PTSD and Some Options for Therapy

Post-Traumatic Stress Disorder (PTSD) can affect both your mental health and your physical health. It can be caused by a single trauma or many traumatic events. It can result from being exposed in some way to death or potential death, serious physical injury, or sexual assault, directed at you or at someone else.

Symptoms of PTSD

PTSD can affect your mental health and your physical health. Here are some examples of how you might be reacting if you have PTSD:

 
  • Out of the blue, I feel upset and I’m having thoughts and memories that are hard to cope with.
  • I feel like I’m panicky – my heart is racing and I feel sweaty and frightened.
  • I’m having a flashback – it’s like I’m right back in the situation that caused the trauma.
  • I’m having trouble sleeping peacefully – I have nightmares and anxious dreams regularly.
  • I’m having difficulty paying attention because of intrusive thoughts or images.
 
  • I don’t want to go out in case I get triggered.
  • I can’t let myself think about what I experienced when the trauma happened – it is too painful and I’m afraid I’m going to lose control.
  • I really try, but I can’t feel anything about the trauma that happened. It’s like it happened to someone else. I know the feelings are in there, but I can’t reach them.
  • I’m drinking, smoking up, or using drugs to help me keep my feelings under control.
  • I spend a lot of time on my own, even though it leaves me feeling lonely and isolated.
  • I have no interest in going out to do things or see people.
  • I keep myself very busy so that I don’t have to remember or feel.
 
  • I find it really hard to feel positive about my life today and in the future.
  • I find it hard to trust other people.
  • I blame myself for causing the trauma, or for not having been able to stop it.
  • I know in my head that I love the people in my life, but I have trouble actually feeling it. I feel separate from them and distant.
  • I have a difficult feelings like anger, aggression, and fear. Other times, I feel guilty, ashamed, and horrified at what I’ve seen or done.
  • So much of the time, I have difficulty feeling happy, optimistic, or content. I often feel little interest in my life or in things that used to matter to me.
 
  • I have a quick temper and get irritated easily. I find myself feeling road rage more often.
  • I feel like I’m waiting for the next trauma or attack – I’m suspicious and on guard looking for possible risks or threats.
  • I need to sit with my back to the wall in public places.
  • I need to know where my loved ones are at all times.
  • I often feel distracted and have trouble concentrating.
  • I will do things that are risky or reckless.

The combination of symptoms will be different in every person, and not everyone who has experienced or seen trauma will develop PTSD. Everyone’s experience of a traumatic event is unique, and your response will depend on factors like life histories, current situation, and emotional characteristics.

These reactions are a natural response to trauma. It is not a sign of weakness if you develop PTSD when someone else, in a similar situation, does not. Your experiences and feelings are valid.

Asking for help is not a sign of weakness either. There are proven treatments for PTSD and many qualified people ready to help you.


A PTSD diagnosis

Getting a diagnosis will not change your symptoms, but it is a useful step in getting the right treatment. A diagnosis of PTSD can be made by a qualified service provider, like a psychiatrist or psychologist.

When checking for the possibility of PTSD, they will be looking for traumatic experiences like

  • Military service in a conflict zone
  • Witnessing atrocities on deployment
  • Incidents during service in uniform like domestic operations or aid to civil power
  • Experiencing a natural disaster and providing rescue/relief support afterwards
  • Terrorism or mass violence
  • Domestic abuse
  • Sexual assault
  • Gender, race, or culture-based attacks or stress

They will also ask about your symptoms. Someone with PTSD will have symptoms in each of these four categories:

  1. Re-experiencing the feelings and sensations felt at the trauma
  2. Avoiding reminders of the trauma
  3. Negative thoughts or feelings about ourselves, those around us, or a situation or location
  4. Being on edge or reactive, either physically or emotionally, without reason (also known as hyper-arousal)

The benefits of therapy

PTSD does not usually go away on its own, and without support, symptoms may even get worse. Getting therapy might help you to:

  • Feel more productive and positive
  • Return to work
  • Heal or strengthen relationships
  • Stop symptoms from getting worse
  • Get better control of your feelings and your life
  • Learn skills and tools to manage your symptoms
  • Feel better in your every day life (mind, body, and spirit)

“I finally realized it didn’t have to be so hard . . . ”
Hear the strong voices of those who are living in Veteran Families with post-traumatic stress.

