauma-focused approaches, thus warranting further research into these factors that moderate treatment outcomes.
As a consumer of mental health resources, it is important to be aware of and respect your own treatment preferences. Seek a provider who will create an environment in which you feel comfortable engaging in therapy, regardless of the approach chosen.
- 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
- 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
- Department of Veterans Affairs and Department of Defense: Management of Post-Traumatic Stress. Department of Veterans Affairs and Deportment of Defense; 2010.
- 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
- 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
- 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
- Resick, P.A., Monson, C.M., & Chard, K.M. (2008). Cognitive processing therapy: Veteran/military version. Washington, DC: Department of Veterans’ Affairs.
- 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
- 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
- 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.
- 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.
- 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
- 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
- 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
Sarah Krill Williston is a PhD Candidate at the University of Massachusetts Boston, working in the Roemer lab. Her research centers on boosting mental health literacy and reducing stigma to encourage evidence-based care-seeking for anxiety and trauma-related disorders. Sarah specializes in offering evidence-based treatments like CBT and ABBT to individuals, particularly military families, active duty service members, and veterans with mood, anxiety, and trauma-related disorders.