Healing PTSD: Emotional Processing with Cognitive Behavioral Therapy
Traumatic experiences are quite common, and survivors must in some way emotionally process and integrate these unwanted and painful events. Successful processing yields a realistic perspective in which the traumatic experience is in the past, reducing the person’s sense of current threat. Many trauma survivors accomplish this over time via natural mechanisms of recovery and do not require treatment. When this process is impeded or the natural processing is insufficient, posttraumatic stress disorder (PTSD), depression, and other problems frequently result.
Studies continue to show that PTSD is a common condition, with prevalence in the general US population of about 8%. Prevalence of PTSD in the active military and veteran population is even higher: Among US active duty service men and women returning from current military deployments, PTSD is estimated as high as 14-16% and among US veterans of the wars in Iraq and Afghanistan, estimates range from 4% to 17% (see Hoge et al., 2004; Richardson et al., 2010).
Given the impact of PTSD on individuals and families affected by this condition, dissemination and implementation of effective treatments is a very high priority.
Psychological treatments are aimed at helping the PTSD sufferer to process and integrate traumatic experiences. Cognitive behavioral therapies have extensive and strong empirical support and often result in remission or a decrease in the severity of PTSD, and decreased severity of depression and anxiety. All effective CBT interventions, which commonly include exposure (imaginal and in vivo), cognitive therapy, or skills training (e.g., stress inoculation; affect regulation and interpersonal effectiveness training), help the survivor to become less afraid of or threatened by trauma memories and reminders and of PTSD symptoms themselves, and to feel more competent and better able to cope. Theorists of exposure and cognitive approaches agree that treatment must in some way access or activate trauma memories, thoughts, and feelings, while providing corrective information that serves to modify the person’s unrealistic expectations of harm and danger and to reduce excessive negative emotion.
Prolonged exposure (PE; Foa, Hembree, Rothbaum, 2007) for PTSD has amassed considerable empirical support and is one of the primary treatments being rolled out by the U.S. Department of Veteran’s Affairs and the Department of Defense. While PE is a highly effective treatment, clinicians are sometimes concerned about whether it is an appropriate treatment for individuals with PTSD resulting from certain types of trauma or for those clients whose trauma narratives and current experience are dominated by emotions other than or in addition to fear: guilt, shame, anger, grief, and sadness. This is understandable – exposure-based treatments were designed for amelioration of excessive and/or unrealistic fear, not excessive guilt or anger. Experienced trauma therapists know that fear is but one of the emotional responses to trauma that are important to address in treatment. And most likely all would agree that facing trauma memories and reminders, and dealing with the feelings that result, are of prime importance.
Clinicians are also sometimes concerned that repeated revisiting of some trauma memories, particularly those associated with guilt or shame or anger about what occurred or what one did or did not do during the trauma, will be ineffective or will result in increased negative emotion. Many years of using and studying PE have yielded a rich understanding of emotional processing of traumatic memories via imaginal and in vivo exposure. Imaginal exposure – repeatedly revisiting trauma memories in imagination – and discussing and processing this experience with the therapist is a potent and efficient means of helping the PTSD sufferer to 1) fully access all of the salient information – facts, emotions, thoughts, behaviors, environment – within the trauma memory, 2) contextualize and understand his or her reactions and experience of the trauma and its aftermath, and 3) achieve a realistic perspective on the traumatic event and one’s behavior during it, as well as the impact it has had and will have in the future.
These outcomes are clearly illustrated in the case of a veteran treated with PE whose traumatic experience involved a deadly engagement with the enemy in which several of the men under his command were killed, despite his considerable and courageous efforts to lead this mission successfully and to save lives. The veteran presented for treatment about 5 years after this event with severe PTSD and depression, and he was suffering from extreme guilt and self-blame for the death of his men. In imaginal exposure he revisited the memory of that painful day in which these men under his command were killed and he was shot at while trying to render them aid. He was given a recording of this first imaginal exposure to take home and asked to listen to it daily before the next session, which he did.
During the review of his homework in the following session, the veteran reported that he had listened to the recording of his imaginal exposure frequently, as requested, and that he had done much ‘soul-searching’. He realized that he had done his job as best he could, and that if he had not done his job well, even more people would have died. Moreover, the veteran reported that thinking this over and listening to the session repeatedly had led him to accept that there was probably nothing that he could have done differently, and that he was beginning to feel a lessening of the “guilt and shame and the blame” he held on to for years after the death of his men. The veteran seemed relieved as he told his therapist that even though he had done everything in his power to bring everybody home, it was just not possible, and not up to him. He ended by saying that he was realizing through this process that he needed to try to let this go and to forgive himself.
This case is a good reminder that our powers of recovery are strong, and that when these powers have stalled or been impeded, they can be unleashed or facilitated by good, trauma-focused psychotherapy so that healing can proceed. Prolonged exposure and cognitive therapy, often primed by imaginal revisiting of the trauma memory as suggested by Ehlers and Clark (2000), are powerful and effective procedures that activate these forces and promote a reorganization of the trauma-related information that is more accurate and whole, an acceptance of what has happened, and a reduction of anxiety, guilt, anger, sadness, and other emotions that have dominated the person’s current experience, and result in reduction of PTSD and other trauma-related disorders.
Ehlers, A., & Clark, D.M. (2000). A Cognitive Model of Persistent Posttraumatic Stress Disorder. Behaviour Research and Therapy, 38, 319-345.
Foa, E. B., Hembree, E. A. & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences. New York: Oxford University Press.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.
Richardson, L. K., Frueh, B. C., & Acierno, R. (2010). Prevalence estimates of combat-related post-traumatic stress disorder: Critical review. Australian and New Zealand Journal of Psychiatry, 44, 4-19.
Elizabeth A. Hembree, PhD
Department of Psychiatry, Perelman School of Medicine
University of Pennsylvania