PTSD in Survivors of Childhood Trauma

An Analysis of Psychotherapeutic Interventions

Abstract

Post-traumatic stress disorder (PTSD) is a psychiatric disorder that may present in individuals who have experienced, witnessed, or been exposed to details surrounding a traumatic event (APA, 2020). A traumatic event can occur at any point throughout the lifespan. 14–43% of males and females under eighteen experience at least one traumatic event (National Centre for PTSD, 2018). Of those exposed, 1–15% will develop PTSD (National Centre for PTSD, 2018). The overall incidence rate of PTSD is 15.9% (Alisic et al., 2014). It is seen worldwide that youth experience a traumatic event before the age of eighteen (62% in the United States, 68.9% in Mexico, 31.1% in the United Kingdom) (McLaughlin, 2022). With this knowledge, it is critical that treatments target the somatic, cognitive, affective, and behavioural effects of trauma that exist across ages and cultures (Sareen, 2022).

Various risk factors exist for youth exposed to trauma. The severity of an event, a parent or caregiver’s reaction to the event, and the proximity the child is to an event will impact both the onset and severity of PTSD (National Centre for PTSD, 2018). High rates of PTSD symptoms are found in children and teens with severely traumatic experiences, typically characterized as events that involve bodily harm from person to person (National Centre for PTSD, 2018). Additionally, the more traumatic events that a youth is exposed to, the more likely it is to result in a PTSD diagnosis (National Centre for PTSD, 2018). Treatment must include a component of psychotherapy that addresses PTSD as a disorder, and the individual's unique experience of trauma.

There are currently many available psychotherapies that target PTSD with varying degrees of success. These therapies can be grouped into three broad categories: cognitive therapies, variant therapies, and behavioural therapies. The following paper describes the various benefits and limitations for some interventions within these domains.

Cognitive therapies

            Cognitive therapies are most likely to be offered to clients, and as a result, are often studied at length (McLeod, 2019). Broadly, cognitive therapy aims to reverse PTSD maintenance mechanisms, such as trauma related misappraisals, trauma memory characteristics, and unhelpful coping strategies such as rumination and safety seeking behaviours (Meiser-Stedman et al., 2017).

Two common cognitive therapies are cognitive therapy for PTSD (CT-PTSD), and trauma focused cognitive behavioural therapy (TF-CBT). CT-PTSD treats symptoms such as trauma-related misappraisals, which are unhelpful ways of thinking that result from the experience of trauma. Trauma-related misappraisals  negatively impact one’s ability to relate to their experience in a productive way. Additionally, characteristics of traumatic memories are addressed, such as flashbacks and somatic symptoms. CT-PTSD also fosters cognitive coping strategies, such as cognitive restructuring, intended for maladaptive behaviours (Mesier-Stedman et al., 2017). This allows individuals to identify limiting cognitions and choose appropriate behaviours that support their well-being (Mesier-Stedman et al., 2017).

TF-CBT instead aims to reduce symptoms among children and adolescents alongside parents and caregivers (Diehle et al., 2015). Both CT-PTSD and TF-CBT utilize problem solving, a change focused approach, and pay close attention to cognitive processes, to effectively treat PTSD (McLeod, 2019). Symptoms are reduced through psycho-education, relaxation, affective expression and regulation, and cognitive coping (Diehle et al., 2015). Relaxation techniques are individualized and work to eliminate bodily changes due to trauma (Cohen & Mannarino, 2008). Techniques used may include deep breathing exercises, progressive muscle relaxation, listening to music, or yoga practices (Cohen & Mannarino, 2008). A benefit of these interventions is that youth experiencing severe emotional disturbances tend to respond favourably, with decreases in depressive symptoms, anxiety, and PTSD (Good Therapy, 2018).

A potential limitation for cognitive therapies is that individuals with significant behavioural or emotional concerns that were present prior to trauma may not receive significant benefits immediately (Good Therapy, 2018). One possible explanation for this may be due to a comorbid disorder that has gone undiagnosed. It would be advised that these individuals seek treatment for pre-existing concerns prior to starting cognitive therapy for PTSD (Good Therapy, 2018).

