Which trauma treatment is best for you?
There are so many different therapy treatment modalities out there nowadays and it can be easy to become overwhelmed by the sheer number of options. Plus, they all start to look like alphabet soup given the number of acronyms- DBT PE, CPT, EMDR, TF-CBT, etc.- it can all get so confusing! I’m hoping to explain a bit more about DBT PE, CPT, and EMDR so that you can make an informed choice of which option is the best for you! These treatments are evidenced-based practices that are recommended by leading health organizations such as the APA, WHO, Department of Veteran Affairs, etc. so their efficacy has been proven through research. This is meant to be an overview, if one modality sticks out to you more than the others, I would encourage you to explore and research that modality more thoroughly!
DBT-PE
DBT PE (DBT Prolonged Exposure) was created by Dr. Melanie Harned specifically to treat PTSD among high-risk clients experiencing a multitude of problems who are in DBT treatment. DBT PE uses exposure principles. Just so you understand why someone would be asking you to do this- exposure, while distressing, helps you train your brain that what you are avoiding due to anxiety/fear, discomfort, shame, etc. is actually not dangerous. When you sit through the distress and the feared situation doesn’t happen, the distress goes down. So, while this explanation is very brief, essentially by doing imaginal exposure and in vivo exposure (described more below), you are exposing yourself to elements of the trauma, sitting with the distress, which will help the distress go down over time or be eliminated.
This treatment modality was modified to fit the needs of a complex client population, many of whom experience self-harm and/or suicidal behaviors. DBT PE is delivered in 3 stages. Stage 1 involves using DBT to achieve behavioral control, essentially helping clients achieve stability and learn new skills before diving into trauma treatment. This is done with weekly 1 hour therapy sessions and a weekly 2-hour skills training group. The client would have access to between-session phone coaching with their individual therapist and their therapist agrees to take part in a consultation team for additional support and consultation. Stage 2 targets PTSD using the DBT PE protocol, described more in the next paragraph. Finally, Stage 3 is using DBT to address any problems that remain after the PTSD is treated.
DBT PE’s Stage 2 involves treating trauma through imaginal exposure and processing. This means revisiting the traumatic experience in one’s imagination and verbalizing it in sessions. Then, you would process the emotions and thoughts elicited by the imaginal exposure helping you to gain a new perspective about what happened before, during, and after the incident. The next step is in vivo exposure, which involves confronting the situations in your life. You would be asked to gradually approach:
- Safe situations you’ve been avoiding because they remind you of the situation
- Safe situations you believe are dangers
- Previously enjoyed activities that have been stopped due to trauma
- Situations that elicit unjustified shame
The typical client receiving DBT PE:
- Has a life time history of more than 10 types of trauma that started before the age of 6
- Has attempted suicide 2-3x and engaged in non-suicidal self-injury more than 60x in the past year
- Meets criteria for 7 current psychiatric diagnoses including PTSD
- Experiences serious impairment in social, occupational, and/or school functioning
In Stage 2, when DBT PE is administered, sessions are typically 90-120 minutes long. During the imaginal exposure portion, you will be asked to record imaginal therapy sessions and listen to the recording outside of sessions. The in vivo portion of treatment is typically done outside of the therapist’s office and is done as homework. You would be asked to visit places, approach people, or do things that remind you of the trauma (note: you will only be asked to approach SAFE situations).
Cognitive Processing Therapy (CPT)
Another option for trauma treatment is CPT, or Cognitive Processing Therapy. Treatment typically begins with psychoeducation regarding PTSD, thoughts, and emotions to help you become more aware of the connection between thoughts and emotions. You would be asked to write an impact statement that details your current understanding of why the traumatic event occurred and the impact this event has had on your beliefs about yourself, others, and the world.
Next, you’ll be asked to pick the worst traumatic experience and write a detailed account of this event. You would read this in your next session to break the pattern of avoidance, which is a type of exposure. Your therapist will help you, as you read your narrative, gain insights into the unhelpful thoughts you have regarding the trauma and address the maladaptive thinking. Once you have the skills to identify and address unhelpful thinking, you will be using those skills to evaluate and modify beliefs related to traumatic events. Your therapist will help you use these strategies in your day-to-day life to improve overall functioning and quality of life. Throughout this process you will be asked to complete worksheets in the office and as homework. CPT usually takes about 12 weekly sessions, typically lasting about 3 months. Sessions are typically 60 to 90 minutes each and you may start to feel better after a few sessions.
Eye Movement Desensitization and Reprocessing (EMDR)
Finally, we have Eye Movement Desensitization and Reprocessing (EMDR). EMDR works by using bilateral stimulation to safely activate trauma networks and integrate those neural networks into your adaptive networks. EMDR is a 3 phase, 8 stage approach. You can read more in-depth about the stages here. Essentially, stage 1 is information gathering and skill teaching. This stage can take a few sessions. Stage 2 all happens very rapidly and can all happen within one session. In stage 2, you are processing the trauma. Typically you and your therapist did the work leading up to this processing session to identify the trauma, the negative belief, and the positive belief you are working towards. Your therapist has you think about the worst part of the trauma, hold that together with the negative belief, and while holding both in your mind, you will start your bilateral stimulation. You’ll notice memories, body sensations, emotions come up during this time. Your therapist will check in with you throughout the process, helping ensure you stay within your window of tolerance and providing assistance if you become elevated. You also have the ability to pause processing at any time to regulate, check in with your therapist, or take a break.
Because EMDR is targeting neural networks with bilateral stimulation, you only have to share enough information to help your therapist work with you to identify the negative belief at play. You don’t have to share your whole narrative and you don’t have to verbalize every aspect of the trauma. Because of the mechanics of bilateral stimulation, the healing happens inside your brain. The neural networks are moving and shifting and your brain works towards healing. You can start to notice positive shifts in your emotions, thoughts, and behaviors after just one processing session. EMDR does not require clients to give detailed descriptions of the event and EMDR does not directly challenge negative beliefs. There is no extended exposure involved, only brief moments of it when asked to bring that memory to mind. Finally, EMDR does not require homework for healing to happen.
EMDR can be used to treat single event traumas (such as assaults, fires, natural disasters, etc.) or more complex cases involving several traumas or traumas such as years long abuse, invalidation throughout childhood, etc. Some studies show that 84%-90% of single-trauma victims no longer have PTSD after only 3 90-minute sessions. Another study showed that 100% of the single-trauma victims and 77% of multiple trauma victims were no longer diagnosed with PTSD after only six 50-minute sessions. Finally, another study showed combat veterans were free of PTSD in 12 sessions. EMDR is not only useful for treating PTSD, but can also be used for other emotion dysregulation including anxiety, depression, and even some personality disorders as these can arise due to negative beliefs formed from “everyday” memories that caused pain and suffering throughout life.
Each of the treatments mentioned above have been shown through research to be effective treatments for trauma and I hope this provided an idea of what to expect for each treatment. Depending on your circumstances, how you learn best, and the symptoms you are experiencing, certain modalities may stand out to you more than others. Whichever option you chose, we are here to help you heal!
About the Author
Maria Mangione (she/her), M.A., LPCC is a licensed clinical counselor who specializes in dialectical behavior therapy. Maria works to help people develop the tools they need to develop trust in themselves and build their life worth living. Maria believes in having meaningful connections with her clients and believes that therapy and healing can be fun. Click Here to learn more about Maria’s experience and therapeutic style.
References:
https://www.apa.org/ptsd-guideline/treatments/cognitive-processing-therapy
https://www.emdr.com/what-is-emdr/