 

“The hope I want is the ability to enjoy life again . . .”
A Veteran talks about life after service and rebuilding after a diagnosis of PTSD. Treatment really can work. Healing is possible.


Therapies for PTSD

If you decide to look for support, your care provider should tell you about trauma in general, and about the plan for your therapy. You should decide together if you are ready to start, and at any time you should be able to ask as many questions as you want about your therapy and progress.

(These options are intended for informational purposes. This information is not a substitute for medical care or advice from a provider. Only qualified, licensed professionals can diagnose PTSD. The Centre of Excellence on PTSD does not provide direct clinical care).

The most recommended therapies for PTSD are called Trauma-Focused Psychotherapies. These types of therapy help you to work through the memories of the trauma and/or what they mean in your life. It is not always easy to do, but by working with a trusted professional, and with the support of family or friends, it can produce very good results.

The five most highly recommended Trauma-Focused Psychotherapies are

Each of these treatments is summarized below.
*Quick Facts questions and/or information were adapted from the National Center for PSTD.

Cognitive Behavioural Therapy for Trauma (CBT-T)

Cognitive Behavioural Therapy for Trauma gets you to look at, and challenge, the unhelpful thoughts and ideas you have developed since the trauma. It slowly helps you to face the painful thoughts, feelings, and situations you have probably been avoiding. [Parts of this therapy are similar to two other highly recommended options: Cognitive Therapy for PTSD and Prolonged Exposure Therapy.]

You and your service provider will identify the situations, places, people, and things that you are avoiding because they are triggering – they remind you of the traumatic event. You will be asked to think of something that you want to be able to do again, something that is safe but that you have been avoiding because of your trauma. Once your goal is set, you and your service provider will break the activity down into manageable steps.

Starting with the easiest step, you will be asked to practice doing the step until you are able to do it with less distress. When you master that step, you move to the next one, until you have finished all the steps. In this way, you will re-learn that the situation, places, people, and things that were triggering are now safe and manageable.

In addition to these non-avoiding strategies, with the help of work sheets, you will learn to recognize that common ways that you might have been thinking about the trauma that haven’t been helpful, such as negative thinking, or always expecting bad or catastrophic things to happen. [This is similar to another highly recommended therapy: Cognitive Therapy for PTSD.] Instead, you will be taught new ways of thinking which provide more balance and asked to take notice of any changes and how they make you feel. Through this process, you will learn that when your thoughts and feelings about the trauma are more balanced, you are likely to feel less guilt, shame, and depression. You can also learn other strategies like healthy coping skills, mindfulness, relaxation, and skills training like assertiveness training. After treatment, memories of the trauma should feel less stressful. You should feel less emotionally numb. And, feelings of being on edge and reactive will likely lessen too.

What is it?
Cognitive Behavioural Therapy for Trauma explores how your thoughts, feelings, behaviours, and physical responses to the trauma are connected. You learn, for example, how changing unhelpful thoughts about the trauma can help change how you react and can support more balanced emotions.

How does it treat PTSD?
Cognitive Behavioural Therapy for Trauma uses strategies like learning helpful thinking and non-avoiding practices, healthy coping skills, mindfulness, and relaxation to develop a more balanced view of the trauma. It is effective in breaking associations made between reminders of the event (e.g., situations, people), conclusions about the event (e.g., I can’t trust others), and responses to triggers (e.g., fear or feeling numb). The combination of strategies allows you to work towards retraining your mind, body, and spirit to decrease your trauma responses. This, in turn, reduces PTSD symptoms.

What can I expect?
With the support of your service provider, you will review the traumatic event. You will learn to identify ways of thinking about the trauma that haven’t really been helping you – negative thinking, generally expecting bad or catastrophic things will happen – and instead develop more balanced and effective ways of thinking. You will also identify the people, places, and activities you have stayed away from since your trauma. You will gradually learn to approach these situations and people so that you can feel more comfortable and not avoid them any longer. And, you’ll learn coping skills like relaxation (e.g., muscle relaxation, breathing exercises) or skills like assertiveness training.

