What is PTSD? How Trauma-Focused Therapy Helps Us Heal
- Bobby Jakucs, Psy.D.
- 14 hours ago
- 14 min read
"The curious paradox is that when I accept myself just as I am, then I can change" - Carl Rogers
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Editor’s Note: This is Part 2 of a three-part series on PTSD. In Part 1, we explored what PTSD is and why it develops. In this article, we’ll examine what the research says about healing through evidence-based trauma treatment. In Part 3, we’ll turn to the existential, spiritual, and post-traumatic growth dimensions of recovery.
PTSD is largely a disorder of non-recovery. Human beings have an innate recovery process when faced with trauma, otherwise we as a species would have faded from existence long ago. That being said, trauma can sometimes overwhelm that process.
Through fear conditioning the internal alarm system remains turned on long after an active threat has passed. This system stays acutely attuned to the environment for potential threats. It remains reactive.
Avoidance is the process by which individuals often cope with trauma. It’s pragmatic in that it provides immediate relief. However, it typically comes at a profound cost: the “I can’ts” start to add up. Moreover, it actually maintains the problem because avoidance prevents us from learning something new.
A metaphor is helpful here. Young children are often afraid of the monster under the bed. Pragmatically, hiding under the covers makes sense. The problem is, if a child never pulls off the covers and takes a look under the bed they never learn what’s actually there.
Perhaps there is a monster.
But perhaps there is not.
Recovery from trauma often takes that same shape: turning toward what we have spent tremendous energy turning away from. It’s more than just “white knuckling” or “facing your fears” though. It is intentionally looking at what trauma taught us to fear and discovering that a different response is possible.
PTSD is Treatable
Among psychiatric conditions, PTSD is among those for which highly effective psychotherapies exist. Just like there are healthy ways for parents to help children face the monster under the bed, there are healthy ways to move forward with trauma. Evidence-based, trauma-focused therapy provides those structures.
Evidence-based, trauma-focused therapies are very different from supportive psychotherapy. Trauma-focused therapies, while varying in their specific targets and mechanisms share a fundamental target: the underlying structures that maintain PTSD.
In other words, they are laser-focused on recovery.
The current (2023) VA/DOD guidelines for treatment of PTSD explicitly recommend prioritizing trauma-focused psychotherapy over medication. And among those the most effective treatments are Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE) and Eye-Movement Desensitization and Reprocessing Therapy (EMDR). The VA/DOD recommend these as first-line treatments. The American Psychological Association’s (APA) recommendations vary slightly, ranking CPT and PE as first-line treatments while conditionally recommending EMDR.
Although the guidelines differ as to how they weight and grade the evidence, all three are well-supported treatments for PTSD.
CPT, PE and EMDR explicitly work by targeting the mechanisms that maintain PTSD. They also are designed to do so relatively quickly, helping people let go of their burdens sooner and get onto living. According to the National Center for PTSD 57 out of 100 people who receive CPT, PE or EMDR experienced meaningful symptom reduction in three months compared to 8 out of 100 people who do not receive treatment.
Recovery does not make someone “forget” or “erase” a trauma. Treatment does not convince you a trauma “wasn’t that bad.” What treatment does do is change the relationships between memory, meaning, threat and our present behavior.
CPT, PE and EMDR look different. But each in its own way helps a person turn toward aspects of trauma that have become feared, avoided or stuck.
And in doing so, they help shift the narrative from “I can’t” to “I can.”
Three Evidence-Based Treatments for PTSD
A metaphor is helpful here. Imagine you are trying to get from Los Angeles to San Diego. You have three options.
You could drive your car and enjoy the beauty of Southern California up close.
You could hop on a plane and fly over any traffic.
You could even climb aboard the Amtrak Surfliner train and cruise along the coast to the rhythm of the rails.
CPT, PE and EMDR are the same way: three means of traveling to the same destination. They are distinct but there is also quite a bit of commonality. The biggest point of overlap is that each was designed and rigorously tested with trauma recovery in mind.
Cognitive Processing Therapy (CPT): Examining What Trauma Taught You
We discussed in Part I of this series how trauma has a way of rewriting the story of our lives. That’s because trauma doesn’t only teach us what to be afraid of, for many people, it challenges what we believe to be true.
