What are the three main recommended treatments for trauma?
The three main recommended treatments for trauma are Exposure Therapy (including Eye Movement Desensitization and Reprocessing [EMDR] and Prolonged Exposure [PE]), Cognitive Processing Therapy (CPT), and Cognitive Behavioral Therapy (CBT) or Trauma Focused Cognitive Behavioral Therapy (TF-CBT).
Psychologists routinely turn to these three treatments for all types of trauma, whether you’ve experienced one major traumatic event or a lifetime filled with ongoing trauma.
What types of therapy work for trauma?
The types of therapy that work best for trauma are Exposure Therapy (including Eye Movement Desensitization and Reprocessing [EMDR] and Prolonged Exposure [PE]), Cognitive Processing Therapy (CPT), and Cognitive Behavioral Therapy (CBT) or Trauma Focused Cognitive Behavioral Therapy (TF-CBT). Exposure Therapy can sound scary, but it has been demonstrated to be extremely effective at reducing the effects of individual events or ongoing trauma. Both EMDR and PE will be discussed in detail later, but they each involve a mental re-imagining of the event, under ideal and safe conditions, generally in a therapist’s office.
CPT is a specific type of CBT that specifically targets trauma. The American Psychological Association (APA) describes a course of treatment that often takes about 12 sessions, and “helps patients learn how to challenge and modify unhelpful beliefs related to the trauma.” CBT, more generally, encourages new ways of thinking about your trauma, often in a way that re-empowers you to feel like you are making your own choices, rather than being driven by a desire to avoid triggering symptoms related to your trauma. CBT and CPT both strive to help you disentangle your emotional triggers from events that commonly occur in your daily life.
When Trauma Becomes PTSD
Trauma becomes Post-Traumatic Stress Disorder (PTSD) when your reaction to traumatic stimuli changes from a regular, somewhat annoying part of life to a distressing occasion that interferes with normal functioning. After a trauma (experiencing or witnessing the threat of death, serious injury, or sexual assault or violence), the criteria for PTSD require at least a month of intrusive or distressing memories or thoughts of the event, avoidance of stimuli that might remind you of the event, negative changes in thoughts or mood in reaction to the traumatic event, and changes in emotional reactivity in any of a variety of settings. These symptoms can show up in a large variety of ways.
First off, let’s define trauma. As mentioned above, the DSM-5 defines trauma as “experiencing or witnessing the threat of death, serious injury or sexual violence.” The most common forms of trauma are sexual assault (as a child or adult), military activity (either combat or domestic), or being the victim of a terrible accident or violent crime. These examples are commonly known as “Big T Trauma.” However, people experience “little t trauma” on a regular basis: being humiliated in front of a large group of people, being bullied on a regular basis, losing a pet or a significant relationship, or suffering a non-life-threatening injury. In my practice, I have certainly seen people develop PTSD after suffering “little t trauma” and it can cause at least as much suffering as PTSD experienced following “Big T Trauma.” Little t trauma is often also the accumulation of a series of events, such as emotional abuse or bullying. The Big T version of this would be complex PTSD, commonly understood among mental health providers as PTSD that develops after a series of life-threatening events, such as being a victim of repeated physical or sexual abuse, or a veteran with more than one life-threatening event in their history.
Many people experience trauma (“big” or “little”) without developing PTSD, but it is not at all uncommon to develop PTSD symptoms after a trauma. The Recovery Institute reports that 49% of rape victims, and nearly 32% of victims of severe physical assault develop PTSD. Additionally, they report that 16.8% of people who are involved in serious accidents, and 15.4% of shooting and stabbing victims develop PTSD. These are not small numbers, but people who are suffering often feel alone or “less than.” It can be helpful to remember that this is a common reaction to trauma, and that there are support groups online or in-person with people who can relate to the symptoms of PTSD.
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What Trauma Therapy Can Help With
Trauma therapy can help mitigate the symptoms that go along with PTSD. First off, most therapists treating PTSD provide psychoeducation about what PTSD is, how and why it develops, and help normalize it for their clients. I like to tell my clients that most of the symptoms of trauma (hypervigilance, avoidance of traumatic stimuli, difficulty feeling safe, etc.) are actually signs that the brain is reacting to a dangerous event by trying to keep them safe. Consider this: if you were in a car accident, your brain *should* be looking around every corner for cars that are headed your way, it *should* be keeping you away from the site where something life-threatening occurred, and it *should* be alerting you to every potential danger in order to avoid another dangerous event. However, these reactions are unsustainable on a long-term basis.
