Trauma Treatment: Evidence-Based Approaches versus Intuitive Approaches
Sitting in her first session, a 24-year old, anxious woman sat across from the therapist. She was clearly anxious and uncomfortable in the office. She had been referred by a crisis center due to a complex and persistent case of posttraumatic stress disorder (PTSD) following a prolonged assault. The therapist assessed her symptoms and history of treatment. The client described at least four courses of “trauma therapy.” The dialogue regarding her past therapy experiences went as follows:
Woman: The therapists were helpful. I always felt better after sessions.
Therapist: And then what happened?
Woman: I don’t know, because I felt bad later on.
Therapist: So, when you were with a therapist you felt better, but in the long run you didn’t get better?
Therapist: Why do you think that is?
Woman: I figured the therapist was so helpful and knowledgeable, so there must have been something broken in me. Something must be wrong with me that I’m not getting better.
The woman described a range of treatment approaches she received since the trauma, including:
- being told to stop thinking about the traumatic memory;
- being encouraged to avoid the memory and the environmental cues;
- being dropped off at a store to face her fears related to being around people;
- being asked about her mother and history of shame; and
- being asked about the role of alcohol in the traumatic event.
Each therapist thought he/she was being helpful and believed in his/her intuition to plan treatment. Both the woman and therapists felt good about what was done in session and she reported relief at the end of sessions. But, in the long run, her symptoms of PTSD were not resolved and actually worsened.
The problem was that the well-meaning therapists were not basing their approach on a research-validated formulation of maintaining factors of PTSD symptoms. Instead, the therapists followed their intuition for treatment choices rather than implementing one of several robust evidence-based interventions for PTSD. The prior ineffective treatments either encouraged the woman to rely on the maladaptive, coping strategies or applied the potentially effective strategy in a haphazard and re-traumatizing manner (for example, dropping her off in a store to face her fears). The negative outcomes reinforced one of the most common and fundamental beliefs of PTSD: “I am incompetent.” Moreover, the woman perceived through past experiences in and out of therapy that something within her was so broken that she was beyond help, leading to a cycle of hopelessness, suicidality, and treatment avoidance.
In February of 2017, the American Psychological Association adopted clinical practice guidelines for the treatment of PTSD. Cognitive behavioral treatments were strongly recommended based on a review of the current literature. These treatments are efficient, effective, and readily available for therapists’ use.
- Exposure therapy (such as prolonged exposure therapy) is principally driven by experiential learning through exposure techniques. The individual systematically engages the two avoidances, the memory of the trauma and reminders of the memory. The therapist follows procedures for the intervention and uses guided discovery to process the exposures.
- Cognitive therapy (including cognitive processing therapy) is driven by a more cognitive approach to the beliefs surrounding the traumatic event and the client’s responses post-event. One component of treatment might be for the individual to write down the narrative of the traumatic event to process it more completely.
Both treatments deal with beliefs (e.g., the self as incompetent, the world as excessively dangerous) and coping strategies (e.g., avoidance of memories and reminders of the memory) that maintain the symptoms of PTSD. These interventions have been tested across treatment settings, trauma types, and across populations. Following an evidence-based intervention can relieve the therapist of the burden brought on by the complexities of PTSD and aid in treating the individual effectively and efficiently.
At the conclusion of prolonged exposure therapy, the woman was asked which parts of the treatment helped the most and which helped the least. Like many individuals before, she said she did not like the process of revisiting the memory (imaginal exposure) but said that the procedure was probably the most helpful part of the treatment. She loved the in vivo exposures once her anxiety subsided, because they helped her return to living her life. She especially appreciated the support of the therapist and the therapist’s adherence to a protocol that was tested. She said the protocol gave her hope for the future, because the approach was research-based, and the therapist demonstrated accurate and compassionate understanding of her experiences.
Finally, in response to her shame about not getting better, she said, “Maybe I messed my life up for years, but I was never offered this approach. There were parts of the treatment I wasn’t thrilled to do but those helped the most. I have my life back.”