What is the best complex PTSD treatment?
The NHS (UK) recommends that those suffering from complex PTSD undergo three stages of treatment. These are as follows :
2) TRAUMA-FOCUSED THERAPY
Let’s look at each of these a little more closely :
NHS guidelines suggest that during the first stage, stabilization, the individual being treated for complex PTSD may wish to focus on:
– redeveloping an ability to trust others
– reestablishing an emotional connection with friends and family
– learning to live in the present again (as opposed to staying trapped in the past ). This normally involves learning to feel safe again and reducing the level of fear that traumatic memories have hitherto provoked (often manifested in the disturbing form of nightmares and flashbacks).
The aim of this first stage of treatment is to improve the individual’s level of functioning to the point whereby s/he is able to start functioning again on a daily basis, no longer paralyzed by anxiety.
These include :
- trauma-focused cognitive behavioral therapy (SEE BELOW FOR MORE INFO ABOUT TRAUMA-FOCUSED THERAPY))
- eye movement desensitization and reprocessing (SEE BELOW FOR MORE INFO ABOUT EMDR))
(The importance of engaging with an appropriately trained and experienced professional if considering these treatments is emphasized.)
- i.e. reintegration into society and the development of improved, more trusting relationships with others (one of the hallmarks of complex PTSD is to avoid others and self-isolate, leading to a vicious cycle driven by operant conditioning and loss of confidence).
What About Medication?
In cases whereby psychotherapy is not helpful or appropriate, the NHS (UK) suggests that antidepressants may be of benefit to some individuals.
N.B. Always consult a suitably qualified professional before taking antidepressants or other psychiatric medication.
Prince Harry, who tragically lost his mother, Princess Diana, at the age of just 12, has recently opened up about his childhood trauma in a series of interviews with Oprah Winfrey and has revealed that to help him process this trauma, he has opted to undergo EMDR therapy. But what does this therapy involve?
Individuals who have suffered severe childhood trauma may, as a result of it, later suffer from Post-Traumatic Stress Disorder (PTSD), or similar conditions. Some professionals advocate a relatively new technique that aims to address this; it is known as Eye Movement Desensitisation and Reprocessing (EMDR).
WHAT IS EMDR?
The therapist administering EMDR will first examine the issues related to the individual’s psychological difficulties and, also, help him/her develop strategies to aid in relaxation and deal with stress. After this, the therapist encourages the individual to recall particular traumas, whilst, simultaneously, manipulating his/her eye movements by instructing him/her to follow the movements the therapist is making with a pen, or similar object, in front of the individual’s face). The theory is that this will facilitate the individual to effectively reprocess his/her traumatic experiences, thus alleviating psychological distress.
THIS SOUNDS A LITTLE ODD; WHAT IS THE RATIONALE BEHIND EMDR AND HOW, EXACTLY, IS IT THOUGHT TO WORK?
My first reaction to hearing about this particular therapy was that it sounded somewhat strange. However, the rationale behind EMDR is that disturbing memories from childhood need to be PROPERLY PROCESSED by the brain in order to alleviate symptoms associated with having experienced childhood trauma (e.g. PTSD, as already mentioned); this is because the view is taken that it is the UNRESOLVED TRAUMA that is the cause of the psychiatric difficulties the individual who presents him/herself for treatment is suffering. Those professionals who recommend the therapy believe that the EYE MOVEMENTS INDUCED BY THE THERAPIST IN THE INDIVIDUAL BEING TREATED LEAD TO NEUROLOGICAL AND PHYSIOLOGICAL CHANGES IN THE BRAIN WHICH AID IN THE EFFECTIVE REPROCESSING OF THE TRAUMATIC MEMORY, and, in this way, ameliorates psychological problems from which the individual had been suffering.
WHAT ARE THE STAGES INVOLVED IN EMDR THERAPY?
These are briefly outlined below:
1) The first stage is the identification of the specific memory/memories which underlie the trauma.
2) Next, the individual is asked to identify particular negative beliefs he/she links to the memory (e.g. ‘I am worthless’)
3) Then, the individual being treated is asked to replace the negative belief with a positive belief (e.g .’ I am strong enough to recover’ or ‘I am a person of value with potential to have a bright future’ etc)
4) In the fourth stage, the therapist moves a pen (or similar object) in various, predetermined motions in front of the individual’s face and he/she is instructed to follow the movements with his/her eyes (e.g repeatedly left and right). Whilst this is going on, the therapist instructs the individual to simply, non-judgmentally observe his/her own thoughts, letting them come and go freely and without trying to influence them in any way – just to accept them, in other words, and let them happen.
