Treatment Modalities for Trauma related Distress

People seeking psychological support for trauma may come across a range of options offered by healthcare professionals. Often, these options take the form of abbreviated acronyms (e.g., CPT; EMDR; PE) making it hard to understand what they refer to and their differences / similarities. In this blog post, we delve into common psychological therapies for trauma and related distress to help you understand what healthcare providers are offering. We also unravel what the acronyms mean!

What is trauma? 

Trauma can mean different things to different people, but it generally refers to a distressing event that may contribute to the development of psychological difficulties. In the case of posttraumatic-stress disorder (PTSD) specifically, a traumatic event most often contains threat to life or/and serious harm¹.

For more information about trauma and PTSD, you can read our blog post on what type of events can lead to PTSD. We also have a page, What is PTSD  and many other blog including: Common Myths Surrounding PTSD , Is recovery from PTSD possible when you have childhood sexual assault?, How do I know if I have PTSD? , and How PTSD affects the family of sufferer. These are just a few of the blogs we have related to PTSD.

What kind of psychological difficulties are associated with a history of trauma?

Trauma can have a profound impact on individuals, affecting various aspects of mental and emotional well-being, how people cope with stress and difficult emotions, and how people relate to others. Common ones are anxiety and depression, PTSD, substance and alcohol use, sleep problems and nightmares, difficulty controlling emotions and expressing personal needs to others, feelings of low self-worth, thoughts of hurting ourselves or others, and even psychosis^2-3. Sometimes, depending on a person’s history (e.g., experiencing chronic / repeated traumatic events early in life) and the trauma (s) event (s), the impact can be enduring and span several aspects of a person’s life³.

While many people often have an understanding of how traumatic events may have influenced their life, consulting a qualified mental healthcare professional can help you understand the exact ways trauma may have shaped (and may continue, in some cases, to shape) your life and how to break those patterns. 

Okay, but which therapy is worth the time, cost, and effort?

To answer this, let’s discuss the main acronyms of prominent therapeutic modalities that you are likely to encounter in order of commonality. 

Prolonged Exposure (PE): 

PE is a therapeutic approach that involves gradually exposing people to the content of traumatic memories, helping them process traumas. It is important to note that the pace of this process is set collaboratively by the clinician and the person receiving the therapy in order for it to feel manageable and safe. 

The basic tenet of PE⁴ is that reducing the urge to avoid traumatic reminders associated with strong emotions (in our imagination, or real life where safe/appropriate) gives our brain a chance to  reorganize the narrative of trauma memories; and reduce the intensity of associated negative emotions. With time, and repetition, thoughts and reminders associated with a traumatic event may no longer prompt the same level of distress helping people to move on from trauma. 

To illustrate how PE works, consider how you may feel when dipping your toes in a pool or the ocean. Initially, you may be overwhelmed by the cold sensation and feel an urge to avoid getting in. You may choose to leave, and try another day. Or, to persevere and dip your foot in. Then your knee, waist, and finally your shoulders. This may be uncomfortable at first. But you are now swimming. And next time you find yourself in a swimming pool, you may remember how it felt to be swimming and choose to jump in the cold water. 

PE is a time-tested approach with strong evidence⁵ for its effectiveness in PTSD (irrespective of the type, and duration, of trauma) and several forms of anxiety, including obsessions and compulsions, specific phobias, panic attacks, and social anxiety. The typical length of PE, depending on your treatment plan and needs, will likely be 8 – 15 sessions. 

Cognitive Behavioural Therapy (CBT)

CBT is a family of tools utilized by psychologists to explore how a person’s thoughts, emotions and behaviors relate to each other, and whether the ways of thinking a person is accustomed to are serving a beneficial purpose in their life. The basic tenet of CBT⁶ is that changes in thoughts, emotions, or/and behaviors can lead to benefits for psychological difficulties. Your clinician may also choose to utilize added components that may be of benefit to you but are not part of traditional CBT, such as relaxation and mindfulness skills. As a result, CBT is a “jack of all trades” therapy that psychologists often utilize to help you tackle a wide variety of psychological difficulties.

