PTSD Series: Evidence-Based Psychotherapy
Updated: Apr 29, 2021
I've been in therapy for years for my PTSD and have tried every medication under the sun, but I'm still having nightmares almost every night. My therapists have taught me a thousand coping strategies, but it hasn't changed how I feel. I'm starting to think that nothing will ever work for me. Will I always struggle this much?
I have heard a variation on this statement from more of my clients than I can begin to count. My first question is always, "Have you received psychotherapy where each session focused on processing the trauma? Did your therapist offer you a treatment that they called PE, CPT, or EMDR?"
The most common answer my clients give? "No, they didn't tell me what the treatment was. We talked a lot about how to manage my reactions, but the therapy wasn't structured or anything. I haven't really talked that much about what happened." So you're there, and you're thinking you've tried everything?
There are a few psychotherapies with evidence for reducing PTSD. Only three are strongly recommended according to evidence-based treatment guidelines:
Prolonged Exposure (PE)
Cognitive Processing Therapy (CPT)
Eye Movement Desensitization and Reprocessing (EMDR)
If you are struggling with symptoms of PTSD, you need one of these treatments.
Prolonged Exposure is a very effective treatment for PTSD, and is my personal treatment of choice. PE involves revisiting the traumatic experience in a safe and supportive environment so that you can finally emotionally process the trauma. This revisiting happens in a therapeutic manner designed to help you heal. Conversations including discussing your perspectives about the trauma and considering new meaning that comes through revisiting the memory. Over time, when the trauma is processed enough, the memories don't "burn to the touch" as much, so to speak. That can often lead to profound shifts in the way you feel on a day-to-day basis. PE usually takes 10-16 sessions or so.
Cognitive Processing Therapy is another evidence-based treatment for PTSD. CPT focuses much more on your thinking about the trauma. Through CPT, you will primarily discuss the meaning you have taken from the traumatic experience. Your therapist will help you think through different "stuck points" in your thinking about the event(s). Then, they will teach you skills to help you think through these "stuck points" on your own in the future. CPT generally takes around 12 sessions.
Eye Movement Desensitization and Reprocessing is evidence-based for PTSD, is extremely popular among therapists in many communities, and is highly controversial among trauma researchers. This treatment involves revisiting the traumatic memory while engaging in back-and-forth eye movements. It may involve another form of bilateral stimulation (such as an alternating buzzer in each hand).
Why is it controversial? There's not really a reason to think that the eye movements actually do anything. There's absolutely no scientific ground to say that it's necessary to have bilateral stimulation when you process a trauma. So, you may be wiggling your eyes back and forth for nothing.
Also, lots of people are doing EMDR who aren't well-trained in PTSD more generally. Its explosion in popularity has made it hard to know if you're actually getting good care. EMDR should also only take around 6-12 sessions. Many therapists will "weave EMDR in" to a much longer course of treatment, which is not usually necessary. That said, EMDR should work - and it's usually fairly easy to find a therapist trained in it!
A caveat: at times, therapists may make the decision not to do one of these treatments for a really good reason. For example, it's not a great idea to do PE, CPT, or EMDR if you are self-harming, very suicidal, or in an ongoing, abusive relationship. Or perhaps your reactions to trauma don't fit cleanly into the "box" of a typical PTSD diagnosis - that might mean your treatment will look a little different. After all, there are many different ways that people react to traumatic events, and PTSD is only one of those ways. PE, CPT, and EMDR are only evidence-based for people whose trauma reactions can be categorized as PTSD.
Is (brainspotting/somatic experiencing therapy/hypnosis/neuro-linguistic programming/equine therapy/art therapy/thought field therapy/rapid resolution therapy) an evidence-based treatment for PTSD? No. These are not evidence-based. You can certainly try them! Some things may work for you, individually, that have not yet been studied sufficiently in scientific research. Generally, it probably makes sense to at least begin with one of the therapies with the most scientific support (PE, CPT, or EMDR) before investing your time, money, and energy into other forms of therapy.
If you have PTSD, I encourage you to seek out a professional who is committed to evidence-based treatment, and is well-trained in PE, CPT, or EMDR. If you haven't had these treatments yet, know that you shouldn't give up hope.