Most of us grow up thinking, “If I do good and work hard good things will happen to me.” We also learn, from parents, teachers, coaches, and others that, “If I do bad things and don’t work hard bad things will happen to me.” We may have individual variations of this but our culture teaches us this very early. It’s why superhero movies are so popular: the bad guys are defeated, the good guy gets the girl, and together they ride off into the sunset.
Psychologists call this the just-world belief and there is some truth in it. If you do good and work hard you are generally more likely to succeed than if you sit on your couch and watch TV all day.
But beliefs like that are so ubiquitous, and so encoded, that they become heuristics we fall back on when faced with something novel – like trauma.
In that way, if someone holds to that just-world belief in the aftermath of a trauma they may say, “Good things happen to good people, bad things happen to bad people, something bad happened to me therefore I must have done something wrong.” Alternatively, they may go the other route and say, “What’s the point in trying to do good when something bad can happen at any time?”
Both of these can cause major problems in someone’s life. Relationships suffer. Personal agency evaporates. And very quickly someone loses their sense of self:
“I’m not who I was before.”
This just-world belief is just one example of the way we can interpret traumatic events. There are a number of beliefs that can get fundamentally changed or reinforced after trauma.
In CPT we call these trauma-generated beliefs stuck points. Like a pair of dark glasses, they color how someone views themselves, other people and the world. Functionally, they keep a person stuck.
These stuck points tend to show up in five major domains:
Safety (“If I had been more alert I wouldn’t have been assaulted”, “I have to be on guard at all times”)
Trust (“I can never trust another man”; “I can’t trust my own judgement”; “I should have known this was going to happen”)
Power and Control (“I can’t control my emotions”; “I have no control in my life”; “I have to be in control or something bad will happen”)
Esteem (“I’m broken”; “I’m not good enough”; “If I had been smarter/stronger/braver I could have prevented this”)
Intimacy (“If I get close to someone I’ll be hurt again”; “Only bad things happen from being in relationships”)
In CPT a therapist will work with a trauma survivor first to uncover these beliefs. Over the course of treatment, a therapist will also teach a patient tools to then question those beliefs.
This is more than just simply a therapist telling someone, “that thought is irrational!” It’s also not learning how to simply “think positive” about a trauma. Rather, through dialogue and exploration a therapist will help someone arrive at a more balanced and contextually accurate belief.
So often, we hear a commentator on TV or a friend say something and immediately say (hopefully internally) “that can’t be true for x, y and z reasons.” But often we don’t apply that same rigor to our own thoughts, particularly when it comes to trauma-generated beliefs. One of my patients called this learning to “raise the BS flag.”
After treatment, the goal might be for a patient to say, “what happened to me was real. But everything trauma taught me about myself and the world isn’t necessarily true.”
Prolonged Exposure (PE): Facing What Trauma Taught You to Fear
Imagine bringing home a baby tiger. When it starts to cry you throw it some food. It quiets down. Then it starts to grow. Its cries turn into growls. So, you throw it more food. Eventually, it gets so big that no amount of food can keep it quiet.
It ends up taking over the whole house.
Avoidance is like feeding the tiger. In prolonged exposure, trauma-survivors learn how to face down the tiger and take back their lives.
Prolonged exposure is based Emotional Processing Theory, developed by Edna Foa and Michael Kozak. This theory proposes that emotions, like fear, anger or grief are not simply things that just happen. Rather, they are based on structured networks of associations that organize around stimulus, response and meaning.
In Part I, we briefly discussed a Marine returning home from Iraq, where garbage piles were often used to hide IEDs. According to Emotional Processing Theory an association was formed between IEDs and garbage. Therefore, seeing garbage, even in another context - being safely back home - could produce a similar response (fear and avoidance).
Foa and colleagues determined that in order for the brain to learn new information (e.g. garbage piles are safe) the fear structure had to be reactivated. In other words, the person has to encounter the feared situation and have a different outcome that contradicts assumptions. This is why avoidance is so detrimental - the fear structure may be activated but a person removes themselves from a situation before new learning can occur.
Prolonged Exposure grew out of this theory. There are two major components:
Imaginal Exposure. A therapist will work with a trauma survivor to approach the memory of a trauma. In time, patients learn that memories, though painful, can be tolerated. Over time, the memory can become better contextualized as something that happened in the past rather than something still happening now.