Is this an individual or group therapy?
Cognitive Behavioural Therapy for Trauma can be offered as individual or group therapy. Groups may be as large as 6 to 10 other people.

From what we know so far, benefits are greatest when CBT-T is done on an individual basis rather than group.

Will I talk about my trauma in detail?
Yes. Your service provider will guide you and support you as you talk about your trauma.

How long does it take?
Sessions usually last 50 minutes. With weekly sessions, Cognitive Behavioural Therapy for Trauma usually takes 12 to 16 weeks. It might help to have more sessions if, for example, you have been exposed to multiple traumas.

Will I have homework?
Yes. You may have worksheets to complete. You may also begin to practice doing some of the things you have avoided since the trauma. Generally, the more time you spend between sessions practicing what you’ve learned, the more you will get out of the process.

Are there any risks?
Talking about trauma-related memories and completing challenging activities can be uncomfortable. These feelings don’t tend to last very long and many people feel better as they continue with Cognitive Behavioural Therapy for Trauma. There is also a slight risk that someone could come across the worksheets you take home. You and your provider can discuss ways to secure your personal information related to this treatment.

Most people who complete Cognitive Behavioural Therapy for Trauma find that the benefits outweigh the initial discomfort.

Cognitive Processing Therapy (CPT)

Cognitive Processing Therapy helps you look at the thoughts you’ve been having that keep you from healing and to challenge those thoughts. [Parts of this therapy is similar to another highly recommended therapy: Cognitive Therapy for PTSD.] It focuses on how you have made sense of the trauma and the way that has affected you.

Your service provider will help you write about the impact the traumatic event has had on your life. This impact statement will help you and your service provider find key ideas that keep you from making progress. Using worksheets and questions from your service provider, you will learn to challenge these ideas. You will explore the effect the trauma has had on your feelings of safety, trust, power, control, esteem, and intimacy. You will be asked to complete work sheets between sessions to evolve your understanding of the trauma. Towards the end of treatment, you will be asked to write a new impact statement and compare it to the first impact statement. Through this process, you will learn that when your thoughts and feelings about the trauma are more balanced, you are likely to feel less guilt, shame, and depression. After treatment, memories of the trauma should feel less stressful. You should feel less emotionally numb. And, feelings of being on edge and reactive will likely lessen too.

What is it?
Trauma affects how we feel about things and also how we think about them. Cognitive Processing Therapy helps you look at the thoughts you’ve been having that keep you from healing and to challenge those thoughts. It focuses on how you have made sense of the trauma and the way that has affected you. Often these thoughts and ideas make things harder, rather than easier. Through Cognitive Processing Therapy, you can learn to redefine these thoughts and ideas and to develop more balance when thinking about the trauma.

How does this treat PTSD?
When you change how you think about an event, the way you feel about it will often change too. When your thoughts and feelings about the trauma are more balanced, you are likely to feel less guilt, shame, and depression. After treatment, memories of the trauma should feel less stressful. You should feel less emotionally numb. And, feelings of being on edge and reactive will likely lessen too.

What can I expect?
The process usually starts with writing about the impact the traumatic event has had on your life. Your service provider will help you with this. This impact statement will help you and your service provider to identify thoughts that keep you from progressing (“stuck points”). Using worksheets and questions from your service provider, you will learn to challenge your “stuck points” and to move forward. You will explore the effect the trauma has had on how you feel about safety, trust, power, control, esteem, and intimacy.

You will be asked to complete worksheets between sessions to help your understanding of the trauma to evolve and change. Towards the end of treatment, you will be asked to write a new impact statement and compare it to the first impact statement.

Is this an individual or group therapy?
Cognitive Processing Therapy can be offered as individual or group therapy. Groups may be as large as 6 to 10 other people. From what is known so far, benefits are greatest when Cognitive Processing Therapy is done on an individual basis rather than in a group.

