Untangling Trauma and Its Treatment

18 years ago this coming September, I was a newly minted college graduate with a full time job in mental health, and plans to attend graduate school in a couple of years.  On September 11th, 2001, life as I knew it fundamentally changed, abruptly and permanently, as it did for people all across the United States and abroad. Two months later, I attended my first Association for Behavioral and Cognitive Therapies (ABCT) conference in Philadelphia, PA, where there was a somewhat urgent focus on Post Traumatic Stress Disorder (PTSD).  It was there that I first began to learn the fundamentals that would shape my understanding of trauma, and my practice treating it.  

• There are very few things therapists can do in the immediate aftermath of a trauma that will help:  The most widely practiced intervention delivered by therapists right after a trauma is called Psychological First Aid (PFA).  It’s a common sense approach that focuses on making sure survivors’ immediate physical and psychological needs are met, triaging people who might need emergency intervention, and providing a means for individuals to seek services later on, if needed.  A large analysis of data from 1990-2010 found that there was no real evidence supporting PFA’s effectiveness in preventing PTSD, but that expert consensus seemed to agree that it was a helpful treatment, and at the very least, not harmful.

• There are some things that well-meaning therapists can do in the immediate aftermath of a trauma that can hurt:  It was at the aforementioned conference that I first came across the term Critical Incident Stress Debriefing (CISD).  This involves, immediately following a trauma, either as an individual or within a group, going through a 7 step model where the traumatic incident is reviewed in detail, and psychoeducation is provided, among other interventions.  Research shows that individuals who undergo CISD do not have lower rates of PTSD, and may actually be more likely to develop PTSD than those who do not. In the aftermath of a trauma, we all feel helpless; it’s important that in our rush to allay our own feelings of helplessness, that we do not inadvertently do harm to others.

• Most people who are exposed to a trauma, and have no psychological intervention at all, will not go on to develop PTSD:  There are some incidents (like mass violence) where this is not the case, but in general, immediately after a trauma, everyone experiences PTSD like symptoms which will abate over time.  These can include difficulty sleeping, flashbacks, nightmares, and increased startle response, among other symptoms. These are normal and expected reactions – think of it as your nervous system slowly coming back to baseline following a threat.  At some point around 3-6 months, most people recover, and some do not. Those who do not, will go on to develop PTSD.

• PTSD is a treatable psychological condition:  While we still might not completely understand how to prevent PTSD, or why some people go on to develop it while others will not, there are several psychological treatments that have demonstrated effectiveness in treating PTSD – Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and Trauma Focused Cognitive Therapy (TF-CBT).  These treatments have several elements in common, including decreasing avoidant behaviors, and exposure to the trauma itself, where the trauma is remembered and recounted within the therapy space, so that the trauma memories cease to be living, breathing nightmares, and become reintegrated along with the rest of a person’s memories. When looking for treatment, it’s very important to seek an evidence based treatment, delivered by a trained provider.

 For more information about PTSD, check out the Anxiety and Depression Association of America.  If you or a loved one is in need of immediate help, call 1-800-273-8255, or text HOME to 741741.

When I was applying to graduate school for Clinical Psychology, I was admittedly naive as to what I wanted out of my career. I knew I wanted to be a therapist, I knew I liked research, and I knew I wanted to live in NYC. I also realized that getting into any program would be difficult having limited publications under my belt. I didn’t know which degree would make the most sense given my interests. Someone told me a PhD lends itself to a few different career types which was appealing to someone who didn’t know what they wanted to do. I applied to most of the clinical psych PhD programs in the tri-state area. Programs that were psychodynamic, mixed, and CBT. 

 In retrospect, I am grateful that I got into Hofstra, a program with strong CBT training and a very supportive environment. Everyone comes into graduate school with different levels of clinical and research experience, though many are unaware that not all therapy is the same. Many don’t understand the importance of scientific research to determine the effectiveness of a psychological intervention.

I believe that for evidence-based practice and research to continue to grow, it is important that we reach students interested in working in the mental health field even before graduate school. If you are reading this message, in all likelihood, you have found a home and a clinical identity in the CBT world or at least utilize CBT skills within your treatment planning. 

To impact your future colleagues, we open our community of licensed practitioners and graduate students to “pre-mental health” students – vetted individuals who have decided that they would like to (or are strongly considering) entering the mental health field. We hope that we could provide guidance in their journey – one that we all traveled – and in doing so support the continued growth of our field. 

