Certain kinds of medication and cognitive-behavioural psychotherapy have been shown to treat the symptoms of PTSD very effectively. Helping all patients with PTSD includes first ensuring the patient’s physical and psychological safety, and that they have access to the required medical care, and needed community resources for self-care and recovery. The patient’s level of functioning and safety, including risk for suicide or harm to others, are always important considerations during the initial assessment, and such factors may determine the intensity of the treatment selected. The goals for patients PTSD also include establishing a stable and trusting therapeutic alliance with the patient; providing ongoing assessment of safety and psychological mindset, including possible reactions to the trauma such as physical injury, job loss, or loss of loved ones. Additional goals of management include providing education about PTSD, enhancing treatment attendance, evaluating and managing physical health and functional impairments, and coordinating care to include collaborating with other health specialists (e.g., family doctor, social workers).
The therapeutic alliance between patient and the mental health professional is important and at times challenging to establish with patients who have experienced traumatic events. Attention to the professional-patient interaction is important, since a positive experience may also make the patient more receptive to future evaluation or follow-up.
Evaluation and treatment by the professional should always be conducted with sensitivity and in a safe environment that facilitates the development of trust. The professional must be experienced enough to ensure that the patient feels safe in the therapeutic relationship. Clinicians must acknowledge the patient’s worst fears about re-exposure to intolerable traumatic memories and recognize that treatment itself may be perceived as painful, threatening or intrusive. The patient is often relieved when the therapist indicates that talking about traumatic life events can be distressing and that the patient will decide how deeply to explore the difficult events and feelings. This suggestion of flexibility helps the patient to maintain or restore a sense of control, which is often lost after exposure to traumatic events. In chronic PTSD, unhelpful reactions like excessive drinking or avoidance may have been present for many years or decades. Therefore, clinicians must be patient and ensure that therapy proceeds at a tolerable pace.
Cognitive-behavioural therapy for PTSD
Cognitive behavior therapy for PTSD has been shown to be an effective psychological treatment for those with PTSD. The therapy helps patients to have less intense negative thoughts, emotions and physical reactions to the initial traumatic event or events. CBT targets the exaggerated thoughts to the initial trauma in an effort to desensitize the patient to events that could trigger traumatic responses. For example, helping the patient believe it is safe to ride the Metro again after being assaulted in the Metro. CBT treatment generally begins with education about the symptoms of the disorder, as well as a rationale for asking the patient to recall painful experiences and relaxation training. After the therapist assesses the patient’s ability to tolerate within-session anxiety and therapeutic provoking of symptoms, the patient is led through a series of sessions in which the traumatic event and its aftermath are imagined and described, and the patient is asked to focus on the negative affect and arousal until they subside. Reassurance and relaxation exercises aid the patient in progressing through these sessions, and homework assignments allow the patient to practice outside the sessions or while confronting triggers of anxiety (specific places or activities) in the real world.
A limited number of well-designed studies demonstrate some success not only in speeding recovery but also in preventing PTSD when cognitive behavior therapy is given quickly after the traumatic event: over a few sessions beginning 2–3 weeks after trauma exposure. Both stress-protection and repeated “exposure” (i.e., confronting various aspects of the initial trauma with the therapist’s help and support) techniques have demonstrated efficacy in women with PTSD resulting from assault or rape. Prolonged exposure (through imagined and real-world exposure to avoided situations associated with previous trauma) has been shown to be effective, particularly in the PTSD-associated symptoms of anxiety and avoidance. However, several studies have noted that exposure may increase rather than decrease symptoms in some individuals, so patient and therapist must work closely together and monitor their progress.
Several forms of CBT have proven helpful for PTSD. For example, stress-prevention training involving breathing exercises, relaxation training, stopping negative thoughts, role playing, and thought restructuring are also CBT techniques proven to reduce PTSD symptoms. Also, studies show that survivors of rape, crime victims, and combat veterans have experienced improvement in overall PTSD symptoms and nightmares when they participate in CBT therapy that uses “imagery rehearsal” (i.e., mental imagery involving reliving the trauma). Finally, CBT group therapy designed to correct distorted perceptions of the initial trauma through the patient’s written narrative of his or her traumatic experience have also shown promise. Most of these trials have been short-term, and the extent to which improvement is maintained over time has not been assessed through follow-up study. It is therefore important to discuss follow-up with the therapist what happens once symptoms start to improve.
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