Trauma therapy helps re-train your brain to see things more accurately. In some cases, this means playing the odds: you’ve been through that intersection a thousand times without getting hit, and one time you got hit. Chances are only 1/1000 that you’ll have another accident. It also helps desensitize you to the stimuli that have gotten attached to “danger” in your brain. For example, sitting in a car is not inherently dangerous, so you may have to re-habituate to merely being inside a vehicle. With PTSD, your brain is just working overtime, and the job of therapy is to give it a well-deserved break. My own therapy with PTSD clients has involved a wide variety of exposure exercises, including the (seemingly) quite mundane.
Types of Trauma Therapy Treatments
Trauma therapy tends to focus around a few core components, which are rearranged and adjusted to some extent depending on the model each therapist chooses to use. The primary components that appear across most types of therapy are psychoeducation, exposure, coping skills/strategies, and cognitive restructuring.
- Psychoeducation generally helps you understand why your brain is responding to the traumatic experience in such a dramatic way, and why it has become such an intrusive and distressing part of your life. This is essential to normalize and destigmatize the symptoms that arise with PTSD.
- Coping skills teach you to relax your body and prevent or mitigate physical and emotional symptoms from escalating, including during intentional upsetting situations, like exposure therapy.
- Exposure to stimuli that elicit a traumatic response helps to habituate the brain and desensitize you to those stimuli.
- Cognitive Restructuring allows a different thought process to take hold in your brain, allowing you to move forward in a world that doesn’t feel inherently dangerous or threatening.
Put together in varying formats, these essential components of trauma therapy allow your brain to be more thoughtful and critical of the world around it, preventing or reducing distressing flights into traumatic responses that interfere with daily life.
Cognitive Processing Therapy (CPT)
Cognitive Processing Therapy is a relatively structured therapy technique which starts with psychoeducation about the traumatic experience. Once you understand more about how the brain processes trauma, you write an “impact statement” detailing why you believe the traumatic event occurred, and how you see the event impacting yourself, the world, and people around you. This statement helps reveal potentially unhelpful thoughts or beliefs about the event and yourself.
Once the impact statement is written, you write out the details of how the traumatic experience happened, as factually and with as much detail as you can include. Working closely with your therapist, you read through the account (which is helpful in desensitizing yourself to the details of the incident itself), and respond to queries designed to challenge the maladaptive thoughts and beliefs that have become associated with the event.
After some time spent going through the account of the event, you shift into challenging more of the thoughts that have developed as a result of the accident, and how they have become a part of your everyday life. Often, maladaptive thoughts regarding safety, trust, intimacy and other aspects of life get challenged and adjusted during this stage of therapy. CPT can be done individually or in a group, and usually requires about 12 sessions, with work done both in therapy and in assignments at home.
Trauma Focused Cognitive Behavioral Therapy (TF-CBT)
Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based trauma treatment, most commonly used for children. In fact, out of 25 studies that have compared the effectiveness of TF-CBT to other trauma therapies used with children, all 25 studies showed TF-CBT to have the best results. TF-CBT combines coping skills/strategies, gradual exposure, and cognitive restructuring to help children heal after a traumatic experience (most often sexual abuse, but TF-CBT has been adjusted to be used for many other types of trauma as well). Because this treatment was specifically designed for children, it involves (non-offending) caregivers and uses a more gentle approach to exposure.
Generally, the therapist works with both the caregiver and the child, and begins by coaching the child in coping and relaxation strategies. In a parallel process, the caregiver is taught the same procedures, and is able to help the child at home. Then the therapist guides the child and caregiver through exposure exercises with gradually more challenging stimuli related to the trauma. At some point in this process, the child will be encouraged to develop a Trauma Narrative, which they will be encouraged to share with their caregiver (this cognitive restructuringoften helps correct misunderstandings in why the trauma occurred).
Throughout the process of TF-CBT, the therapist will incorporate challenges to maladaptive thoughts and beliefs, helping the child (or adult) adjust their views on the world, relationships, safety and threat. Although originally developed for children, TF-CBT can be a more appropriate choice for adults who, for whatever reason, do not have the resources to dive more fully into an intense exposure experience.
Prolonged Exposure Therapy (PE)
Prolonged exposure therapy (PE) was the gold standard of therapy treatment for many years, and is still commonly used because of its relatively high effectiveness. In PE treatment, you are first taught relaxation and breathing techniques so that you are able to regulate your nervous system if and when it gets activated. Once you are able to consistently relax, you are asked to go over your trauma in great detail, in present tense, as if it were happening right now. As you do, your therapist guides you through the event, possibly asking questions to provide more detail and keep you in that moment. Your therapist pays close attention to your level of anxious arousal, and when it gets too high, they will stop you and guide you through a relaxation technique. Once your nervous system has calmed, the process resumes. As you might guess, this can be an uncomfortable treatment, but your therapist is there to help when it gets too intense. The reason PE is so effective is that it desensitizes your brain to the details of the trauma, and begins to associate a feeling of relaxation with the events, rather than a feeling of anxiety.