5) This procedure is repeated several times.
Each time the process is undertaken, the therapist asks the individual being treated to rate how much distress he/she feels – this continues until his/her self-reported level of distress becomes very low. Similarly, each time the process is undertaken, the individual is asked to report how strongly he/she now feels he/she believes in the positive idea given in stage 3 (see examples provided above); therapy is only concluded once the level of reported belief becomes very high.
N.B. The therapy is actually more involved than this, so the above should only be taken as a brief outline. There are, too, different variations of the procedure outlined above which can be employed within the EMDR range of therapies available.
EMDR CAN HELP UNBLOCK TRAUMATIC INFORMATION HELD IN THE BRAIN AND HELP US TO HEALTHILY INTEGRATE IT INTO OUR LIFE STORY AS A WHOLE :
When we suffer severe trauma we are not able to fully mentally process what it is that has happened to us and the trauma becomes mentally entrenched – in other words, what happened to us becomes locked or ‘stuck’ in our memory network. The effect of this may include us experiencing various symptoms such as irrational beliefs, painful emotions, anxiety and fears, flashbacks, nightmares, and phobias. It may well also cause blocked energy and greatly reduce our self-efficacy.
When we experience events that trigger memories of the trauma, images, sounds, physical sensations, and beliefs that echo the original experience of the trauma cause our perception of current events to be distorted.
EMDR (Eye Movement Desensitization and Reprocessing) can unblock this traumatic information and thus allow us to healthily mentally integrate it with our other life experiences and our life story as a whole.
Trauma can occur in the form of SHOCK TRAUMA and DEVELOPMENTAL TRAUMA. Shock trauma consists of a sudden threat that is overwhelming and/or life-threatening – it occurs as a single episode such as a violent attack, rape, or a natural disaster. Developmental trauma, on the other hand, refers to a series of events that occur over a period of time. These events GRADUALLY ALTER THE PERSON’S NEUROLOGICAL SYSTEM to the point that it REMAINS IN THE TRAUMATIC STATE. This, in turn, can cause an interruption in the child’s long-term psychological growth. Experiences that can lead to developmental trauma include abandonment by a parent, long-term separation from a parent, an unsafe environment, an unstable environment, neglect, serious illness, physical and/or sexual abuse, or betrayal by a caregiver.
The effects of developmental trauma include damaging the child’s sense of self. self-esteem, self-definition, and self-confidence. Also, the child’s sense of safety and security in the world will be seriously undermined. This makes it far more likely that the individual will experience further trauma in life as an adult as his/her sense of fear and helplessness remain unresolved.
EMDR works by allowing the locked or ‘stuck’ traumatic information to be thoroughly mentally processed. This leads to the disturbing information becoming psychologically resolved and integrated.
HOW DOES EMDR ACTUALLY WORK?
EMDR is based on the idea that it is our memories that form the basis of our PERCEPTIONS, ATTITUDES, and BEHAVIOURS. Because, as we have already established, traumatic memories fail to be properly processed they lead to these perceptions, attitudes, and behaviors becoming DISTORTED and DYSFUNCTIONAL. In effect, the trauma is too large and too complex to be properly processed so it remains ‘STUCK’ and DYSFUNCTIONALLY STORED. This often leads to MALADAPTIVE ATTEMPTS TO PROCESS AND RESOLVE THE INFORMATION CONNECTED TO THE TRAUMA SUCH AS FLASHBACKS AND NIGHTMARES (Sharpio, 2001).
When this problem occurs it is EMDR which is being increasingly turned to allow effective processing and mental healing to occur. I will look in more detail at what EMDR involves in later posts.
WHAT DO EVALUATION STUDIES OF EMDR THERAPY SUGGEST ABOUT ITS EFFECTIVENESS?
A study conducted by Boterhoven de Haan et al. (2020), published in The British Journal of Psychiatry involved 145 individuals who had suffered significant childhood trauma (in the form of either physical or sexual abuse) and had been diagnosed with PTSD no longer fulfilled the criteria to be diagnosed with the condition after undergoing 6-8 weeks of EMDR therapy.