Will I talk about my trauma in detail?
No. Cognitive Processing Therapy focusses more on the impact the trauma has had on us than on the trauma itself. Some discussion of the actual trauma is necessary but this doesn’t need to involve a lot of detail. What is important to remember is that you are in charge of the process and can go at a pace that is manageable for you.

How long does it take?
Each session usually lasts between 50 and 90 minutes. With weekly sessions, Cognitive Processing Therapy usually lasts about 12 weeks. Some people benefit from more sessions if, for example, they have been exposed to multiple traumas.

Will I have homework?
Yes. You will be asked to do some writing and to complete worksheets between sessions.

Are there any risks?
Talking about trauma-related memories and how that’s impacting you can be uncomfortable. These feelings don’t tend to last very long and many people feel better as they continue with Cognitive Processing Therapy. There is also a slight risk that someone could come across the writing and worksheets you take home. You and your provider can discuss ways to secure your personal information related to this treatment.

Most people who complete the Cognitive Processing Therapy find that the benefits of the process are far greater than any discomfort they experience during it.

Cognitive Therapy for PTSD (CT-PTSD)

Cognitive Therapy for PTSD helps you look at and challenge the thoughts and ideas you have developed since the trauma that keep you from recovery and healing. [Parts of this therapy are similar to two other highly recommended options: Cognitive Behavioural Therapy for Trauma and Prolonged Exposure Therapy.]

With your service provider guiding you, you will learn to talk about the trauma. You will identify key parts of the trauma that were particularly hard (“hot spots”) and talk through the different emotions and thoughts that come up. You will be asked to recognize that common ways that you might have been thinking about the trauma that haven’t been helpful, such as negative thinking, or always expecting bad or catastrophic things to happen. Instead, you will be taught new ways of thinking which provide more balance and asked to take notice of any changes and how they make you feel.

And like other therapies, you can learn to identify your triggers to break the connection between the memory and triggers and to see that the trauma that happened “then” isn’t happening “now.” You’ll also learn that when your thoughts and feelings about the trauma are more balanced, you are likely to feel less guilt, shame, and depression. After treatment, memories of the trauma should feel less stressful. You should feel less emotionally numb. And, feelings of being on edge and reactive will likely lessen too.

What is it?
Cognitive Therapy for PTSD focuses on changing how you think about and cope with your trauma. It shines a light on the actions that you have been taking that result in difficult emotions (like feelings of guilt and shame), overestimating the level of danger in a situation, and other symptoms of PTSD.

How does it treat PTSD?
Cognitive Therapy for PTSD uses various strategies to help you develop a more balanced perspective on the trauma and limit unhelpful ways of coping. It will guide you to a more balanced perspective of your memories of the trauma, helping you to understand, in your mind, body, and spirit, that the traumatic event is no longer a present and severe threat.

What can I expect?
With your service provider, you will talk about the trauma. You will find “hot spots” of the trauma that were particularly hard, and recognize the thoughts and conclusions connected with these “hot spots.” You will learn to change these thoughts and conclusions into a more balanced memory of the trauma. With your service provider, you will also learn to identify your triggers, to break the connection between the memory and the trigger, and to see that the trauma that happened “then” isn’t happening “now.”

Is this an individual or group therapy?
Cognitive Therapy for PTSD can be offered as individual or group therapy. Groups may be as large as 6 to 10 other people. From what is known so far, benefits are greatest when Cognitive Therapy for PTSD is done on an individual basis, rather than in a group.

Will I talk about my trauma in detail?
Yes. It will be done in a way that is manageable for you and with the support of your service provider. Reviewing and processing the trauma can be done in various ways – writing about it, talking, or imagining it.

How long does it take?
Usually, the first session takes 90 minutes. After that, each treatment session usually lasts 60 minutes. With weekly sessions, Cognitive Therapy for PTSD usually lasts about 12 weeks. Some people benefit from more sessions if, for example, they have been exposed to multiple traumas.