When talking about trauma treatments, you are likely to see two versions of CBT: a) CBT for PTSD; and TF-CBT (trauma-focused CBT). Both versions explore associations between the memory of traumatic events and their meaning for a person’s life, how it may have changed what people believe about themselves, the world, other people, and the future, and how people cope with the resulting emotional distress and reminders. The term TF-CBT, however, originally referred to treatment of PTSD and trauma-related distress in children, rather than adults, in a way that is developmentally appropriate⁷. However, some people may refer to CBT for PTSD across age groups as TF-CBT as well. 

Here is a fictional example of a person called “John Doe”  to illustrate how CBT may look like. John recently lost a close friend to illness, and feels guilty because they believe that “If only I was there, they would still be alive”. John spends a lot of time thinking about this event, which keeps their guilt going. If John was receiving CBT, their psychologist could start to support them by collaboratively working through John’s thought process and developing alternative perspectives. As a result John would likely feel less guilty and start thinking about this event less frequently in time, focusing more on the future and ways of honoring their friend. 

CBT is the most researched psychological therapy, shown to be effective for a large range of psychological difficulties across the human spectrum^7-9, including depression, substance and alcohol use, personality concerns, interpersonal difficulties, sleep problems, PTSD, anxiety, suicidal thoughts and self-harm, and many more. CBT, depending on your circumstances and needs, may range from 6-20 sessions for meaningful change in your difficulties. 

Cognitive Processing Therapy (CPT):

CPT is a form of CBT developed for the treatment of PTSD, and was originally developed as a way to support people who experienced sexual assault and subsequent post-traumatic stress¹⁰. CPT like PE focuses on reducing avoidance of traumatic reminders by targeting beliefs and ways of thinking that keep you stuck in PTSD. In CPT this is called an approach focus or attitude.  CPT focuses on the meaning of traumatic events that have stuck with you around the causes [e.g., why the event (s) happened, who was responsible] and the consequences across different aspects of your life (e.g., on your self-esteem¹⁰). The exploration of specific beliefs about ourselves, the world, and other people that are often impacted by trauma (safety, trust, power/control, esteem, intimacy) is a key feature of CPT¹⁰. Additionally, unlike CBT and PE, your therapist may not ask you to provide an extended and detailed story of your trauma (s) unless they, and you  believe it would enhance your treatment outcomes.

Here is an example of what you may encounter in CPT. A person that holds the belief “I am always responsible for everything that happens in my life” may blame themselves for an accident, even if they were not directly responsible. Encouraging this person to work through (“process”) how they have arrived at this conclusion, and the associated emotions and reactions, and practicing different ways of thinking can promote recovery from PTSD. 

CPT, like TF-CBT and PE, is an evidence-based therapy with a wealth of support for the treatment of PTSD^10-12. It is also the Centre for Clinical Psychology’s preferred PTSD treatment modality, delivered across  approximately 12 sessions (but this can range from 8-18 depending on your needs) in a structured format. You can find out more about CPT in this entry from our website here https://ccp.net.au/about-cpt-for-ptsd/.

Eye Movement Desensitization and Reprocessing (EMDR):

EMDR is a form of trauma therapy that incorporates a distracting element (called bilateral stimulation), such as the therapist moving their fingers from side to side in a windscreen wiper motion, in the context of a guided discussion focused on traumatic memories¹³. Current scientific thinking suggests EMDR  is likely to work through interactions between neurological circuits implicated with memory and sleep, which are activated by the EMDR process¹⁴. EMDR is a promising trauma treatment with an evolving evidence base¹⁵ for the treatment of trauma and PTSD; and more recently, has been shown to work particularly well when administered after a PE-based protocol¹⁶. Similarly to CPT, it is also often delivered in an 8-12 session format. Like all treatments discussed in this blog entry, it is important to find a person trained in the delivery of EMDR to ensure that you receive effective and safe psychological support. 