Furthermore, a recent meta-analysis of evidence (ie an overview of a large number of particular, individual studies of EMDR) supported the claim that it is effective, as have other meta-analyses. However, some researchers have suggested that it is not the EYE MOVEMENT PART of the therapy which is of benefit, but only the act of repeatedly recalling traumatic memories which is the effective component (based on the idea that these repeated mental exposures, under close supervision and in a supportive and safe environment, of the traumatic memories alone facilitate their therapeutic reprocessing).
In response to this criticism, its exponents (and there are many professionals who are), regard the EYE MOVEMENT COMPONENT of the therapy as ESSENTIAL in giving rise to the NECESSARY NEUROLOGICAL CHANGES which allow the EFFECTIVE REPROCESSING OF THE TRAUMA; these proponents also emphasize that the therapy only requires short exposures to the traumatic memory/memories, thus giving it an advantage over therapies which utilize far more protracted exposures.
Research into EMDR is ongoing. To visit the EMDR Institute website (external link), click here.
WHAT IS TRAUMA-FOCUSED THERAPY?
Trauma-Focused Therapy (TFT) utilizes the following treatments, either on their own or in combination :
1) EXPOSURE THERAPY – this type of therapy encourages the person to confront the stimuli connected to the trauma which s/he fears. The exposure may be IMAGINAL (ie a mental picture of the feared stimuli is imagined, often using hypnotherapy to stimulate imagery and visualization) or IN VIVO (ie in real life). Repeated exposures to the feared stimuli lessen the emotional impact it has on the individual.
2) SYSTEMATIC DESENSITIZATION – this is similar to the above but the individual is gradually introduced to the feared stimuli (ie stimuli that remind the individual of the trauma and trigger memories of it). The person is taught relaxation exercises to utilize whilst having the memories of the trauma which has the effect of inhibiting the fear response. Again, this therapy can be combined with hypnotherapy.
3) BIOFEEDBACK – this technique uses electrophysiological instruments to provide feedback to the trauma sufferer about physiological states connected to anxiety, fear, and panic (e.g. of heart rate) which helps him/her in relaxation training (the instruments show the individual when s/he is using relaxation techniques effectively).
4) DIALECTICAL BEHAVIOUR THERAPY
5) ACCEPTANCE AND COMMITMENT THERAPY (ACT) – this technique is based upon the idea that much of human suffering is the result of trying to control internal states (ie feelings and emotions). We try to avoid unpleasant feelings like sadness and guilt – this has been termed ‘EXPERIENTIAL AVOIDANCE’. According to this therapy, we should not try so hard to avoid our unpleasant feelings, but, instead, accept our personal, and internal experiences and make a commitment to live our lives in accordance with our personal values, irrespective of how it makes us feel.
6) STRESS INOCULATION TRAINING – this technique includes education, muscle relaxation, training in breathing techniques that induce relaxation, role-playing, guided self-dialogue, thought stopping, and assertion training.
7) COGNITIVE BEHAVIOUR THERAPY (CBT)
8) COGNITIVE PROCESSING THERAPY (CPT)
RECENT DEVELOPMENTS IN TRAUMA-FOCUSED THERAPY :
a) Cognitive Behaviour Therapy (CBT) is now being used to specifically treat those who suffer from trauma-related nightmares
b) Trauma-Focused Therapy is now making use of VIRTUAL REALITY innovations (eg during Exposure therapy – see above)
c) Trauma-Focused Therapy is now being delivered over the internet
THE ROLE OF MEDICATION :
it has been found through research that trauma tends to be treated even more effectively if the above therapies are combined with appropriate medication
TIME FRAMES FOR TREATMENTS: generally, trauma-focused therapy involves about 8-12 sessions which are usually carried out at weekly intervals. However, some studies have demonstrated that just 1-4 sessions can lead to significant improvements. Sessions usually last from 60-90 minutes and the individual undergoing the treatment is given homework to complete between sessions.
EVIDENCE: Overall, the evidence for the effectiveness of trauma-focused therapy is compelling. Numerous studies, which have been well controlled and have adhered to high methodological standards, have shown it to work.
USEFUL (EXTERNAL) LINKS:
For those who would like extremely detailed information relating to ISTSS ‘s guidelines for the prevention and treatment of complex PTSD, it is possible to download the relevant PDF from this here.
The main NHS (UK) website can be found by clicking here.