If you know of someone who is strongly considering working in the mental health field (pre-psychologists, MH counselors, psychiatrists, social workers…) and would be helped by joining this community. Please have them apply via this link.

 If you are interested in serving in a mentorship role, please click here. 

Thanks,

Elliot 

“You meet a guy, relinquish a tiny bit of control, and the next thing you know, you’re eating a different part of the pig.”  – David Sedaris describing his experience of ending up in Normandy with his husband Hugh pretty much describes my experience of winding up rounding 40 as a CBT therapist specializing in anxiety and related disorders. Only my former graduate advisor is the guy (I didn’t marry him, and this is not that sort of blog post), and I suppose ‘the part’ of the pig I’m referring to is my theoretical orientation.  

20 years ago, I was a college senior who had put off securing an honor’s thesis advisor to the last minute.  It was pure happenstance that had me waltzing into the office of the Rutgers Anxiety Disorders Clinic to meet with Dr. P, who wanted an undergrad to work with him on validating a scale.  He went on to hire me to work as an in home behaviorist following undergrad, and then became my graduate advisor upon my acceptance to the Graduate School of Applied and Professional Psychology at Rutgers.  By the time I attended my first class, I was so steeped in CBT that I had no understanding that, as a theoretical orientation, CBT was a relative newcomer to the game, and not necessarily universally beloved by all psychotherapeutic practitioners.  Throughout my education and experience in the field, I came to realize that myths and misconceptions about CBT abound. So, welcome to CBT Base Camp 101 – Mythbusting!

Myth #1:  CBT is just a set of techniques:  There are a lot of treatments and techniques that fall under the umbrella of CBT,  however, CBT in and of itself is a rich theoretical orientation. Just as with any theoretical orientation, it provides a framework from which you can conceptualize and plan treatment for any individual client.  

Myth #2:  CBT Therapists don’t attend to the therapeutic relationship:  The work that I do is primarily with clients who have anxiety and related disorders.  As such, I’m often asking them to face their worst fears – there is no way that I would be able to do this type of work if I didn’t constantly attend to the therapeutic relationship.  CBT therapists absolutely believe in the necessity of the therapeutic relationship; we also acknowledge that it’s not wholly sufficient when it comes to creating change.  

Myth #3:  CBT takes about 12-15 sessions:  Whenever someone asks me off the bat how long treatment will take, I provide the answer universally loathed among clients and insurance companies – “it depends.”  If a client is coming to treatment for a specific phobia, has never been in treatment before, only wants to focus on their phobia, has zero comorbidity, and is highly motivated, then we might be able to complete treatment in a handful of sessions!  That being said, human beings are complex, and treatment is not 100% predictable, therefore, every client’s treatment timeline is going to be based on her unique strengths, difficulties, goals, and diagnosis/es.

Myth #4:  CBT is only effective for surface level problems:  Please refer back to myth #1.  Sure, under the umbrella of CBT, there are a variety of techniques that are effective with regards to behavior change.  I guess we need to bust two myths here – one that behavior change is somehow surface level, and two, that behavior change is all that CBT treatments provide.  Research demonstrates that when people change their behavior, their thoughts and feelings actually follow. For example, if you’re a lifelong smoker who stops smoking, your attitudes and feelings around smoking will actually change once you stop the behavior.  Further on, CBT derived treatment has been demonstrated to be effective in treating borderline personality disorder (DBT), schizophrenia, and other psychotic disorders. It’s hardly limited to getting folks to stop biting their nails – although if any of you out there could help me with that, much appreciated.   
Myth #5:  Thou shalt be a theoretical pureist:  Ok, this isn’t strictly a CBT myth, but hang in there, the post is almost over.   I can still picture my grad school class – there were about 4 or 5 of us who chose the CBT tract, and about 10 others who chose the psychodynamic route.  There was one magical unicorn (I hope you’re reading this) who actually did both, but in general, we were told to choose, and choose wisely, because this choice was set in stone.  Something I often find myself saying to clients who are in a rush to figure it all out and foreclose on their identities is that the day we stop growing and learning would be an incredibly sad day.  I hope that this is what brings you here, to CBT Base Camp – a desire to continue growing and learning, regardless of theoretical orientation or training up until this point.