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Rethinking Exposure Therapy as First-Line Trauma Treatment

A new vision for best-practice trauma care.

Key points

  • Exposure therapies have long been considered best-practice first-line approaches for trauma sufferers.
  • Many who suffer trauma will not pursue therapy if exposure if their only choice.
  • Failing to address the biological injury aspect of trauma not only limits therapeutic engagement but also its efficacy.
  • Using biological approaches before talk therapy is a more effective, compassionate, empowering way to help people heal.

In the past two decades, exposure therapy has been seen as the gold standard, first-line approach for post-traumatic stress symptoms. Exposure therapy proponents argue that healing from trauma requires people to approach what they would rather avoid. In practice, patients are asked to write or verbally narrate detailed accounts of their traumatic events. They are then repeatedly exposed to this until the trauma memory or memories lose their sting.

There is often an in vivo—or real-life practice—component to exposure therapy as well. Specifically, patients are asked to identify situations that cause them to feel anxious and then to actively engage with anxiety-triggering environments. Patients are told that their anxiety will spike, then plateau, then drop if they remain in the exposure scenario long enough. This occurs through a process known as habituation.

Within the Department of Veterans Affairs, and other large healthcare systems, such treatments have been touted as highly effective, best-practice approaches. Over the past several years, however, I’ve changed my view that this is truly the best practice approach for many patients. Here are three major reasons why.

First, many patients may not elect to pursue therapy if they are told that their only choice is to repeatedly confront the worst day of their lives. For many people, trauma brings a loss of control in their own bodies. They are continually ambushed by panic attacks or overwhelming feelings of dread. The loss of control that is inherent in exposure therapy approaches is a bridge too far for them. They continue to suffer in silence rather than pursue treatment.

Second, a traumatized brain is not an efficient brain. Difficulties with concentration and memory are common for those who have suffered trauma. Therapy is hard work. It requires being mindfully present while accessing past memories. It requires challenging default thinking patterns, which draws on high-level metacognitive capacity. People who are distracted by the intensity of their trauma are often not in the right mind state to benefit most fully from talk therapy.

Finally, starting with exposure therapy fails the compassion test for me as a therapist. We therapists are charged to “do no harm.” For many years, while I was doing exposure-based therapies as a front-line treatment, even with containment exercises, patients left my office in an overactivated state. It takes time for the body to return to a state of calm. Sending overactivated patients out to drive home on California’s busy freeways didn’t feel like a good call, but I didn’t perceive any other option at that time.

Now I do. There are a number of biologically focused treatments—stellate ganglion block, ketamine, and transcranial magnetic stimulation, for example—that can restore a sense of calm and control within the body. When these kinds of treatments are used prior to talk therapy, patients can then approach therapy with confidence rather than fear or anxiety.

When biologically focused trauma treatments are provided prior to therapy, patients can do deeper therapeutic work without feeling overwhelmed by anxiety or out of control in their own bodies. Combining biological treatments and therapy enhances and accelerates treatment outcomes. By changing mind state to one that is calm and positive as a first priority, therapists can effectively promote the integration of new insights, thoughts, and behaviors.

Some have argued that biologically focused treatments should not be tried unless noninvasive exposure talk therapy fails. I fundamentally disagree with this approach based on what I’ve observed. Exposure therapies are extremely invasive in that they create loss of control and overwhelming aversive emotions during therapy sessions. Addressing the biological injury associated with trauma before starting talk therapy, which helps restore somatic calm and control, is a more effective, compassionate, empowering way to help people heal.

This is a new model for the care of those who suffer from trauma, and this model is what I believe should be the new best practice approach for healing.

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