Important Developments in PTSD Treatment

In the 1800s, you would have heard the phrase ‘battle exhaustion.’ During and after World War I, it was known as ‘shell shock.’ Around World War II, you’d have called it ‘combat fatigue.’ Today, we call it Post-Traumatic Stress Disorder (PTSD), and it was recognized as a diagnosable condition in 1980, when the American Psychological Association included it in its Diagnostic and Statistical Manual of Mental Disorders.¹

Despite its association with military suffering, PTSD is by no means limited to combat veterans. People of every age, gender, nationality and culture are vulnerable to this psychiatric disorder, which brings powerful, disturbing thoughts and feelings related to trauma one has experienced or witnessed. The ordeal may have been a single event, a series of events or an ongoing set of circumstances experienced as physically or emotionally harmful or life-threatening. Such trauma can affect a person’s well-being mentally, physically, socially and spiritually. Examples of it include but are not limited to:

• Violence, including military combat, terrorist attack or any other violent assault
• Harassment, bullying and other types of abuse targeting one’s identity
• Kidnapping, being held hostage or any event causing fear for one’s life
• Rape or other sexual assault
• Seeing other people hurt or killed
• Repeatedly seeing or hearing distressing things in the line of work, such as in emergency services or the military
• Natural disaster such as flooding, earthquake or pandemic
• Traumatic childbirth experienced as the mother or as a witness
• Loss of a loved one under especially upsetting circumstances
• Being treated in a mental health ward
• Being diagnosed with a life-threatening condition

The after-effects of such suffering last far beyond the chronology of the events themselves. Survivors may relive trauma through flashbacks or nightmares. Their emotions may run the gamut from sadness, fear and anger to feeling detached or estranged from other people. They may feel driven to avoid situations or people that remind them of the trauma, and they may react in strongly negative ways to seemingly ordinary loud noises or accidental touches.

According to the American Psychiatric Association:²

• PTSD affects approximately 3.5% of U.S. adults every year
• The lifetime prevalence of PTSD in adolescents ages 13 to 18 is 8%
• An estimated one in 11 people will be diagnosed with PTSD in their lifetimes
• Women are twice as likely as men to have PTSD
• U.S. Latinos, African Americans and Native Americans/Alaska Natives are disproportionately affected and have higher rates of PTSD than non-Latino whites

Treatment for PTSD has evolved significantly in the last 125 years. From the so-called ‘talking cure’ introduced by Josef Breuer in 1895 and later popularized by Sigmund Freud to ‘disciplinary’ and electric-shock treatments administered in the nineteen-teens, from group therapy of the 1940s to psychiatric drugs introduced in the 1950s³ and beyond, the progression continues. Read on to explore three of the important developments in treatment for Post-Traumatic Stress Disorder.

Cognitive Behavior Therapy

While working as a psychiatrist at the University of Pennsylvania in the 1960s, Dr. Aaron T. Beck—“one of the five most influential psychotherapists of all time”⁴—pioneered Cognitive Behavior Therapy (CBT). This form of structured talk therapy helps people learn to recognize and change negative patterns of thinking and behavior so that they can cope more effectively with challenging situations and improve their overall quality of life.

In early research, Dr. Beck found that many of his depressed patients had underlying negative beliefs associated with loss and failure. They were aligned with the patients’ spontaneously expressed thoughts, which he called ‘automatic thoughts.’ The Beck Institute’s website explains, “Based on the idea that thoughts, feelings and behaviors are interconnected, Dr. Beck had the patients first identify and then evaluate these automatic thoughts. As they learned to recognize their negative thoughts and inaccurate perceptions for what they were, the patients were able to think more realistically and feel better emotionally.”⁵

CBT sessions include these components:⁶

• Identifying values and aspirations: What’s important to the client, and what do the therapist and client hope to achieve?
• Setting the agenda: What goal or problem will be addressed in this session?
• Working on agenda items: gathering information, identifying unhelpful thoughts/beliefs, planning a strategy, creating an action plan for the client
• Measuring progress: Clients complete scales and/or report on their mood and functioning to help track and continue progress

Today, therapists use CBT to treat challenges including PTSD, anxiety, substance use, sleep disorders, migraine headaches, dementia and obesity. More than 2,000 outcome studies have scientifically proven CBT’s effectiveness.⁵

Eye Movement Desensitization and Reprocessing

It’s commonly accepted that healing from severe emotional pain takes a long time. By using the evidence-based psychotherapy called Eye Movement Desensitization and Reprocessing (EMDR), however, people can gain benefits of psychotherapy that used to take years to achieve. Developed in the late 1980s by American psychologist Francine Shapiro³ for treatment of PTSD, this approach is now also used to treat adults and children with complex trauma, anxiety disorders, depression, addictive behavior problems and other clinical problems.⁷

