Treatment of PTSD

A Handout From the National Center for PTSD by Jessica Hamblen, PHD

Most people experience considerable distress and avoidanceafter being exposed to a severely traumatic experience. This is a normal andadaptive response and often includes reliving the event in thoughts, images, and dreams. Thisinitial reliving of the event may in fact contribute to the healing process and provide a wayof achieving mastery over the event. For most people, these symptoms usually become lesssevere and gradually disappear over time. For others, the symptoms persist andbecome chronic, leading to PTSD.

What treatments have been shown to be effective for PTSD?

PTSD is treated by a variety of forms of psychotherapy(talk therapy) and pharmacotherapy (medication). There is no single besttreatment, but some treatments are quite promising, especially cognitive-behavioral therapy(CBT). CBT includes a number of techniques such as cognitive restructuring, exposuretherapy, and eye movement desensitization and reprocessing (EMDR).

Cognitive therapy isbased on the idea that thoughts and feelings are connected. The goal in cognitive therapy is therefore to help people identifyand challenge problematic thinking patterns to reduce distress. For example, asoldier who fired on and killed civilians at a checkpoint might feel guilty because hebelieved “it is my fault.” Through cognitive restructuring he would challenge the belief thatit was his fault and replace it with a more accurate one, such as “Firing my weapon was alast resort.”

Exposure therapy isanother form of CBT and is based on the idea that during the traumatic event people learn to be afraid of thoughts,feelings, and situations that remind them of the traumatic event. Exposure therapy involvescareful, repeated, detailed imagining of the trauma (exposure) in a safe, controlledcontext to help the survivor face and gain control of the fear and distress that wasoverwhelming during the trauma. For example, a sexual assault survivor may be asked to describewhat happened to her over and over again in the session until she “learns” not to beafraid of the memory of her assault. In some cases, trauma memories or reminders can beconfronted all at once ("flooding"). For other individuals or traumas,it is preferable to work up to the most severe trauma gradually by using relaxation techniques andby starting with less upsetting life stresses or by confronting the trauma one piece at atime ("desensitization").

Eye movement desensitization and reprocessing (EMDR) is a relatively new treatment for traumatic memories that involves elements of exposuretherapy and cognitive-behavioral therapy combined with techniques (eye movements, hand taps,sounds) that create an alternation of attention back and forth across the person'smidline. Although research suggests that the eye movements are not necessary, EMDR isan effective treatment.

Medication. Studieshave also shown that medications help ease associated symptoms of depression and anxiety and help with sleep. The most widelyused drug treatments for PTSD are the selective serotonin reuptake inhibitors(SSRIs), such as Prozac and Zoloft, which are approved by the Food and Drug Administration astreatments for PTSD. At present, cognitive-behavioral therapy appears to besomewhat more effective than drug therapy. However, it would be premature to conclude thatdrug therapy is less effective overall since drug trials for PTSD are at a very earlystage. Drug therapy appears to be highly effective for some individuals and is helpful formany more. In addition, the recent findings on the biological changes associated with PTSDhave spurred new research into drugs that target these biological changes.

Are there any other PTSD treatments?

Group Treatment. Althoughthere is not strong support for the effectiveness of group treatment, many people find it to be of value. Traumasurvivors are able to share traumatic material within the safety, closeness, andunderstanding of other survivors. As group members achieve greater understanding and resolutionof their trauma, they often feel more confident and able to trust. As they discuss andshare how they cope with trauma-related shame, guilt, rage, fear, doubt, and beingdown on themselves, they begin to focus on the present rather than the past. Telling one'sstory (the "trauma narrative") and directly facing the feelings related to trauma allowsmany survivors to cope with their symptoms, memories, and other aspects of their lives.

Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event, particularly as they relate to early lifeexperiences. Through the retelling of the traumatic event to a calm, understanding,kindhearted, and nonjudgmental therapist, the survivor feels better about him or herself,develops effective ways of thinking and coping, and learns to deal more successfullywith strong emotions. The therapist helps the survivor identify current lifesituations that set off traumatic memories and worsen PTSD symptoms.

How long does treatment last?

For some people, treatment for PTSD can last 3 to 6 months.Others, especially those with additional on-going psychiatric problems, may requireongoing treatment for continued symptoms of PTSD, including professionalcounseling, medicines, and stress management. In these cases, treatment for PTSD may last for1 to 2 years or longer.

What if someone has PTSD and another disorder? Is thetreatment different?

It is very common to have PTSD at that same time as anotherdisorder. Psychiatric disorders that commonly co-occur with PTSD includedepression, alcohol/substance abuse, panic disorder, and other anxiety disorders. In manycases, the PTSD treatments described above will also help with the other disorders.Although crises that threaten the safety of the survivor or others must be addressed first,the best treatment results are achieved when both PTSD and the other disorder(s) aretreated together rather than one after the other. This is especially true for PTSD andalcohol/substance abuse

How do I find a therapist?

