Visions Journal

Kyle Burns, MD

Reprinted from the Intergenerational Trauma issue of Visions Journal, 2023, 18 (2), pp. 10-12

When something terrible happens to a person, it can have deep and lasting effects. People tend to be resilient and recover, but many find the effects of a trauma to be lasting and debilitating. They often turn for help to a psychiatrist, like me, or to a range of other helping professionals. Most of us recognize the role trauma can play in a person’s suffering. We are also aware of effective treatments that can help.

To help frame the discussion of trauma treatments, I think it is worth retracing the history of how these came about and outlining some current challenges we face applying these today.

Evolution of trauma treatment

Neurologist Sigmund Freud’s first theory was that the psychological problems he saw in his patients were the result of childhood abuse. He later abandoned this explanation and, instead, embraced a model of the human mind where psychological problems come from internal conflicts; in this view, mental illness is only indirectly related to events of daily life.

Freud—and the generations of psychoanalysts who followed him—went on to dominate the treatment of anxiety-related conditions in the first half of the twentieth century. As a result, psychotherapy focused on people’s internal world. It would be decades before trauma was addressed directly in therapy.¹

Following World War II, the psychiatrist Joseph Wolpe worked with soldiers in military hospitals. These soldiers suffered from war neurosis, a term that covered a range of psychological conditions. Wolpe disagreed with Freud. He believed soldiers’ anxiety was related not to their inner worlds, but directly to the trauma of war. He adapted a technique called desensitization from a colleague, the psychologist Mary Cover Jones. Desensitization involved helping people confront their fears by gradually introducing whatever triggered their fear and helping them learn to respond without the usual fear response.

Wolpe called his new version of this technique reciprocal inhibition, which eventually became the foundation of modern behavioural treatments for anxiety and post-traumatic stress disorder (PTSD).

Indeed, even though that diagnosis didn’t yet exist, reciprocal inhibition (also known as systematic desensitization) was designed to treat a broad range of the symptoms we now associate with PTSD.²

It was only in 1980 that the American Psychiatric Association’s third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) included a diagnosis for PTSD. The disorder was defined as being caused by an event or situation that would “be markedly stressing to almost anyone.”³ The response could happen months after the event and included three sets of symptoms:

• intrusive recollections of the trauma
• avoidance of the recollection by avoiding thoughts, people or reminders
• a state of tension, hypervigilance or hyperarousal (i.e., being overly alert)

The DSM also gave a coherent description of trauma and how it can affect some people. This gave professionals new tools to make more consistent diagnoses. More importantly, it allowed for research and development of effective treatments.

Since then, many organizations have adopted trauma-informed approaches that consider the effects of trauma in order to provide more equitable and accessible services. Trauma-informed approaches are broad principles that guide people and organizations, though they do not address the direct, individual effects of trauma. Any organization that provides health care should provide access to effective treatments for a range of problems associated with trauma if it would consider itself trauma informed.

Treatment options for PTSD

At least seven types of psychotherapies have since been shown to be effective for PTSD (see sidebar, next page). While these might seem like a lot of options to choose from, these treatments are not as different as you might think. In all of them, the goal is for people to confront their fears in a safe therapeutic environment. Whether the fears are memories, emotions or behaviours, the therapist’s task is to help the person approach them without the usual, often overwhelming fear response. All of them have a foundation similar to the therapy developed by Wolpe in the 1950s. Their differences lie in how each therapy approaches the task, which fears they address and how they help people manage this incredibly difficult work.  

It would be reasonable for a potential client to ask which is the best treatment (or at least, which is the best for them) or whether medications would be a better option. Unfortunately, the science is not helpful here. There are no clear winners when we compare different treatments. Medications are certainly not better than psychotherapies. Generally, the psychological therapies see larger improvements than we see in medication studies,⁴ but these are not direct comparisons, so it is hard to tell if this is a real difference.

Challenges in treating trauma

The reality is that most people don’t have the luxury of asking which therapy is best. Most people with a history of trauma need to know which (if any) therapy is available. Unfortunately, effective treatments for PTSD are often inaccessible due to the cost of treatment. A psychologist will typically charge over $200 per session, which adds up when a therapy can last months. The public system (i.e., the government-funded system), while trying to implement trauma-informed care, seldom has the skills or resources to provide psychotherapy that is specific to trauma.

Publicly-funded mental health programs often look for treatments that fit into a manufacturing model, where people receive rigid and inflexible treatment, with little consideration for the person delivering the service. This leads to ineffective help that wastes resources and further overwhelms the system. Effective treatments are often much more difficult to deliver than abstract policies that pay lip service to well-intentioned principles.

Providing effective treatments ultimately means investing in effective therapists. Helping a person with trauma is not a simple task. It demands a combination of flexibility, compassion and skill. Unfortunately, in a mental health system that sees itself as overwhelmed and under-resourced, this is not the type of therapy that is promoted.

Another challenge in treating PTSD is that the disorder seldom happens in isolation. Trauma can lead to a host of other problems—depression, social anxiety and substance use problems are incredibly common.⁵ Therapists often navigate intersecting issues that complicate treatment plans. When a person has experienced multiple traumas, especially at a young age, treatment becomes even more complicated. Often called complex posttraumatic stress disorder (C-PTSD), the disorder, related to earlier and more pervasive traumas, involves wide-ranging problems in managing emotions, self-perception and consciousness. C-PTSD often needs longer and adapted treatments.⁶

Research shows that choosing the right therapy is less important than choosing the right therapist.⁷ Helping people with trauma means having therapists who can establish a strong relationship by understanding and responding to the needs of the person they are treating. To truly provide trauma-informed care, we ought to be investing in therapists who are resources, and who have the ability to help.

Related resources

The American Psychological Association’s treatment guidelines⁸ show that the following treatments are effective and scientifically supported for PTSD:

• cognitive-behavioural therapy (CBT) – addresses thinking patterns and behaviours that can lead to ongoing trauma-related difficulties
• cognitive processing therapy – helps people seek meaning in traumas, leading to emotional healing
• cognitive therapy – changes underlying beliefs about traumas by restructuring thinking patterns
• prolonged exposure – supports people to confront and overcome traumatic memories through gradual exposure to triggering memories or situations

The following treatments are also likely to be effective for trauma, though the volume of evidence supporting these is not large:

• brief eclectic psychotherapy – uses elements of different therapies to change emotions connected to traumas
• eye movement desensitization – asks people to focus on traumatic memories while using specific eye movements to process traumas
• narrative exposure therapy – often group-based, helps people re-understand stories of themselves