Dialectical Behaviour Therapy (DBT):

DBT integrates CBT with the idea that we can build capacity for accepting, but also taking steps towards meaningful change, in patterns in thinking and behavior that create difficulties in our lives¹⁷. Unfortunately, there is little (but emerging) evidence for the efficacy of DBT for PTSD in adapted and extended formats¹⁸. This means that most psychologists will not offer DBT as a treatment for PTSD. 

However, DBT is an evidence-based treatment¹⁷ for people struggling with suicidal thoughts and self-harming behaviours, who may find it hard to sit with and /or express difficult emotions, and who may find it difficult to assert their needs to others, for many years.  If the above difficulties resonate with you, your psychologist may discuss DBT as a useful component of an individualized treatment plan. Most clinicians utilize specific components of DBT, mainly the provision of “DBT Skills” around tolerating distress, acceptance and mindfulness, emotional regulation, and interpersonal effectiveness skills. 

Note that DBT, in its full form and delivered by a multidisciplinary team of trained healthcare professionals (e.g., a hospital), is the gold standard treatment for psychological difficulties associated with the borderline personality spectrum¹⁷ (alongside mentalisation based therapy, which we will not cover here). 

Other

Trauma-focused psychodynamic therapy, schema therapy, acceptance and commitment therapy (adapted for PTSD / trauma), narrative exposure therapy, and internal family systems therapy show promise but are still being investigated as standalone trauma therapies. However, it is important to note that some of these treatments have been shown to be effective for other psychological difficulties beyond trauma / PTSD – and so, they may be offered to you as an option to address other clinical goals. 

So what should I go for? 

The above paragraphs illustrate the variety of available and effective trauma treatments. However, the ones consistently recommended for adult populations are: PE, CBT for PTSD / TF-CBT, CPT, and EMDR. 

All have the common goal of reducing avoidance, addressing emotions within trauma memories, promoting flexibility in thinking (explicitly, or implicitly), and are similar in treatment duration. The differences lie in the way that they work, whether they highlight specific factors more than others (e.g., thoughts in CBT/CPT), level of structure, and ease of integrating other therapeutic components that may be useful for your needs. 

Ultimately, the trauma-focused therapy you receive comes down to your preferences, your clinician’s expertise, your needs and a treatment plan, and if applicable insurance provider preferences / coverage as well. Sometimes, your psychologist may also decide to “mix-and-match” aspects of different treatments, incorporating them in your treatment plan if appropriate for your psychological needs. 

It is important to remember that people progress towards their trauma treatment goals at different rates. For instance, a proportion of people receiving CBT for PTSD show no improvement initially but experience sudden and significant improvements across different points of their therapeutic journey¹⁹. Others may take an extended amount of time to work through the trauma they experienced. It is a very personal journey. Finding a therapist that you feel comfortable with, and making the choice to be brave and show up to work through trauma together every session can make a real difference. 

How can we help?

If you’re struggling with trauma and/or PTSD don’t hesitate to seek help. You can contact the Centre for Clinical Psychology in Melbourne at 03 9077 0122 or visit our website https://ccp.net.au/booking/ to book an appointment. Our experienced professionals can provide the support and guidance you need to overcome trauma-related distress and PTSD. 

