Therapy for post-traumatic stress disorder (PTSD) and overcoming traumas such as accidents, natural disasters, violence, physical assault, child abuse, sexual violence, and other traumatic events, e. g. potential life-threatening medical conditions.

What is a Trauma?

According to the American Psychiatric Association (2013), trauma is defined as an “exposure to actual or threatened death, serious injury, or sexual violence.“

When thinking of trauma, many of us think of big events that we read about in the newspaper such as wars, natural catastrophes and terrorist attacks. But apart from these major traumas, research indicates that general adverse life experiences  can result in even more post traumatic stress symptoms than major trauma can. Examples include experiences that makes us feel unsafe, without control or hope, or unloved, such as failures, humiliations and losses.

Therefore a broader definition characterizes an event as traumatic if it is extremely upsetting, overwhelms the individual’s resources, and results in lasting psychological problems.

What is Post-traumatic Stress Disorder or PTSD?

The American Psychiatric Association (2013) defines the diagnostic criteria for post-traumatic stress disorder (PTSD) as:

A) Exposure to death, serious injury, or sexual violence (actual or threatened)

B) Presence of intrusion symptoms

  1. Recurrent distressing memories of the traumatic event
  2. Recurrent distressing dreams with a content related to the traumatic event
  3. Dissociative reactions
  4. Intense psychological distress when exposed to cues that resemble an aspect of the traumatic event
  5. Marked physiological reactions to external cues that resemble an aspect of the traumatic event

C) Persistent avoidance of stimuli associated with the traumatic event

  1. Avoidance of distressing thoughts, feelings, or memories about the traumatic event
  2. Avoidance of external reminders (people, places, activities, conversations, situations, objects)  that arouse distressing memories, feelings, or thoughts about the traumatic event

D) Negative alterations in cognitions and mood associated with the traumatic event

  1. Inability to remember an important aspect of the traumatic event
  2. Persistent negative beliefs about oneself, others, or the world
  3. Distorted cognitions about the cause or consequences of the traumatic event that lead the patient to blame herself/himself and others
  4. Persistent negative emotions (e.g. fear, horror, anger, guilt, shame)
  5. Diminished interest and participation in important activities
  6. Feelings of detachment or estrangement from others
  7. Persistent inability to experience positive emotions (e.g. inability to experience satisfaction, happiness, or loving feelings)

E) Marked alterations in arousal and reactivity

  1. Irritable behavior and angry outbursts (verbal or physical aggression)
  2. Reckless or self-destructive behavior
  3. Hypervigilance (enhanced state of sensory sensitivity)
  4. Exaggerated startle response
  5. Problems with concentration
  6. Sleep disturbance

F) Duration of the disturbance is more than 1 month

G) Significant distress and and impairment in social and occupational areas of functioning

H) The disturbance is not caused by effects of a substance (e.g. alcohol or medication) or other medical conditions

Trauma Therapy

Many clinicians and researchers agree that adult survivors of childhood trauma should be treated by a phase-oriented and skill-focused approach.

The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults propose a therapy model that involves three phases:

  1. Stabilization, skills strengthening, establishment of safety
  2. Change: Review and reappraisal of trauma memories; remembrance and mourning
  3. Maintenance: Consolidation of therapy gains, and planning for follow-up care; reconnection with life

The Stabilisation Phase (Stage 1)

Many therapists see the early stage of therapy („stage 1“) as the most important: This is the stage where the treatment frame is defined, collaborative alliance is built, safety is provided; and it includes such relevant issues such as affect regulation, stabilization, skill-building, education, and the building of social relationships.

Traumatized patients need the stabilization phase to feel safe in the therapeutic environment, learn more about their symptoms and psychotherapy, and build important skills that are needed during later phases of treatment.

The Change Phase (Stage 2)

Psychotherapy (cognitive therapy (CT), cognitive behavioural therapy (CBT), exposure therapy, eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy) and pharmacological treatments are considered efficacious in the therapy of PTSD.

What should be included in a broad therapeutic approach to trauma therapy?

Pioneers of evidence-based treatments for PTSD identified the following commonalities in psychotherapy for posttraumatic stress disorder:

  1. Psychoeducation: Information on the nature of posttraumatic stress reactions, how to cope with trauma reminders, strategies to manage distress
  2. Cognitive processing and restructuring and/or meaning making
  3. Coping and emotion regulation skills
  4. Imaginal exposure
  5. Targeting emotions (fear, shame, guilt, anger, grief, sadness)
  6. Reorganization of memory functions

The Maintenance Phase (Stage 3)

Phase 3 of PTSD therapy (also called maintenance phase) is dedicated to:

  • The consolidation of therapy gains in social and emotional competencies
  • Planning for follow-up care
  • Proposal of booster sessions to refresh important skills (e.g. stress management) or address new challenges in life
  • Interventions for relapse prevention

Literature:

American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders 5th edition American Psychiatric Association

Briere JN, and Scott C (2015) Principles of trauma therapy: a guide to symptoms, evaluation, and treatment 2nd edition Sage

Chu JA (2011) Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders 2nd edition John Wiley & Sons

Courtois CA (2004) Complex trauma, complex reactions: Assessment and treatment Psychotherapy: Theory, Research, Practice, Training 41(4): 412-425

Cusack K, Jonas DE, Forneris CA, Wines C, Sonis J, Middleton JC, … and Weil A (2016) Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical psychology review 43: 128-141

Foa EB, Keane TM, Friedman MJ, and Cohen JA (2009) Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies Guilford Press

Herman CL (1992) Trauma and recovery: The aftermath of violence – From domestic to political terror Basic books

Korn DL (2009) EMDR and the treatment of complex PTSD: A review. Journal of EMDR Practice and Research3(4): 264-278

Korn DL, and Leeds AM (2002) Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder. Journal of clinical psychology 58(12): 1465-1487

Leeds AM (2009) Resources in EMDR and other trauma-focused psychotherapy: A review. Journal of EMDR Practice and Research3(3): 152-160

Schnyder U, Ehlers A, Elbert T, Foa EB, Gersons BP, Resick PA, Shapiro F and Cloitre M (2015). Psychotherapies for PTSD: what do they have in common? European Journal of Psychotraumatology 6(1): 1-10

Steele K, Van Der Hart O, and Nijenhuis ER (2005) Phase-oriented treatment of structural dissociation in complex traumatization: Overcoming trauma-related phobias. Journal of Trauma & Dissociation 6(3): 11-53

Van der Hart O, Groenendijk M, Gonzalez A, Mosquera D, and Solomon R (2013) Dissociation of the personality and EMDR therapy in complex trauma-related disorders: Applications in the stabilization phase. Journal of EMDR Practice and research7(2): 81-94

Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB and Friedman MJ (2013) Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. The Journal of clinical psychiatry 74(6): 541-550