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Effective Therapies for Post-Traumatic Stress Disorder

Prolonged Exposure therapy, Dialectical Behavior Therapy and EMDR are reviewed.

Key points

  • Brief prolonged exposure, cognitive processing therapy, and eye movement desensitization and reprocessing are effective for a majority of people.
  • New research shows that even severe complex PTSD can be healed with Dialectical Behavior Therapy.
  • All the top treatments involve exposure, which helps a person face trauma memories repeatedly until they can be better tolerated.

Posttraumatic Stress Disorder (PTSD) is a difficult long-term struggle in the aftermath of traumatic events. The American Psychological Association concludes that the most effective approaches for adults with PTSD are seven specific cognitive-behavioral therapies (CBT): prolonged exposure therapy (PE), cognitive processing therapy (CPT), eye movement desensitization, and reprocessing (EMDR), and four other approaches. Rigorous studies show that, overall, these trauma-focused psychotherapies resolve PTSD for slightly more than half of the adults who attend 9-12 sessions.

Choosing a Specific Therapy

You have several effective choices. PE, CPT, and EMDR are the therapies that are easy to find and have strong research support for a wide variety of traumas. Because they are similar in effectiveness, you may want to start with whichever evidence-based therapy is the most available.

Most patients with trauma do EMDR because it’s much more available than the others. I found 5349 fully certified EMDR therapists in California compared to 27 certified in PE. EMDR is the most popular because many therapists believe it’s the most gentle and effective, even though research does not support those beliefs.

You can also choose a therapy based on your preferences and needs. Although effective therapies have a lot in common, they also differ in ways that may matter to you. All the top treatments have exposure, which involves helping you face your trauma memories repeatedly until you can better tolerate them. Most of them require you to thoroughly talk through the most challenging parts of your memories, although EMDR does not. Most have you write out your full trauma stories or repeat visual mental imagery of your memories. The therapies help you emotionally process your traumas, change your negative beliefs, stop avoiding reminders and safe situations, and reclaim or rebuild your life. PE provides the most structure for you to thoroughly remember your trauma events and stop avoiding safe situations that feel dangerous.

What if Your PTSD Does Not Improve?

Unfortunately, treatment failures are quite common when a specific therapist tries to do a specific therapy with a specific person with PTSD. Fortunately, you are likely to overcome PTSD if you switch to one of the other therapies if your first therapy is not helpful enough. So don’t despair! You can also switch to a therapist with objectively more expertise and not rely on their claims of success.

Complex trauma and complex PTSD are more challenging to treat. Complex trauma is when a person has had multiple traumatic events over long periods. Having complex PTSD means the person also struggles with other significant problems like addiction, rage, self-injury, suicide attempts, or borderline personality disorder. Overall, treatments are much less effective for people with complex trauma, especially if their trauma started at a younger age or has complex PTSD.

Suppose you have complex trauma and don’t recover enough after ten sessions focusing on your trauma memories. In that case, your therapist likely needs to provide more thorough exposures or do more to build your coping skills and block your avoidances. This idea is supported by a rigorous study that found that after EMDR, 67 percent of patients with complex trauma (mixed childhood and adult traumas) still had PTSD compared to 25 percent of patients who reported only adult trauma. Many patients with complex trauma likely need more exposure than what standard brief PTSD therapies provide.

What If You Have Complex PTSD?

PE addresses severe complications due to complex PTSD within Dialectical Behavior Therapy (DBT-PE), the most thorough approach for complex PTSD. DBT-PE begins by building up a broad set of skills for emotions and behaviors. After demonstrating skillful coping, the patient repeatedly tells their main trauma stories and acts opposite to their avoidant behaviors.

In a 2014 study, 13 sessions of PE were added to a full year of twice-per-week outpatient DBT. Many of the patients had struggled with self-injury and suicide attempts before starting the treatment. Adding PE to DBT improved the PTSD recovery rate to 80 percent (compared to 40 percent among patients who got standard DBT without PE) and cut suicide attempts in half. If you have complex PTSD, I recommend you enroll in an adherent DBT program that provides DBT-PE, which includes two weekly DBT sessions and 24/7 skills coaching between sessions.

Can You Tolerate Trauma Therapy?

Despite the reputation that PE “retraumatizes” patients, all the trauma therapies are equally tolerated by patients. They have similar dropout rates—about 18 percent. Skilled therapists thoroughly prepare you and adjust the pace as needed. You start by writing about what happened to you, talking through it, or silently bringing memories into your mind. You also can start with your least distressing memory and slowly work your way up to the more difficult ones. Never start distressing therapy tasks if you feel confused or pressured.

EMDR is the least directive, emphasizing natural pacing above all else. You flexibly flow through your trauma processing as you attend to your inner experiences and move freely back and forth between various difficult life experiences in the past and present. EMDR also reduces the emotional intensity of every exposure by having you engage in a distracting task, usually alternating eye movements, sounds, or touches, while thinking about your traumatic experiences.

If you don’t improve enough after ten sessions of this lower-intensity exposure, your therapist likely needs to be much more directive. Many patients with complex trauma need more exposure than what standard EMDR provides (67 percent still have PTSD after eight weeks of EMDR). EMDR therapists do not do much to discourage avoidance of trauma memories and safe situations that feel dangerous. Making this change will likely make your therapy more uncomfortable than you would prefer, but it’s so worth it to recover from your complex trauma finally!

Whenever you decide to embark on your trauma therapy journey, I applaud your courage.

To find a therapist, visit the Psychology Today Therapy Directory.

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