Will I have homework?
Yes. There may be worksheets or writing assignments to complete. You will also practice (slowly and at your own pace) doing some of the things you might have avoided since the trauma happened. Generally, the more time you spend practicing what you’ve learned, the more you’ll get out of the Cognitive Therapy for PTSD.

Are there any risks?
Talking about trauma-related memories and completing challenging activities can be uncomfortable. These feelings don’t tend to last very long and many people feel better as they continue with Cognitive Therapy for PTSD. There is also a slight risk that someone could come across the writing and worksheets you take home. You and your provider can discuss ways to secure your personal information related to this treatment.

Most people find that the benefits of Cognitive Therapy for PTSD outweigh any initial discomfort.

Eye Movement Desensitization and Reprocessing Therapy (EMDR)

Eye Movement Desensitization and Reprocessing Therapy focuses on addressing how your mind processed and stored the trauma. When we experience trauma, sometimes our brains don’t properly process and store the event. When this happens, your brain may store the intense emotions and physical sensations exactly as you originally experienced them. By focusing on specific movements or sounds as you recall the trauma, Eye Movement Desensitization and Reprocessing Therapy helps your brain to reprocess the trauma and to turn it into a more manageable memory.

In therapy, you will be asked to remember a difficult trauma memory along with the negative thoughts, feelings, and physical sensations that go with it. You will be asked to think about the memory, while at the same time paying attention to a sound, or a movement (like your service provider’s finger) moving back and forth. Paying attention to the sound or movement keeps you grounded in the present while remembering what happened in the past. You will repeat this process of recalling the memory for short periods at a time until the stressful feelings connected to the memory decrease, allowing more balanced thoughts about it emerge. In this way, Eye Movement Desensitization and Reprocessing Therapy helps your brain reprocess the memory into something more manageable and this helps to decrease your PTSD symptoms.

What is it?
When you experience trauma, sometimes your brains doesn’t process the memory in the usual way. Your brain may respond to the intense emotions and physical sensations of the moment by storing them exactly as you originally experienced them. By focussing on specific movements or sounds as you remember the trauma, Eye Movement Desensitization and Reprocessing Therapy helps your brain to reprocess it and to turn it into a more manageable memory.

How does it treat PTSD?
Currently, it’s not entirely clear how Eye Movement Desensitization and Reprocessing Therapy helps the brain to reprocess a traumatic experience and shift it into a more manageable memory. Researchers are studying this and the role the sounds and movements play in the treatment so that we can better understand how EMDR works.

What can I expect?
You will be asked to remember a difficult “target” memory along with the negative thoughts, feelings, and physical sensations that go along with it. You will be asked to think about the memory, while at the same time paying attention to a sound, or a movement like your service provider’s finger moving back and forth. Paying attention to the sound or movement keeps you grounded in the present while remembering what happened in the past. This helps your brain to process the experience and turn it into a more manageable memory.

Is this an individual or group therapy?
This is an individual therapy. Each session will involve meeting one-on-one with your service provider.

Will I talk about my trauma in detail?
No. In most cases, you will be asked to think about the trauma during the session, rather than talking about it.

How long does it take?
Sessions usually last 90 minutes, but can be as short as 50 minutes. With weekly sessions, Eye Movement Desensitization and Reprocessing Therapy generally takes between 4 and 12 sessions. Many people report feeling better after a few sessions. Some people benefit from more sessions if, for example, they have been exposed to multiple traumas.

Will I have homework?
No.

Are there any risks?
You may feel uncomfortable when you are focussing on trauma-related memories, thoughts, or beliefs. These feelings don’t tend to last very long and many people feel better as they continue with Eye Movement Desensitization and Reprocessing Therapy. Most people who complete Eye Movement Desensitization and Reprocessing Therapy find that the benefits outweigh the discomfort.

Prolonged Exposure Therapy (PE)

Prolonged Exposure Therapy helps you gradually face the painful thoughts, feelings, and situations you have been avoiding since the trauma. [Parts of this therapy are similar to two other highly recommended options: Cognitive Behavioural Therapy for Trauma and Cognitive Therapy for PTSD.]

