Evidence-based, trauma-focused psychotherapy is the first-line treatment for PTSD. Psychotherapy is defined as a treatment where a therapist and patient build a
therapeutic relationship and focus on the patient's thoughts, attitudes, affect, behavior, and social development to lessen the patient's psychopathologies and functional impairment.
Cognitive behavioral therapy Cognitive behavioral therapy (CBT) focuses on the relationship between someone's thoughts, feelings, and behaviors. It helps people understand the discrete nature of their thoughts and feelings, and to be better able to control and relate to them. It began with the work of American psychologist
Albert Ellis in the late 1950s, and was notably expanded on by American psychiatrist
Aaron Beck. CBT involves exposure to the trauma narrative in a controlled way to reduce avoidance behaviors related to the trauma. Education about the effects of trauma and
stress management techniques are common aspects of CBT. There is evidence that CBT combined with exposure therapy can reduce PTSD symptoms, lead to a loss of PTSD diagnosis, and reduce depression symptoms. The most applicable techniques vary from person to person, with no current front-runner showing any particular advantage over the other.
Trauma-focused cognitive behavioral therapy Trauma-focused cognitive-behavioral therapy (TF-CBT) was developed by Anthony Mannarino, Judith Cohen, and Esther Deblinger in the mid-1990s to help children and adolescents with PTSD. Individuals work through the memories of the trauma in a safe and structured environment, trying to correct negative cognitions and thoughts while also performing gradual exposure to triggers. This therapy is held over 8 to 25 sessions with the child/adolescent and their caregiver. The treatment helps correct distorted beliefs in the children while also helping parents and caregivers process their own distress and support the children. Cultural adaptations may rely on targeting the unique experience of a group, such as chronic exposure to
racial trauma, or culture-specific coping strategies, such as including racial socialization and community support. In recent years, psychologists have tested the effectiveness of culturally modified TF-CBT approaches with different communities, such as unaccompanied child migrants and women in war-torn countries. Research suggests that cultural adaptations to TF-CBT can improve intervention effectiveness. and the National Institute of Clinical Excellence (NICE). The
Australian Psychological Society considers it a Level I (strongest evidence) treatment method. developed a cognitive model that explains what prevents people from recovering from traumatic experiences and thus why people develop PTSD. The model suggests that PTSD develops when individuals process the traumatic event in a way that makes them feel that there is serious current threat. This perception of a threat is followed by reexperiencing arousal symptoms and persistent negative emotions like anger and sadness. Differences in how the individual appraises the event ("I cannot trust anyone anymore" or "I should have prevented what happened") and the poor integration of the most intense moments of the trauma into memory contribute to the distorted way people with PTSD make sense of what happened to them. Ehlers, Clark and others developed a cognitive therapy based on this model, the details of which were first published in 2005. It is a form of cognitive behavioural therapy that involves developing and believing a new, less threatening understanding of the trauma experiences. Patients gain an increased understanding of how they perceive themselves and the world around them, and how these beliefs motivate their behavior, before beginning the process of changing these thought patterns. Thus, three goals drive cognitive therapy for PTSD: • Modify negative appraisals of the trauma • Reduce reexperiencing symptoms by discussing trauma memories and learning how to differentiate between types of trauma triggers • Reduce behaviors and thoughts that contribute to the maintenance of the "sense of current threat" One specific practice is
imagery rescripting where the therapist guides the patient to reimagine their traumatic memory in a way that gives them control so that they can create new outcomes. For example, adult patients with childhood trauma are encouraged to imagine their trauma from the point-of-view of an adult rescuing and protecting the vulnerable child.
Imagery rehearsal therapy helps people with nightmares by documenting their dreams and creating new endings to them. They then write down their dreams, monitor them, and regularly act out the improved dream scenarios. "Cognitive therapy" of this kind should not be confused with the earlier established
cognitive therapy of
Aaron Beck. Ehlers and Clark inspired cognitive therapy is strongly recommended for treatment of PTSD by the
American Psychological Association.
