Think you might be suffering from PTSD? Below we identify and explain the three prominent cognitive behavioral therapy (CBT) techniques you should explore: cognitive processing therapy, prolonged exposure, and eye movement desensitization and reprocessing (EMDR). These might sound like confusing and daunting methods, but Dr. Lindsay Bira makes them accessible and easy to understand. Read on to make progress towards dealing with your trauma and PTSD.
This blog post covers part of my conversation with American clinical health psychologist, therapist and coach Dr. Lindsay Bira. This is the third part to our interview. She was a TEDx speaker in San Antonio and speaks often about health, mindfulness, the brain, and stress. She has been featured on public radio, Women's Health Magazine, and more media outlets for her work.
The context behind the start of the following interview excerpt is that she had a traumatic experience in college when a stranger broke into her dorm room in the middle of the night. She woke up to find a man next to her bed staring at her.
Zach: You suggested that your posttraumatic stress didn't arise until later on, after the incident. Is this very common?
It’s not very common, but it does happen. A misconception about PTSD is that if the trauma doesn’t bother someone significantly afterward, then it never will. Most people would have symptoms of post-traumatic stress after a trauma: accidents, assaults, natural disasters, etc. If the symptoms persist longer than a month, then they may meet criteria for the diagnosis of post-traumatic stress disorder. However, it can also take 6 months or even years before somebody has significant symptoms. Usually, when we see this delay, it’s because they’ve stayed busy and distracted, or maybe their life changed in a way that brought the event back to the forefront. The mind is good at avoiding difficult memories but sometimes it can’t put them away properly if the memory is complex. The brain has difficulty creating a category for a trauma because it's such a new and complicated experience. When life slows down and things become quieter, though – and a lot of times we see this when kids leave the house or in retirement– then that's when things that you haven't dealt with start to pop up and affect you. That's when some people start experiencing difficult PTSD symptoms if they haven’t before.
Zach: I understand, and please correct me if I'm wrong, that two people can experience the exact same event together and one can be left traumatized and have PTSD while the other can walk away relatively unaffected. So, what factors influence the onset of PTSD?
Yeah, good question. It can be explained by several different things, but there are still some that we aren’t sure about. There is a genetic vulnerability that may get turned on for some people when they experience a trauma, or can lay dormant without the experience of a trauma. Another risk factor for developing PTSD is having multiple traumas, especially during childhood. Sometimes that can set somebody up to handle it better because they already have a similar experience. But most times, previous trauma makes somebody more sensitive to a future trauma because unhelpful ways of thinking may have already developed and become reinforced, or the nervous system is already on edge and becomes more so with a new trauma. In addition, there's certain socioeconomic status factors that predict PTSD. When people don't have as many resources as somebody else they’re more at risk for developing any mental health difficulties, including PTSD, and they may have less access to care. Beyond these risk factors, we know that some reactions to a trauma can increase the likelihood of developing PTSD. When we look at what plays a factor in the development of PTSD it's usually two main things.
2 main factors in the development of PTSD
- Avoidance After a trauma, symptoms of posttraumatic stress are very normal for everyone. However, if someone begins to significantly avoid reminders of the trauma -- other people, places or things -- then the “this is dangerous” trauma association becomes locked in. So, say that I survived a bombing. In the future, fireworks would activate my fight-or-flight response (understandably so due to similar noise) and so I it would make sense to my brain to avoid all fireworks, stay inside on Fourth of July, etc. The problem with this is that the brain doesn’t get a chance to learn something new and to differentiate sources of ‘bangs’ and the nervous system’s startle response is locked in. Any time I hear a loud bang, it's going to make me feel exactly like I felt when the bomb went off, which will really restrict my activities and cause isolation, problems sleeping, irritability, etc. Avoidance of emotions related to the trauma is also a way that avoidance plays out. If someone avoids emotions and stuffs them down, the brain doesn’t get a chance to sift through what happened and everything that it means. So, avoidance is something that's a huge predictor of PTSD developing because the brain just can’t put away the trauma memory and exist accurately in current life. It relives the memory instead of overcoming it.