In-vivo Exposure. Here, trauma survivors and therapists will develop a hierarchy of reminders of a trauma (sights, sounds, places and situations) that are safe but generate fear and are avoided. Then, survivors will work up the hierarchy approaching these situations allowing the brain to update assumptions.
Originally PE was based off the principle of habituation, that individuals would gradually habituate to distress with a memory or in a feared situation, and their distress would naturally go down.
Kind of like stepping into a pool for the first time. The temperature of the water does not change, but someone’s ability to tolerate does. Someone learns “pools are cold at first but as I swim, I’ll get used to it and then have fun.”
Often, this occurs in PE. Someone learns “when I’m in a situation that causes fear eventually my anxiety will go down.”
However, newer models indicate habituation need not happen for recovery to happen. Inhibitory learning is a newer model that proposes old learning may not be erased (“pools are cold” or “garbage is dangerous”) but instead new associations develop that can outcompete the old ones.
So instead of learning “pools are cold at first but I get warmer” someone might learn “pools are a place where I get to swim and have fun. I feel great after swimming” even while still being cold.
Consequently, our Marine Veteran might learn, “garbage makes me anxious but driving allows me to get to work and do the things I love.”
How ever the learning occurs, whether through habituation, inhibitory learning or something else PE helps trauma survivors say, “I can face what I have been fearing. Fear no longer has to dictate my life.”
EMDR: Helping Memories Become Memories
Among the three trauma-focused treatments covered here, EMDR is unique. While PE and CPT are broadly derived from Cognitive-Behavioral Therapy EMDR does not neatly fall under any broader model.
In 1987, Francine Shapiro, the developer of EMDR, was walking through a park and noticed that certain eye movements greatly decreased the negative emotions associated with her own distressing memories. She began testing out the use of eye movements in therapy with her patients, particularly among the veterans she was working with, and noticed similar outcomes.
EMDR follows an eight-phase protocol that includes history taking and preparation, building internal and external resources for coping with current distress, identifying the source of the distress, and then ultimately moving into reprocessing of traumatic experiences.
Unlike CPT and PE where treatments developed out of established theories, EMDR is also unique in that a theory was developed to explain what was happening in treatment. This became the Adaptive Information Processing (AIP) Model.
According to the model, the brain naturally has an adaptive sense of self that, like our bodies, is oriented towards growth and healing. The brain here is like a train moving along a railroad track. Traumatic experiences are like roadblocks on the track.
When a trauma occurs, aspects of the experience become linked to images, thoughts, feelings and bodily sensations. In effect, they are perceived as cut off in time and space and are activated when an image, thought, feeling or sensation is triggered. These in turn become linked to other past negative experiences.
In this way, “the past breaks into the present.”
Within the AIP model, bilateral stimulation used in reprocessing is understood as helping traumatic material become integrated into the broader, adaptive memory network. In other words, it is thought this process removes the blocks on the track to move the train along. It’s important to note, while EMDR itself has strong evidence as a PTSD treatment, researchers continue to debate the precise mechanism responsible for it.
Eye movements were originally the primary means of bilateral stimulation. Other methods of bilateral stimulation like auditory (alternating sounds) and touch (alternating hand buzzers, alternating tapping) are often used as well in EMDR therapy.
While PE utilizes verbal recounting during imaginal exposures, and CPT incorporates Socratic questioning to explore the content of cognitions, EMDR reprocessing relies primarily on bilateral stimulation to “move the train” along.
Generally, during EMDR for PTSD the focus of reprocessing (the “target”) is the traumatic experience itself. However, the focus may shift to different images, sensations, cognitions, or bodily sensations. Other memories, traumatic or not, may also present themselves and subsequently be reprocessed.
Again, according to the model, the brain will go where it needs to go in the healing process– the goal is to remove the roadblocks that keep it stuck.
EMDR also operates along three lines: past, present, and future. In this way, reprocessing may also be used on present triggers of distress. Similarly, future templates of a potential or upcoming experience (asking someone on a date, going on a job interview, etc.) may also be reprocessed over the course of treatment.
In time, the goal is for traumatic material to become better integrated into one’s memory and identity. In other words, through successful treatment, a memory no longer feels like it’s happening now.
Which PTSD Treatment Is Best?