Prolonged exposure therapy Prolonged exposure therapy (PE) was developed by
Edna Foa and Micheal J Kozak from 1986. It has been extensively tested in clinical trials. While, as the name suggests, it includes exposure therapy, it also includes other psychotherapy elements. Foa was chair of the PTSD work group of the
DSM-IV. Prolonged exposure therapy typically consists of 8 to 15 weekly, 90 minute sessions. Patients will first be exposed to a past traumatic memory (imaginal exposure), after which they immediately discuss the traumatic memory and then are exposed to, "safe, but trauma-related, situations that the client fears and avoids". Slowed
breathing techniques and psychoeducation are also touched on in these sessions. PE is theoretically grounded in emotional processing theory, which proposes "a hypothetical sequence of fear-reducing changes evoked by emotional engagement with the memory of a significant event, particularly a trauma." While PE has received substantial empirical support for its efficacy (albeit with high dropout rates), emotional processing theory has received mixed support. PE is strongly recommended as a first-line treatment for PTSD by the
American Psychological Association.
Cognitive processing therapy Cognitive processing therapy (CPT) was developed by
Patricia Resick from 1988. It is an evidence-based treatment aimed at individuals diagnosed with PTSD. This therapy focuses on processing and working through the trauma, designed using techniques from Cognitive Behavioral Therapy discussed previously. CPT is founded on the principle that generally, individuals can gradually recover from traumatic events over time, but in those diagnosed with PTSD, this recovery pathway is impaired. During therapy sessions, clients write and recite written passages either related to why the individual thinks they were exposed to the traumatic event, or narratives outlining the event in explicit detail. CPT is typically completed over 12 one-hour weekly sessions with a practitioner. The first phase of treatment is psychoeducation. During this part of therapy, individuals learn about the relationship between thoughts and emotions, and importantly, they look for "automatic thoughts" The patient discusses their distressing thoughts as the therapist reinforces positive cognitions and utilizes strategies such as a body scan. These sessions are usually once or twice a week for about 6 to 12 weeks. By the end of these sessions, individuals usually demonstrate reduced emotional distress related to the traumatic event. The methodology behind EMDR focuses on the Adaptive Information Processing model of PTSD Therapy with the incorporation of EMDR has been shown to aid patients in processing distressing memories and reducing their harmful effects. A proposed neurophysiological basis behind EMDR is that it mimics REM sleep, which plays a vital role in
memory consolidation. Imaging studies suggest that "eye movements in both REM sleep and wakefulness activate similar cortical areas". The bilateral stimulation facilitated by EMDR "shifts the brain into a memory processing mode", reintegrating the traumatic events with more positively reinforced cognitions. The information can then be integrated completely to lessen the symptoms of triggers. The restoration of the pathway can help with recovery from traumatic events. Some social scientists argue that EMDR is a
purple hat therapy.
Narrative exposure therapy Narrative exposure therapy creates a written account of the traumatic experiences of a patient or group of patients, in a way that serves to recapture their self-respect and acknowledges their value. Under this name it is used mainly with refugees, in groups. It also forms an important part of cognitive processing therapy. Patients are asked to narrate their life-story while staying in the present moment. They receive an autobiography at the end from their therapist and this often serves as motivation to complete their narration. It emphasizes the psychodynamic perspective of shame and guilt in addition to the principles of cognitive-behavioral therapy. In 16 sessions, patients create a detailed account of the primary trauma experience, explore the connected emotional reactions, and how to move forward. The first few sessions deal with the traumatic experience as well as reliving the event in the present using objects or core memories. Through this process, the client discusses upsetting feelings and emotions as the therapist helps them to process the event. The individual also writes a letter to the person or group they feel holds responsibility for the trauma although it is not sent. The therapists then assist the individual in assessing the impacts of the trauma from beliefs to physical changes to help them learn and grow from the event instead of avoiding and fearing the impacts. Finally, the therapist helps to develop
relapse prevention methods and looks forward to a better future.
