Dr. Lisa Benson

Understanding Post-Traumatic Stress Disorder (PTSD)

If you are a trauma survivor, whatever symptoms you are experiencing all make perfect sense given what you've been through. Symptoms in which you re-experience the trauma all over again, like flashbacks, nightmares, and upsetting thoughts coming into your mind, occur because of how the brain processes traumatic memories (Foa, Hembree, & Rothbaum, 2007). Think of your memory as a filing cabinet. A typical experience, such as what you had for breakfast, is like one piece of paper - you file it away neatly in the drawer where it belongs. But when a trauma happens, it's like a box of papers getting dumped on your head. Nothing gets filed away like it's supposed to. Instead, all the papers end up on the floor. As you walk around throughout your day, you can't help but trip on the papers. The harder you try not to trip on them, the more you lose your balance and fall.

If you're having some kind of re-experiencing symptoms, unfortunately your body doesn't know the difference between those and the trauma happening again. Therefore, you may be having symptoms of your body getting "hyperaroused": gearing up to protect you using "fight, flight, or freeze." (You may have only heard of "fight or flight," but freezing is actually an extremely common reaction to trauma as well - think of it like an animal "playing dead" to prevent an attack.) You may have trouble sleeping or be hypervigilant, always looking around for danger. Your heart rate may be faster, making you agitated and irritable. All this would make perfect sense if there was a threat to escape, and your body doesn't know there isn't.

If you're having these symptoms, you are likely having a lot of thoughts and feelings - anxiety, frustration, perhaps guilt or shame. Most people learn as young children that bad things happen to bad people and good things happen to good people (i.e. good kids get rewarded). Now that something terrible has happened to you, you may have come to believe there is something wrong with you that made this happen. Or, you may have concluded that actually bad things happen to everyone all the time: other people are untrustworthy and the world is a dangerous place. These are all extremely common ways of trying to make sense of something incomprehensible.

No one wants to have your mind and body in high gear all the time - so you are likely trying to find ways to avoid feeling these things. Many trauma survivors avoid people and situations that remind them of the trauma. You may have reduced your activities or stopped traveling as far from home because it reduces your anxiety in the short-term. This is extremely understandable. As you may have realized, though, avoiding may be preventing you from living your life in ways that are important to you. Also, unfortunately, avoiding reminders of trauma does not reduce symptoms of PTSD at all in the long term. Avoiding keeps the trauma re-experiencing going, so the cycle of symptoms continues (Foa, Hembree, & Rothbaum, 2007).

TREATING PTSD

What does reduce PTSD symptoms and get you back into your life? We can break the cycle in a few different places. Two evidence-based treatments, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), approach PTSD treatment in different ways:

Re-experiencing: For some trauma survivors, the most distressing symptoms are the nightmares and flashbacks. What works to address these directly is essentially rebuilding how the trauma memories are stored in your brain. Going back to the file cabinet metaphor: to deal with the pile of papers on the floor, you need to pick up each one and look at it, then file it away in its proper place. You will never be able to get rid of the trauma memory completely - it's a thing that happened to you. However, it is possible to file it away so it's part of your past, less present in your daily life. The way to "look at it and file it away" is to tell the story of your experience. In "imaginal exposure," we would create a safe, contained space for you to repeatedly tell me the story of your trauma. Over time, you likely will be able to remember and talk about the trauma without reliving it or feeling as distressed by it. The treatment which most emphasizes imaginal exposure is Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007).

Avoiding: Prolonged Exposure also involves the very important work of starting to engage in life activities you may have been avoiding. Together, we would write up a list of things you would like to work toward doing: perhaps being in crowded places, or being around reminders of the trauma. These short-term goals would be designed to move you toward your long-term goals: rebuilding relationships, going back to work or school, having new adventures, etc. We would work together to make plans and check in on how you're doing each week. To complete all this, PE sessions typically last 90 minutes (a double session).

Thoughts and feelings: An alternative to PE is Cognitive Processing Therapy (CPT; Resick & Schnicke, 1993), which uses strategies from Cognitive Behavioral Therapy (CBT) for teaching you how to modify your thoughts. Specifically, we would look for thoughts that are "stuck points" keeping you from recovery. For example, if you're frequently having the thought, "I can't trust others," we would work on examining evidence for and against this thought. The goal would not be to switch to an unrealistic thought like "I can trust everyone!" Instead, you would find a more balanced thought in your own words that you can actually believe, possibly something like "I don't have to trust everyone at first, but I can trust some people once I've had some time to get to know them and see how they treat me." We would work on thoughts in the areas of safety, trust, power and control, self- and other-esteem, and intimacy. This can help you start making changes in how you live your day-to-day life. CPT also has an imaginal exposure component: you would write out the story of what happened in your trauma and read it to me in session, then read it to yourself throughout the week. CPT sessions typically last 45 minutes (a standard session).

Will These Treatments Work?

There is a great deal of evidence that both Prolonged Exposure and Cognitive Processing Therapy are effective. Both have been tested in dozens of clinical trials worldwide with survivors of combat trauma, sexual trauma, and other traumas (Powers et al., 2010). Meta-analysis of the data from thirteen of these studies put together (with a total of 675 participants) indicates that PE and CPT are equally effective, and both are much more effective than no treatment. On measures of PTSD at the end of the treatment period, the average participant in PE did better than 86% of the no-treatment participants! It did not make a difference what kind of trauma the participant survived or how long it had been since the trauma.

Some survivors are particularly worried about whether the imaginal exposure component will increase their symptoms. Studies on this specific issue indicate that symptoms increase temporarily for only a minority of participants in therapy. Even when this happens, the participants with the temporarily increased symptoms benefit from treatment just as much as other participants - their outcomes are just as good at the end of treatment (Foa et al., 2002).

If you can commit to giving this process a fair shot, even when it's difficult, it’s possible to make a great deal of progress toward your recovery.

How Long Do These Treatments Take?

Both PE and CPT are designed to be completed in 12 sessions. Of course, many individuals find they need more sessions, so each treatment can be expanded to meet your needs. As noted above, PE typically requires a 90-minute double session.

NOT SURE IF YOU'RE Ready?

Give me a call and we'll talk it over. If it's not the right time for you to start PE or CPT, I can make some recommendations of other treatment programs to try first.

My Trauma-Focused Treatment Practice

I have worked with many individuals with all different kinds of traumatic experiences in childhood and adulthood. No matter what you have been through, I am ready to listen and help you find a way to move toward the life you want.

It’s an honor for me to have the opportunity to stand beside a survivor and become part of your recovery process. I believe in the importance of the stories we tell about our own lives, and trauma-focused therapy is all about creating a new story for yourself.

References