Cognitive Behavioral Treatment (CBT)
Cognitive-behavioral strategies have been the most frequently studied and most effective form of psychotherapy treatment for PTSD. The essential feature in all cognitive therapies is an understanding of PTSD in terms of the workings of the mind. Implicit in this approach is the idea that PTSD is, in part, caused by the way we think. CBT helps people understand the connection between their thoughts and feelings. CBT can help change the way we think (“cognitive restructuring”) by exploring alternative explanations, and assessing the accuracy of our thoughts. Even if we are not able to change the situation, we can change the way we think about a situation.
CBT is based on the understanding that many of our emotional and behavioral reactions to situations are learned. The goal of therapy is to unlearn the unhelpful reactions to certain events and situations and learn new ways of responding. CBT relies on evaluating thoughts to see whether they are based on fact or on assumptions. Often we get upset because we think something is occurring when it is not. CBT encourages us to look at our thoughts as hypotheses to be questioned and tested. CBT for trauma includes strategies for processing thoughts about the event and challenging negative or unhelpful thinking patterns.
Exposure therapy
Exposure is one form of CBT. Exposure uses careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context to help the survivor face and gain control of the fear and distress that was overwhelming during the trauma. In some cases, trauma memories or reminders can be confronted all at once ("flooding"). For other individuals or traumas, it is preferable to work up to the most severe trauma gradually by using relaxation techniques and by starting with less upsetting life stresses or by taking the trauma one piece at a time ("desensitization"). When exposure is conducted by having the person imagine the trauma (such as a rape) it is called “imaginal exposure.” When it is done in real life, such as having the person go into a feared situation such as a crowded place, it is called “in vivo exposure.” In most cases, both forms of exposure are used.
CBT often involves reading assignments and homework so that clients can practice on their own the techniques they have learned in therapy.
Pharmacotherapy (medication)
Medications can reduce the anxiety, depression, and insomnia often experienced with PTSD, and in some cases, they may help relieve the distress and emotional numbness caused by trauma memories. Several kinds of antidepressant drugs have contributed to patient improvement in most (but not all) clinical trials, and some other classes of drugs have shown promise. The FDA has approved two medications, Paroxetine and Sertraline, for use in the treatment of PTSD. Although no medication has been proven to cure PTSD, medications are clearly useful for symptom relief, which makes it possible for survivors to participate in psychotherapy.
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR is a relatively new treatment for traumatic memories that involves elements of exposure therapy and CBT combined with techniques (eye movements, hand taps, sounds) that create an alternation of attention back and forth across the person's midline. While the theory and research are still evolving for this form of treatment, evidence suggests that it is the exposure and cognitive components of EMDR that make it effective, rather than the attentional alternation.
Group treatment
Group therapy is often an ideal therapeutic setting because trauma survivors are able to share traumatic material within the safety, cohesion, and empathy of other survivors. In such a setting, the PTSD patient can discuss traumatic memories, PTSD symptoms, and functional deficits with others who have had similar experiences. As group members achieve greater understanding and resolution of their individual traumas, they often feel more confident and able to trust. As they discuss and share how they cope with trauma-related shame, guilt, rage, fear, doubt, and self-condemnation, they prepare themselves to focus on the present rather than the past. Telling one's story (the "trauma narrative") and directly facing the grief, anxiety, and guilt related to trauma enables many survivors to cope with their symptoms, memories, and other aspects of their lives.
How can I tell if therapy is working well?
When you begin psychotherapy, you and your therapist should decide together what goals you hope to reach in therapy. Not every person with PTSD will have the same treatment goals. For instance, not all people with PTSD are concerned with lessening their symptoms. Some people want to learn instead the best way to live with existing symptoms and how to cope with other problems associated with PTSD. Perhaps you want to lessen your feelings of guilt and sadness? Perhaps you would like to work on more tangible aspects of your distress, like your relationships at work, or communication issues with your friends and family. Your therapist should help you decide which of these goals seems most important to you, and he or she should discuss with you which goals might take a long time to achieve.
Your therapist should also provide you with a good rationale for the therapy. That is, you should understand why your therapist is choosing a specific treatment for you, how long they expect the therapy to last, and how they will evaluate its effectiveness. The two of you should agree at the outset that this plan makes sense for you and what you will do if it does not seem to be working. If you have any questions about the treatment your therapist should be able to answer them.
Another aspect important to the course of good therapy, is the relationship you have with your therapist. If you feel comfortable with your therapist and feel you are working as a team to tackle your problems, it is likely that the therapy will go well.
If you have concerns about your therapist, or concerns about the therapy, you should speak with your therapist about them. Therapy is not easy. It can be difficult to talk about painful situations in your life, or about traumatic experiences that you have had. Feelings that emerge during therapy can be frightening and challenging. Talking with your therapist about the process of therapy, and about your hopes and fears in regards to therapy, will help make therapy successful.
If you have concerns about your therapy or concerns about your therapist that have not been successfully worked out with your therapist, it might be helpful to consult another professional. It is recommended, however, that you let your therapist know you are seeking a second opinion.
How do I find a qualified therapist?
Selecting a therapist is a highly personal matter. A professional who works very well with one individual may not be a good choice for another person. There are several ways to get referrals to qualified therapists such as licensed psychologists.
Listed below are some ways to find help. When you call, tell whomever you speak to that you are trying to find a mental-health provider who specializes in helping people who have been through traumatic events. Check this website regularly for updated information on how to get help. We will be listing more ways to get help as they become available.
For veterans
VA medical centers and Vet Centers provide veterans with mental-health services that health insurance will cover or that costs little or nothing, according to a veteran's ability to pay. VA medical centers and Vet Centers are listed in the phone book in the blue Government pages. Under "United States Government Offices," look in the section for "Veterans Affairs, Dept of." In that section look for VA Medical Centers and Clinics listed under "Medical Care" and for "Vet Centers - Counseling and Guidance," and call the one nearest to where you live. On the Internet, go to
http://www.va.gov/ and look for the VHA Facilities Locator link under "Health Benefits and Services," or go to
www.va.gov/rcs.
For more information see Specialized PTSD Treatment Programs in the U.S. Department of Veterans Affairs
For non-veterans
Some local mental-health services are listed in the phone book in the blue Government pages. In the "County Government Offices" section for the county where you live, look for a "Health Services (Dept. of)" or "Department of Health Services" section. In that section, look for listings under "Mental Health." In the yellow pages, services and mental-health professionals are listed under "counseling," "psychologists," "social workers," "psychotherapists," "social and human services," or "mental health." Health insurance may pay for mental-health services and some are available at low cost according to your ability to pay.
For anyone
Call your doctor's office or ask friends if they can recommend any mental-health providers.
If you work for a large company or organization, call the human resources or personnel office to find out if they provide mental-health services or make referrals.
If you are a member of a Health Maintenance Organization (HMO), call to find out if mental-health services are available.
Call the National Center for Victims of Crime's toll-free information and referral service at 1-800-FYI-CALL. This is a comprehensive database of more than 6,700 community service agencies throughout the country that directly support victims of crime.
Contact your local mental-health agencies or family physician. To learn more about discussing PTSD with your physician, see the fact sheet "Discussing PTSD with your doctor" below.
Treatment for PTSD