Eye Movement Desensitization and Reprocessing (EMDR)/Accelerated Resolution Therapy (ART)
Eye Movement Desensitization and Reprocessing (EMDR) and Accelerated Resolution Therapy (ART–a more specialized form of exposure therapy that shares a background with EMDR) have replaced PE as the gold standard for PTSD treatment. Although the psychological community was skeptical that eye movement would make a difference in effectiveness, research eventually showed that bilateral stimulation (an essential component of EMDR) somehow speeds up the process of desensitization. With your therapist, you create resources (i.e. a safe space, allies) to help you as you re-create the circumstances of your trauma. However, instead of re-living the trauma as it actually happened, EMDR allows you to introduce an alternative (and much better/safer) ending. You can imagine that this therapy is also quite intense, which is why therapists often take significant time to ensure that you have fully developed resources before you dive into the actual EMDR.
Dialectical Behavioral Therapy (DBT)
Dialectical behavioral therapy (DBT) is a treatment used in many cases independent of trauma or PTSD. However, the skills it teaches can be particularly useful for individuals suffering from the negative effects of experiencing trauma, especially when the modified version designed for PTSD is used (DBT-PTSD). In fact, JAMA-Psychiatry, a leading publication in the medical field, recently found that DBT-PTSD is even more effective than CPT for the treatment of adult survivors of childhood sexual abuse. Marsha Linehan, a researcher and psychologist at the University of Washington, put together a curriculum of sorts that can be used with individuals, in groups, or both. The therapy process teaches, and encourages the practice of, skills related primarily to emotional regulation. These skills emphasize utilizing the brain in an intentional way, thinking through events that typically cause a quick, adverse reaction, and practicing responding differently. When you get practiced at using these skills, you find that the initial emotional reactions are less likely to happen, and your emotional flow is less volatile on a daily, or day by day, basis.
Cognitive Behavioral Therapy (CBT)
Cognitive behavioral therapy (CBT) is used in almost every version of therapy for PTSD, including each of the ones described above. The American Psychological Association (APA) suggests it as one of the primary ways to treat PTSD. In general, once you have been taught about the brain’s reaction to trauma and PTSD, learned some coping and relaxation strategies, and gone through some type of exposure therapy, your therapist will work with you on developing skills with their foundation in CBT. This might involve you learning to reconsider your thought patterns in order to identify “distortions,” which are maladaptive patterns that have developed as a result of your PTSD. These distortions often include a tendency to expect negative outcomes, a reduction in positive thinking, and generalizing one bad outcome to apply to more neutral outcomes. A CBT therapist will ask questions and guide you toward different interpretations, which will improve your self-awareness and your ability to cope with symptoms and stimuli that trigger PTSD.
How do I know if I need trauma therapy?
Trauma therapy usually becomes helpful, even essential, once you find that your symptoms have become very distressing and/or are beginning to interfere with your everyday life. These symptoms can include a heightened startle response; hypervigilance; a sense of a foreshortened future for yourself or loved ones; avoidance of places, people, or things that remind you of your trauma; and decreased mood. Sometimes you may not notice how much these symptoms are beginning to interfere with your life, and it can be helpful to solicit the feedback of family or friends who see you regularly. If other people are mentioning that you seem “different,” or “distracted,” or “unhappy,” it may be time to seek help from a skilled trauma therapist.
Client & family testimonials
"Sessions with Amanda are empowering.
Sessions with Amanda are empowering. She is a deeply kind therapist who has helped me to process, heal, and develop as a person.
—Kelly
"I have been a client of Cabot since the inception in 2010
I have been a client of Cabot since the inception in 2010; my experience with the therapists and administrative staff have always been positive. I trust them and have referred both family and friends to Cabot and all have come back thanking me for the referral and have benefited from the caring and compassionate work of the Cabot staff.
—KM
"Cabot provides a welcoming and safe environment
Cabot provides a welcoming and safe environment for those who may be struggling or need additional support. Each time I come for an appointment I am welcomed with a smile and hello not only from my therapist but others who pass through the waiting room.
—KG
How does good trauma therapy work?
Good trauma therapy works by combining the elements described above: psychoeducation, coping skills, exposure therapy, and cognitive restructuring. When a therapist guides you through these steps, using any one (or a combination) of the different models for PTSD treatment, you will find that places or things that you once tried to avoid become less aversive. You may be less easily startled and not so vigilant of your surroundings (especially when they are ostensibly safe). It will be easier to consider a happy and positive future for yourself and loved ones. Not everybody who undergoes trauma therapy has a complete reduction of their symptoms, but the rates of recovery are quite encouraging. The National Institutes of Health (NIH) found in 2019 that “a substantial proportion of cases remit within 6 months, a majority within 2 years, and 77% within ten years.” 20% of people even recover within three months. A study like this does not control for the quality of the therapist, or the therapy provided, but it does provide a snapshot of a positive prognosis for a PTSD diagnosis.