When it comes to treatment, many times clinicians get asked by patients, “Doc, which one should I choose?” Honestly, that’s both a complicated question and a very straightforward one. It’s complicated because every person, every trauma, and every life story is different.
On the other hand, the research shows there is no single treatment that is universally superior for every person. They each work, just in different ways. Choosing a treatment should be a collaborative process that incorporates discussion of goals, lifestyle factors, history and what a person is willing to engage in.
A quick summary of the evidence-based treatments for PTSD might be:
In CPT survivors approach trauma-related beliefs and the meaning they have distilled from those events. In doing so, it creates the opportunity to learn, “something terrible happened and it did change what I believe. But now I can choose whether those beliefs really hold weight.”
In PE survivors approach a memory and triggers, rather than avoid them. In time, this creates opportunities to learn, “what happened was real, but I no longer need to live in fear.”
In EMDR survivors approach inadequately processed memories. Through reprocessing, opportunities are created to learn, “there is more to me than my trauma.”
None of the treatments erase a memory. None of them change what happened. But each, by approaching different aspects of a trauma, gives new opportunities for learning to occur.
And in doing so, each creates opportunities to start living again.
Beyond Symptom Reduction in PTSD Recovery
Trauma-focused EBPs are incredibly powerful in reducing symptoms of PTSD. They are in many ways like an antivirus software.Antivirus programs are great at identifying and removing malware. Though for anyone who has had to deal with a computer virus, sometimes files then need to be repaired.
The same thing can happen in recovery from traumatic events. Once the impact of PTSD is removed, other work may still be needed.
One of those areas is insomnia and nightmares. Research demonstrates that these two symptoms often, though not always, remain elevated after trauma-focused treatment. In part, that is because both insomnia and nightmares can take on maintaining mechanisms of their own. Over time, conditioned arousal, disrupted sleep schedules, time awake in bed and other behavioral patterns can cause insomnia and nightmares to persist even after PTSD symptoms have improved.
Fortunately, these can be addressed. Treatments like Cognitive Behavioral Therapy for Insomnia and Cognitive Behavioral Therapy for Nightmares are often used before or after trauma-focused treatment and can substantially improve sleep issues in the context of trauma recovery.
(If you are interested I’ve written more on the impact of PTSD on sleep, what maintains insomnia and what to do about it here: Why Can’t I Sleep Even When I’m Tired?)
Another area is moral injury. Though they often overlap, PTSD and moral injury are not identical. PTSD is a psychological disorder that includes characteristic patterns of intrusions, avoidance, changes in mood and cognition and hyperarousal.
Moral injury is not a diagnosis. It describes enduring psychological, relational and often spiritual distress following events that violate deeply held moral beliefs or values. Treatments like PE, CPT and EMDR can be helpful in navigating moral injury, but often, further treatment is warranted.
(For further reading, I’ve reflected on moral injury, particularly among combat veterans, here: Carrying the Things They Carried).
Which leads into the last area that may be unresolved. Lingering questions may remain that, by their nature, aren’t resolved cleanly. Questions like:
“Who am I now?”
“Where was God when I needed Him?”
“Can I ever be forgiven?”
“What do I do with the life I have left?”
Evidence-based treatments can profoundly reduce suffering from trauma-related symptoms. But symptom reduction, while incredibly helpful, does not automatically answer the bigger questions of life.
Sometimes it amplifies them.
Healing Means Recovering Freedom
Recovery from PTSD is not simply about reducing symptoms. Freedom from being ruled by fear, memories and the painful past creates the conditions so that we have the freedom to do what matters.
Successful treatment means the freedom to:
Be in relationship
Have meaningful employment
Be engaged as a parent
Attend church
Pursue joy
Learn to laugh again
Pursue hobbies and creative activities
Ultimately, recovery means having the freedom to say “I can” where trauma once said “you can’t.”
But with that freedom other questions may arise. When trauma no longer sets the same limits on life, questions like, “What is my life really about now?” can come rushing into the foreground.
Recovery may present questions that trauma - by its very nature - did not give space to ask. Like walking out of Plato’s cave, sunlight has a way of revealing things that darkness hides.
That part of the journey is exactly where we will go in Part III.
Additional Resources:
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If you'd like to explore these ideas further, here are a few books, organizations and articles I frequently recommend.
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