There are many ways to find a therapist. A good place tostart is to ask friends and family members if they know anyone who they wouldrecommend. However, even if they know someone they liked, this therapist might not haveexpertise in trauma treatment.

Another way to locate a therapist is to make some phonecalls.

Contact your local mental-health agency or familyphysician.
Call your local state psychological association
Consult a local university o college department ofpsychology
Call the National Center for Victims of Crime's toll-freeinformation and referral service at 1-800-FYI-CALL. This is a comprehensivedatabase of thousands of community service agencies throughout thecountry that directly support victims of crime.
If you work for a large company or organization, call thehuman resources or personnel office to find out if they provide mental-healthservices or make referrals
If you are a member of a Health Maintenance Organization(HMO), call to find out if mental-health services are available.

Some local mental-health services are listed in the phonebook in the blue Government pages. In the "County Government Offices" sectionfor the county where you live, look for a "Health Services (Dept. of)" or"Department of Health Services" section. In that section, look for listings under "Mental Health."In the yellow pages, services and mental-health professionals are listed under"counseling," "psychologists," "social workers," "psychotherapists," "socialand human services," or "mental health." Health insurance may pay for mental-health services and some areavailable at low cost according to your ability to pay.

There is also a lot of information that can be foundon-line (on the computer). In many cases you can access a list of services or therapists inyour area. In some cases areas of expertise are provided. To find online resources to helpyou in finding a therapist, see our website.

Choosing a therapist

Selecting a therapist is a highly personal matter. Aprofessional who works very well with one individual may not be a good choice for anotherperson. There are several ways to get referrals to qualified therapists such as licensedpsychologists.

There are a many things to consider in choosing atherapist. Some of these issues are practical such as location, cost, and what insurance thetherapist accepts. Some are more professional such as the therapist’s background andtraining. Still others are more personal such the interpersonal style of the therapist.There are some questions that you can ask before you select a therapist that may help infinding a good fit. Other issues, such as a therapist’s style you wont know until you begintherapy.

Some people choose to meet with a few therapists at thebeginning before determining who to work with. Most however try and get a referral tosomeone known in their area and then proceed with that person unless a problem occurs.Either way, here is a list of questions you may want to ask a potential therapist.

What is your educational background? Are you licensed?How many years have you been practicing?
What are your areas of expertise?
What experience do you have working with people withtrauma and or PTSD? Do you have any specialized training in PTSD treatment?
What kinds of PTSD treatments do you use? Have they beenproven effective for dealing with my kind of problem or issue?
What are your fees? (Fees are usually based on a 45-minute to 50-minute session.) Do you have a sliding-scale fee policy? How much therapy wouldyou recommend?
What types of insurance do you accept? Will you acceptdirect billing to or payment from my insurance company? Are you affiliated with anymanaged care organizations? Do you accept Medicare or Medicaid insurance?

What can I expect from my therapist?

When you begin psychotherapy, you and your therapist shoulddecide together what goals you hope to reach in therapy. Not every person withPTSD will have the same treatment goals. For instance, not all people with PTSD areconcerned with lessening their symptoms. Some people want to learn instead the bestway to live with existing symptoms and how to cope with other problems associatedwith PTSD. Perhaps you want to lessen your feelings of guilt and sadness? Perhaps youwould like to work on more tangible aspects of your distress, like your relationshipsat work, or communication issues with your friends and family. Your therapist should helpyou decide which of these goals seems most important to you, and he or she should let youknow which goals might take a long time to achieve.

Your therapist should also provide you with a goodrationale for the therapy. That is, you should understand why your therapist is choosing a specifictreatment for you, how long they expect the therapy to last, and how they will evaluateits effectiveness. The two of you should agree at the outset that this plan makes sensefor you and what you will do if it does not seem to be working. If you have any questionsabout the treatment your therapist should be able to answer them.

Another aspect important to the course of good therapy isthe relationship you have with your therapist. If you feel comfortable with your therapistand feel you are working as a team to tackle your problems, it is likely that the therapywill go well. If you have concerns about your therapist, or concerns about thetherapy, you should speak with your therapist about them. Therapy is not easy. It can bedifficult to talk about painful situations in your life, or about traumatic experiencesthat you have had. Feelings that emerge during therapy can be frightening and challenging.Talking with your therapist about the process of therapy, and about your hopes andfears in regards to therapy, will help make therapy successful.

If you have concerns about your therapy or concerns aboutyour therapist that have not been successfully worked out with your therapist, it mightbe helpful to consult another professional. It is recommended, however, that you let yourtherapist know you are seeking a second opinion.

For more information see www.ncptsd.va.gov

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