References

References

1. Kleber R. J. (2019). Trauma and Public Mental Health: A Focused Review. Frontiers in Psychiatry, 10, 451. https://doi.org/10.3389/fpsyt.2019.00451
2. Khoury, L., Tang, Y. L., Bradley, B., Cubells, J. F., & Ressler, K. J. (2010). Substance use, childhood traumatic experience, and Posttraumatic Stress Disorder in an urban civilian population. Depression and Anxiety, 27(12), 1077–1086. https://doi.org/10.1002/da.20751
3. Gu, W., Zhao, Q., Yuan, C., Yi, Z., Zhao, M., & Wang, Z. (2022). Impact of adverse childhood experiences on the symptom severity of different mental disorders: a cross-diagnostic study. General Psychiatry, 35(2), e100741. https://doi.org/10.1136/gpsych-2021-100741
4. Stojek, M. M., McSweeney, L. B., & Rauch, S. A. (2018). Neuroscience informed prolonged exposure practice: Increasing efficiency and efficacy through mechanisms. Frontiers in Behavioral Neuroscience, 12, 281.https://doi.org/10.3389/fnbeh.2018.00281
5. Eftekhari, A., Stines, L. R., & Zoellner, L. A. (2006). Do You Need To Talk About It? Prolonged Exposure for the Treatment of Chronic PTSD. The Behavior Analyst Today, 7(1), 70–83. https://doi.org/10.1037/h0100141
6. Beck, A. T. (1993). Cognitive therapy: Past, present, and future. Journal of Consulting and Clinical Psychology, 61(2), 194–198. https://doi.org/10.1037/0022-006X.61.2.194
7. Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1
8. de Arellano, M. A., Lyman, D. R., Jobe-Shields, L., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Huang, L., & Delphin-Rittmon, M. E. (2014). Trauma-focused cognitive-behavioral therapy for children and adolescents: assessing the evidence. Psychiatric Services (Washington, D.C.), 65(5), 591–602. https://doi.org/10.1176/appi.ps.201300255
9. Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Frontiers in Behavioral Neuroscience, 12, 258. https://doi.org/10.3389/fnbeh.2018.00258 
10. Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. New York, NY: Guilford Publications.
11. Asmundson, G. J. G., Thorisdottir, A. S., Roden-Foreman, J. W., Baird, S. O., Witcraft, S. M., Stein, A. T., Smits, J. A. J., & Powers, M. B. (2019). A meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder. Cognitive Behaviour Therapy, 48(1), 1–14. https://doi.org/10.1080/16506073.2018.1522371
12. LoSavio, S. T., Holder, N., Wells, S. Y., & Resick, P. A. (2022). Clinician concerns about cognitive processing therapy: a review of the evidence. Cognitive and Behavioral Practice. https://doi.org/10.1016/j.cbpra.2022.08.005.
13. Shapiro, F. (1989). Efficacy of the Eye Movement Desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2(2), 199–223. https://doi.org/10.1002/jts.2490020207
14. Shapiro F. (2014). The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: addressing the psychological and physical symptoms stemming from adverse life experiences. The Permanente Journal, 18(1), 71–77. https://doi.org/10.7812/TPP/13-098
15. Simon, N., Robertson, L., Lewis, C., Roberts, N. P., Bethell, A., Dawson, S., & Bisson, J. I. (2021). Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults. The Cochrane Database of Systematic Reviews, 5(5), CD011710. https://doi.org/10.1002/14651858.CD011710.pub3
16. Van Minnen, A., Voorendonk, E. M., Rozendaal, L., & de Jongh, A. (2020). Sequence matters: Combining Prolonged Exposure and EMDR therapy for PTSD. Psychiatry Research, 290, Article 113032. https://doi.org/10.1016/j.psychres.2020.113032
17. Linehan, M., M., (2014). DBT Training Manual. New York, NY: The Guilford Press.
18. Oppenauer, C., Sprung, M., Gradl, S., & Burghardt, J. (2023). Dialectical behaviour therapy for posttraumatic stress disorder (DBT-PTSD): transportability to everyday clinical care in a residential mental health centre. European Journal of Psychotraumatology, 14(1), 2157159. https://doi.org/10.1080/20008066.2022.2157159
19. Kelly, K. A., Rizvi, S. L., Monson, C. M., & Resick, P. A. (2009). The impact of sudden gains in cognitive behavioral therapy for posttraumatic stress disorder. Journal of Traumatic Stress, 22(4), 287–293. https://doi.org/10.1002/jts.20427