With your service provider guiding you, you will learn to talk through the trauma. You will identify “hot spots” of the trauma that were particularly hard and talk through the different emotions and thoughts that come up. Your description of the trauma is recorded so you can listen to it at home. Retelling and listening to the trauma memory repeatedly helps you to process trauma-related emotions; it can also reveal information that will help you to understand the trauma differently. Through this, you learn that the trauma memory is a memory, not a reality today.

Together, you and your service provider will also identify the situations, places, people, and things that are actually safe, but which you avoid because they are triggering – they remind you of the traumatic event. You will be asked to think of something that you want to be able to do again, something that is safe but that you have been avoiding because of your trauma. Once your goal is set, you and your service provider will break the activity down into manageable steps.

Starting with the easiest step, you will be asked to practice doing the step until you are able to do it with less distress. When you master that step, you move to the next one, until you have finished all the steps. In this way, you will re-learn that the situation, places, people, and things that were triggering are now safe and manageable.

What is it?
While this may feel like the opposite of what you want to do, with Prolonged Exposure, you will learn to face the painful thoughts, feelings, and situations that you have been avoiding. By confronting what you’re afraid of in a safe, supportive way, you will learn that you don’t need to avoid those things that are associated with the trauma. In time, you will feel more capable and confident.

How does it treat PTSD?
Repeated retelling of the trauma memory helps you process trauma-related emotions. It can also reveal information that will help you to understand the trauma differently and to identify helpful ways of recovering. By gradually confronting the situations, people, places, and things that you’ve been avoided, you can learn to challenge your painful feelings and thoughts, and live a fuller life.

What can I expect?
With your service provider guiding you, you will learn to talk about the trauma. You will discuss and process the emotions and thoughts that come up as you talk about the trauma. Your description of the trauma is recorded so that you can listen to it later at home. This allows you to continue to process your feelings, and learn that the trauma memory is a memory, not a reality today.

Is this an individual or group therapy?
This is an individual therapy. Each session will involve meeting one-on-one with your service provider.

Will I talk about my trauma in detail?
Yes. Around the third session you will start talking about the trauma in detail. Your service provider will guide you through this. They will pay close attention to your anxiety level and adjust to make sure it is manageable for you.

How long does it take?
Sessions usually last about 90 minutes but can be as short as 50 minutes. On average, Prolonged Exposure Therapy lasts 8 to 15 weeks. Some people start to feel better after just a few sessions.

Will I have homework?
Yes. You will be asked to practice some of the things you have avoided since the trauma. You will be asked to start with activities that may feel a little uncomfortable. You will work up to activities that are more challenging. You will also be asked listen to recordings of your description of the trauma.

Are there any risks?
Talking about trauma-related memories and completing challenging activities can be uncomfortable. These feelings don’t tend to last very long and many people feel better as they continue with Prolonged Exposure. There is also a slight risk that someone could come across the worksheets you take home. You and your provider can discuss ways to secure your personal information related to this treatment.

Most people who complete Prolonged Exposure Therapy find that the benefits outweigh the initial discomfort.

How do I know which PTSD treatment is best for me?

Individual characteristics and experiences play an important role in understanding and shaping treatment. Examples of characteristics include demographics, trauma variables, symptoms and other mental and physical health conditions.

While people with PTSD may have some characteristics in common, all individuals have their own particular needs and goals. When choosing the best treatment for you, you and your service provider can take into account your personal characteristics, values, and preferences, the research evidence about treatments for PTSD, and clinical expertise. This fit may also change over time, as you change and as new research and treatments emerge.

I have other mental and physical health conditions, in addition to PTSD. Is treatment for PTSD the best place to start?

It is common for people with PTSD to have other mental or physical health conditions as well. These can include chronic pain, depression, anxiety, suicidal thoughts and substance-use disorder. Depending on your circumstances, your service provider may recommend starting with PTSD therapy or, they may recommend treating another condition first so that the PTSD treatment is as effective as it can be when the time comes. Your characteristics, experiences, and therapy goals will influence this decision. Work with your doctor, therapist, or other service provider to make the best decision for you.


Selected References

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