- Perspective/Way of thinking When any new event happens, we should incorporate that new information into our current view of ourselves, other people and the world, in order to move forward in a balanced way. An example of this is if I get mugged at a bus stop. If I previously believed that bus stops are 100% safe, that other people can be trusted and I can protect myself, I'm going to have to figure out how to make sense of what happened. If I jump to "bus stops are not safe, other people can never be trusted, and I am powerless to protect myself," then I'm going to have a lot more symptoms when I see a bus stop, when I see other people who are strangers, or when I’m in a situation I can’t control. That nervous system activation is going to happen, that fight or flight response is going to be strong. The reality is that yes, my thoughts need to change to incorporate the event, but if that change goes overboard, the exaggerated beliefs will set the stage for PTSD.
For tips and tricks on changing how you think about things, see how to get yourself out of "thinking traps."
Zach: Your main tactic for dealing with PTSD is cognitive behavioral therapy? What is this and why does it work?
Yes. CBT is a short-term treatment approach that's structured and focused on two pieces: the cognitive side (how the brain is interpreting things) and on the behavioral side (unhelpful actions in response to difficult emotions). There are three approaches under cognitive behavioral therapy that I use because they have been shown through extensive and well-designed research to be the best, the gold standards for trauma-focused treatment.
One is cognitive processing therapy (CPT). Cognitive processing therapy is 12 sessions and it focuses on the cognitive side: let's lay out all your thoughts that have changed as a result of this event and together we're going to look at them to adjust them to make sure that they're solid and realistic. We're not going for positive thinking – that won’t help. We want realistic thinking. By adjusting thoughts, you can bring down the intensity of the emotion and retrain the nervous system.
The second treatment is prolonged exposure, which is 8-15 sessions and is more focused on the behavioral side. It’s a structured and guided approach to having the person to talk about exactly what happened, over and over in detail. By doing so, the brain stops responding to the memory with such high levels of emotion and fight-or-flight. The more you face the trauma head-on, the more you desensitize the person to that event. That doesn’t mean that they forget about it. Definitely not. But it shifts from a horrific, terrible memory that they can hardly think about to “yes that happened and it sucked, but I can handle it now and can move forward.” It's very effective.
The third approach is eye movement desensitization and reprocessing (EMDR), which has 8 phases. It has components of both the cognitive and behavioral sides, with some distraction / different approach to processing. It focuses on identifying main thoughts that developed from the trauma and feeling natural emotions while undergoing the task of eye movement back and forth. EMDR is a little bit more unclear as to what the eye movement adds, if anything. I think it’s more of a distraction than anything, which decreases avoidance, but regardless, EMDR has the cognitive and behavioral elements that we know work very, very well.
Zach: How does a therapist like yourself choose between these methods?
Generally, for any therapist or professional, it depends on how much training and experience you have with each one. Competence is important. I'm trained in all three and have been involved in some of the world’s leading research studies using these treatments. The two that I pick most often in my private practice are cognitive processing therapy and prolonged exposure because they're very straightforward. I can explain exactly how each one works. If I have somebody who is specifically requesting EMDR, I bring them in for an evaluation to see if EMDR would be a good fit. Sometimes I may suggest one of the others, but if a client wants a certain approach, and it appears it would be helpful, I know treatment will be more effective if I match up with what they desire.
Zach: Yeah for sure. And so just to be clear, all three techniques fall under the umbrella of cognitive behavioral therapy?
Yes, they do. There is some argument about EMDR being CBT, but when you look at the research and understand the mechanisms behind it, it is CBT. All three treatments are evidence-based and accepted by the Institute of Medicine 2011 report, though CPT and PE are recommended over EMDR, and all three treatments are accepted within the VA system (the Veterans Health Administration: the largest integrated health care system in the United States). The VA hospital system, even though it has issues sometimes, is very in line with cutting-edge research and makes sure to offer treatments that are shown to work. Of course, the VA focuses on treating veterans, but it’s important to highlight that these treatments started within civilian populations and are just as effective, sometimes more so, for PTSD that isn’t military-related.
Dr. Lindsay Bira and I also spoke about destigmatizing mental health, improving the global health scene, whether mental health care is a luxury or necessity, and the importance of responding versus reacting to the world around you. Follow our blog to hear more from Dr. Lindsay Bira on these and other topics.
To consult with Dr. Lindsay Bira in-person or remotely from her San Antonio office, contact her directly through her profile.
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