Proponents of EMDR therapy find that the mind can heal from psychological trauma in much the same way that the body recovers from physical trauma. For example:⁸

• When we cut ourselves, our bodies work to close the wound
• A foreign object or repeated injury irritating the wound makes it fester painfully
• Healing resumes when the irritation is removed

EMDR therapy has revealed that the mind heals in similar ways, as the brain’s information processing system naturally progresses toward mental health:

• If the system is blocked or imbalanced by the effects of a disturbing event, the emotional wound festers and can cause intense suffering
• Healing resumes when the block is removed⁸

The eight-phase treatment approach of EMDR therapy involves revisiting memories while performing movements that mimic rapid eye movement.⁹ In an EMDR session, the therapist determines which memory to address, then asks the client to focus on different aspects of that event or thought while keeping their eyes on the therapist’s hand as it moves back and forth across the client’s field of vision. As this happens, for reasons believed to be connected with the biological mechanisms involved in Rapid Eye Movement (REM) sleep, internal associations arise and the client starts to process the memory and disturbing feelings. When the therapy is successful, the meaning of painful events is transformed on an emotional level. A rape victim, for example, can make a transition from feelings of horror and self-disgust to the belief that, “I survived and I am strong.”

In EMDR therapy, unlike in talk therapy, clients gain insights that result from their own sped-up intellectual and emotional processes, rather than from a clinician’s interpretation. Ultimately, they finish EMDR therapy feeling empowered by the experiences that once harmed them. Their thoughts, feelings and behavior indicate robust emotional health and resolution—without their having spoken in detail or done homework used in other therapies.

More than 30 positive controlled outcome studies have been conducted on EMDR therapy.⁸

• Some of them show that 84-90% of single-trauma victims no longer have PTSD after three 90-minute sessions
• A study funded by the HMO Kaiser Permanente found that 100% of the single-trauma victims and 77% of multiple trauma victims no longer were diagnosed with PTSD after six 50-minute sessions
• In another study, 77% of combat veterans were free of PTSD in 12 sessions

In 2002, Dr. Francine Shapiro received the International Sigmund Freud Award for distinguished contribution to psychotherapy, presented by the city of Vienna in conjunction with the World Council of Psychotherapy.¹⁰ Each year since 2008, the EMDR European Association has presented the Francine Shapiro Award to researchers credited with making a significant contribution to the advancement of EMDR research.¹¹

Today, EMDR therapy is recognized as a best practice for the treatment of PTSD by the U.S. Departments of Veterans Affairs and Defense, the International Society for Traumatic Stress Studies, the World Health Organization (WHO), the U.K. National Institute for Health and Care Excellence (NICE), the Australian National Health and Medical Research Council, the Association of the Scientific Medical Societies in Germany, and other health care associations/institutes worldwide.⁷

Prolonged Exposure Therapy

Developed in the early 2000s by Israeli-born psychologist Edna B. Foa—one of Time’s 100 Most Influential People in the World for 2010¹²—Prolonged Exposure Therapy teaches the method of gradually approaching trauma-related memories, feelings and situations that survivors have avoided.¹³

This specific type of Cognitive Behavior Therapy uses “repeated, detailed imagining of the trauma or progressive exposures to symptom ‘triggers’ in a safe, controlled way to help a person face and gain control of fear and distress and learn to cope.”² In other words, while working in a safe environment, clients are gradually exposed to imaginary or real-world scenarios that remind them of the trauma they’ve survived. In a 2010 interview, Dr. Foa said that people “are taught through exposure therapy to become less afraid, or not afraid at all, of the things they’re fearful of.”¹⁴

The components of PE Therapy include:

• Imaginal exposure: repeatedly recounting/revisiting the traumatic memories
• In-vivo exposure: gradually approaching trauma reminders (such as situations and objects) that, despite posing no harm, cause distress and are avoided
• Psychoeducation about common reactions to trauma and the cause of chronic post-trauma difficulties
• Breathing retraining for the management of anxiety

In 2018, a 200-participant trial found that ten weeks of Prolonged Exposure Therapy reduced PTSD symptoms more than the antidepressant sertraline (commonly known as Zoloft) did.¹⁵ Prolonged Exposure is recommended as a first-line treatment in all major PTSD treatment guidelines including the American Psychological Association, the International Society for Traumatic Stress Studies (ISTSS), the United Kingdom's National Institute for Health and Care Excellence (NICE), the U.S. Department of Veterans Affairs and Department of Defense (VA, DoD) and the Australian Guidelines.¹⁶

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