Benefits of Trauma Therapy
The benefits of trauma therapy are frankly endless. I have had clients in my practice say that they “got my life back.” Trauma and PTSD can seem to take you hostage, invading your life with flashbacks or intrusive thoughts at inconvenient times, preventing you from seeing a happy future for yourself, and having a negative impact on your mood. All these symptoms make it harder to have positive relationships with family and friends.
After going through trauma therapy (even before “completing” therapy), you may find that some of these negative effects lessen or even disappear. Flashbacks and intrusive thoughts become less frequent, and/or less distressing, you can start to imagine positive events in your future, and you feel happier, or at least less distressed. You may find that it is easier to relate to other people when you aren’t symptomatic, or preoccupied with your symptoms, and that happier future may seem even more within reach.
Quite simply, life is better when you have some skills that help you cope effectively with symptoms of PTSD. Treatment can be challenging, but it should help you gain those skills, and then you’ll be able to enjoy the benefits of the therapy.
How long does trauma therapy last?
Trauma therapy lasts exactly as long as you need it. As cited above, in a study by the NIH, 20% of people felt recovered within three months. Also in that study, 27% felt recovered by six months, and 50% felt recovered within 24 months. The study did not provide statistics on how many people felt “better,” but not recovered. In my experience, this is an extremely common outcome. In fact, there are few people that undergo trauma therapy without feeling at least some improvement or reduction in symptoms. On the other hand, doing trauma therapy may help uncover underlying or preexisting issues that may be helpful to work through in therapy. That, of course, is up to you. Some people enjoy the process of gathering insight and want to understand themselves as thoroughly as possible. Many people are very comfortable with experiencing a decrease in symptoms and the knowledge that they have skills to counteract symptoms in the future.
Treatments that may also help trauma
Aside from the therapies described, some other treatments may also have a positive impact on individuals experiencing symptoms following trauma. For example, insight-oriented therapy can help clients understand why they are responding to an event in a certain way. Acceptance and Commitment Therapy (ACT) can encourage people to engage in behaviors that might counteract negative thoughts and feelings. And outside the therapy office, people suffering from trauma or PTSD can often find support groups, either online or in the community. Depending on the person, going outside, spending time with friends, exercising creativity, balancing your nutrition and getting exercise, and meditation/breathing can all provide some positive feedback for your brain and body. It should be noted that some of these interventions could be sources of traumatic triggers, so each person must decide for themself what they need.
How effective is Trauma Therapy?
Trauma therapy is quite effective. I have referenced the JAMA article that demonstrated a high efficacy of trauma therapy in general, and I have cited other studies wherein specific types of trauma therapy were shown to be quite effective. In my own experience, I have moved from using Prolonged Exposure (PE) early in my career to using Eye Movement Desensitization and Reprocessing (EMDR) now. I have found both to be effective in reducing symptoms, but noticed that clients had an easier time doing the work involved with EMDR. The exposure in EMDR is somewhat less intense, and allows for creativity and imagination, which are boosts to people’s experience. Additionally, symptom reduction often happens more quickly. I have colleagues who prefer Accelerated Resolution Therapy (ART), stating that it is even a little faster at reducing symptoms than EMDR. Although people experience levels of severity across the spectrum, it is reasonable to expect that trauma therapy will provide some reduction in symptoms and an improvement in quality of life.
Case Study
At Cabot, we have treated hundreds, if not thousands, of people suffering from PTSD and/or the negative after-effects of trauma. Most of the people that come in for treatment leave feeling at least a little bit better; many leave feeling recovered. One client came in after suffering for many years from trauma following extensive child abuse. Her self-esteem was low, she struggled with relationships, and she experienced a sense that her life was “going nowhere.” She rarely felt safe, even in environments with people she knew well, and she had developed depression as a result of her trauma symptoms.
I worked with this client for over a year. Because of the extent of her trauma, we spent a great deal of time developing “resources,” finding therapeutic tools that could be used in her trauma therapy, including relaxation, imagery and grounding exercises. At the point at which she felt ready to do the “uncomfortable” work, we began using EMDR to tackle her PTSD symptoms. As we worked together, she slowly began to feel some relief from her symptoms, most notably in feeling more comfortable with the people around her and having a lighter mood. The most profound thing that happened during her courageous and challenging work with EMDR was that her negative beliefs about herself began to adjust. The terrible things she had believed to be 100% true about herself were no longer quite so certain, and eventually she replaced many of those negative beliefs with more positive, self-affirming truisms.
Accompanying individuals on their journey through trauma treatment is an honor and a privilege. My colleagues and I all feel humbled by your willingness to let us into your most vulnerable selves and try to make that self even stronger and more resilient than it already was. As a trauma informed therapist, I do not take that privilege lightly, and hope to provide all my clients with as much symptom relief as possible.