Variants of cognitive therapy

Three variant psychotherapeutic treatments include meta-cognitive therapy (MCT), cognitive behavioural writing therapy (CBWT), and narrative exposure therapy (NET). MCT is a newer therapy that aims to remove barriers to recovery (Nordahl et al., 2018). Experiencing a traumatic event may result in an individual adopting a new worldview. For example, if an individual has been assaulted, they may view the world as being unsafe. MCT encourages reflecting upon one’s thinking to regulate thoughts and address worry, rumination, and coping behaviours that may not support recovery (Nordahl et al., 2018). Using the previous example, a psychotherapist utilizing MCT would help their patient to establish a more balanced perspective that the world has components of both safety and harm.

CBWT instead uses written exposure by creating an essay surrounding trauma and recovery (Van der Oord et al., 2009). This process can create opportunities for social sharing with loved ones, which is an important factor in recovery as the absence of social support following a traumatic event is a key predictor in PTSD development (Brewin et al., 2000; Ozer & Weinstein, 2004). However, CBWT may re-traumatize an individual. For example, the repeated use of “I” may cause overidentification with their trauma which may ultimately misdirect healing (Capozzi, 2021).

Lastly, NET is an approach based on CBT principles in addition to being influenced by exposure based and testimonial therapies (Peltonen & Kangaslampi, 2018). NET is an individualized, short term intervention that looks to process experienced traumatic events (Peltonen & Kangaslampi, 2018). NET is informed by a dual representation of PTSD as well as emotional processing theory (Peltonen & Kangaslampi, 2018).

Behavioural therapies

Behavioural therapies address distressing events using validation, and help clients develop skills such as emotional regulation and behavioural coping (McLeod, 2019). Three behavioural therapies involved in PTSD treatment are dialectical behavioural therapy (DBT), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing therapy (EMDR).

DBT integrates TF-CBT and exposure-based interventions to prioritize life threatening behaviours that may exist as a result of experienced trauma (Steil et al., 2018). DBT encourages people to accept past instances and memories of trauma while  teaching emotional regulation skills (Görg et al., 2017). Potential limitations for DBT lie not within the theory itself, but the rigorous training. Most DBT practitioners  must have a  doctoral level of education, as it utilizes a detailed manual and requires intensive training to implement (Good Therapy, 2018).

Cognitive processing therapy (CPT) is well established for its ability to challenge dysfunctional trauma-associated cognitions and emotions (Bohus et al., 2020). Although CPT efficacy has been supported, there are certain limitations that still exist. Further research is needed in order to determine why some veterans who undergo CPT still experience PTSD after treatment completion (Good Therapy, 2016). Because homework and written assignments are required components to the approach, individuals with difficulty completing tasks may struggle within this therapy (Good Therapy. 2016).

Finally, EMDR’s protocol includes psycho-education about trauma and therapy, preparation of the target memory, desensitization of the memory, identification and processing of bodily sensations, and re-evaluation of the target (Diehle et al., 2015). EMDR is unique in its approach because opposed to a focus on altering emotional states, EMDR has a direct focus on the traumatic memory itself (APA, 2017). Opposed to treating an individuals relation to their trauma, EMDR focuses on the way traumatic memories are stored in order to decrease problematic symptoms (APA, 2017).  However, some side effects may include an increase in distressing memories, increased emotional and physical sensations during therapy, and the surfacing of new traumatic memories (Leonard, 2019).

Conclusion

Experiencing a traumatic event can result in debilitating outcomes such as a PTSD diagnosis. Anyone can be exposed to a traumatic event at any point in their life. Because of this, it is important that interventions exist in order to address an individual's concern and promote healing. Given the subjective nature of trauma, having a variety of therapeutic treatments allows individuals to address a traumatic event, and engage in a recovery process that is most comfortable and meaningful to them. With careful consideration of the nature, expression, and treatment of trauma, this paper has analyzed clinical results of various therapies for PTSD and their efficacy.

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