Dialectical behavioral therapy Dialectical behavioral therapy is a branch of cognitive behavioral therapy aimed at helping individuals to "accept the reality of their lives". Therapists use strategies such as behavioral therapy techniques and mindfulness to address thoughts and behaviors, and help individuals to regulate and change these. It is usually recommended and used in patients with
borderline personality disorder and other personality disorders which are difficult to treat. The specific skills focused on are mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation. The main goal of DBT is to help clients manage their treatment and better understand their symptoms. The focus of DBT for PTSD is the future and adapting to the symptoms of the trauma. DBT has been studied as another potential treatment for PTSD. When used during partial hospitalization (PH) and intensive outpatient (IOP) programs, it's been reported to help reduce depression, anxiety, and hopelessness - at the same time improving mindfulness. Even in studies where PTSD was not the main focus, these programs have been connected to improvements in PTSD symptoms and mood. As of yet, DBT isn't recommended as a primary PTSD treatment, but using DBT in PH and IOP programs in combination or as a supplement with other therapies like PE, CPT, or EMDR has been explored. A major premise of EFT is that emotion is fundamental to the construction of the self and is a key determinant of self-organization. At the most basic level of functioning, emotions are an adaptive form of information-processing and action readiness that orient people to their environment and promote their well-being. EFT suggests that the developing cortex added the ability for complex learning to the emotional brain in-wired emotional responses. It was also shown that negative social support intensifies PTSD. Metacognitions control the negative thoughts and ruminations prevalent in many psychiatric diseases such as PTSD. Metacognitive therapy (MCT) was developed by
Adrian Wells and is based on an information processing model by Wells and Gerald Matthews. This psychotherapy aims at changing metacognitive beliefs that focus on states of worry, rumination, and attention fixation. As per the metacognitive model, the symptoms are caused by worry, threat monitoring, and coping behaviors that are thought to be helpful but actually backfire. It has also shown clinically significant results for different causes of PTSD such as accident survivors, and assault and rape victims. The
Australian Psychological Society considers
metacognitive therapy (MCT) to be a Level II treatment method. The
Australian Psychological Society considers
mindfulness-based stress reduction to be a Level II treatment method. Researchers began experimenting with
virtual reality therapy in PTSD exposure therapy in 1997 with the advent of the "Virtual Vietnam" scenario. Virtual Vietnam was used as a graduated exposure therapy treatment for Vietnam veterans meeting the qualification criteria for PTSD. A 50-year-old Caucasian male was the first veteran studied. The preliminary results concluded improvement post-treatment across all measures of PTSD and maintenance of the gains at the six-month follow up. Subsequent open clinical trial of Virtual Vietnam using 16 veterans, showed a reduction in PTSD symptoms. Exposure therapy remains a controversial form of therapy to treat PTSD. Those suffering with extreme re-experiencing and arousal symptoms may find exposure to be triggering. Confronting trauma too early after a traumatic event may be upsetting and only worsen symptoms for patients; severe negative reactions include self harm, panic disorder, dissociative disorder, and even suicidal thoughts. It is suggested exposure therapy, if used, should be resorted to only as second line of treatment—therapy ought to first focus on stabilizing and solving present symptoms before incorporating exposure.
Occupational therapy Occupational therapy (OT) assists individuals in meaningful daily activities. OT helps individuals in response to an impairment such as an illness, disability, or in the case of PTSD, a traumatic event. Occupational therapists are equipped to address this meaningful area through
sleep hygiene. Some examples of this technique are reducing screen time, developing nighttime routines, and creating a safe and quiet environment within the bedroom. Another meaningful area of occupational therapy is
self-care. Occupational therapists provide education and adaptation/modification in self-care to maintain independence and prevent triggers that may cause
flashbacks. Occupational therapists help clients with PTSD engage in meaningful life roles in daily lives, leisure, and work activities through healthy habit formation and stable daily routines while managing PTSD triggers. Occupational Therapy interventions are wide-ranging, from group therapy to therapy tailored to the specific cause of PTSD. Other more unique OT interventions include, high intensity sports, role playing scenarios, and sensory modulation therapy. One specific study with promising results, analyzed a sports-oriented OT intervention using surfing to help veterans with PTSD return to civilian life.
Stress inoculation training Stress inoculation training was developed to reduce anxiety in doctors during times of intense stress by
Donald Meichenbaum in 1985. It is a combination of techniques including relaxation, negative thought suppression, and real-life exposure to feared situations used in PTSD treatment. The first phase identifies the individual's specific reaction to stressors and how they manifest into symptoms. The second phase helps teach techniques to regulate these symptoms using relaxation methods. The third phase deals with specific coping strategies and positive cognitions to work through the stressors. Finally, the fourth phase exposes the client to imagined and real-life situations related to the traumatic event. This training helps to shape the response to future triggers to diminish impairment in daily life. == Biological interventions ==