Treating PTSD by Jim Stabler, M.S.W


What is Trauma?

There are a variety of traumatic events that are outside the normal range of human
experience. These are traumas that would produce intense fear, terror and feelings of
helplessness in anyone. Examples of traumatic experiences are natural disasters such as
earthquakes, tornadoes, car or plane crashes, sexual or physical assault and domestic
violence. Most people following a trauma will experience symptoms such as sleep
disruption, decrease in appetite, difficulty concentrating, intrusive thoughts or memories,
nightmares and other common symptoms of anxiety. For the majority of people these
symptoms begin to decrease in intensity over time and they are able to move on with their
lives without ongoing anxiety problems.

What is PTSD (Post Traumatic Stress Disorder)?

The essential feature of Post Traumatic Stress Disorder is the development of disabling
psychological symptoms following a traumatic event. There are a variety of symptoms
that can occur:

1. Repetitive, distressing thoughts about the event;


3.Flashbacks so intense that you feel or act as though the trauma were occurring over again;

4. An attempt to avoid thoughts or feelings associated with the trauma;

5. An attempt to avoid activities associated with the trauma-such as a phobia about driving after you have been in an auto accident;

6. Emotional numbness-being out of touch with your feelings;

7. Losing interest in activities that used to give you pleasure;

8. Persistentsymptoms of increased anxiety, such as falling asleep, difficulty concentrating, or startling easily.

If you suffer from PTSD, you tend to be anxious and depressed. Sometimes you will find
yourself acting impulsively, suddenly changing residence or going on a trip with hardly
any plans. If you have been through a trauma where others around you died, you may
suffer from guilt about having survived. The symptoms cause you significant distress or
impairment in psychological functioning and involve having trouble at work, school,
social situations or in relationships.

Your efforts to avoid the traumatic memories are doomed to failure. They return in the
form of nightmares and/or intrusive unwanted thoughts during the day. These reexperiencing symptoms occur because the traumatic memories are "stuck" in what is called the active memory system. In addition you almost always worry about a repetition
of the traumatic experience and/or losing emotional control and having an anxiety attack
or a rage attack. Your chronic worry leaves you constantly on edge, irritable, easily
startled and often experiencing impaired sleep. In an effort to cope with your symptoms
you begin to avoid people, places and activities you previously enjoyed and you may also
tend to cope by drinking alcohol or using drugs.

Treating PTSD

Exposure based cognitive-behavioral therapy is the treatment of choice. Adjunctive
medication, particularly anti-depressants, can help with depression, sleep disturbances,
generalized anxiety and panic attacks. Approximately 60% of those who seek treatment
significantly improve in 15 sessions or less. Not all PTSD can be treated so quickly,
however, if it is complicated by substance abuse or by multiple traumatic experiences that
occur over an extensive period of time.

The treatment protocol emphasizes the importance of integrating and applying two forms
of Exposure: brief and prolonged. This is a gradual form or psychotherapy which induces
clients to confront distressing stimuli such as memories, worries, sensations, objects or
situations in such a manner that the emotional distress is always in the mild to moderate

Exposure Strategies

The brief exposure strategy incorporates client-directed emotion focused coping skills:
including the relaxation response and rational thinking. Clients are taught to apply these
coping skills to reduce moderate levels of distress produced by brief exposure in
imagination and in real life to traumatic memories and other trauma-related cues such as
thoughts, worries, images, objects, sensations, or situations. The relaxation response
training is designed to teach the client to induce relaxation in stressful or competitive
situations. There are a variety of procedures including progressive muscle relaxation,
passive muscle relaxation, breathing exercises, and directed visual imagery. Rational
thinking as a coping skill is accomplished by educating the client about the importance of
cognitive appraisals, beliefs or assumptions and modifying the stress inducing irrational
self talk and associated beliefs.

Prolonged exposure is introduced after the client demonstrates strong coping ability and
a sense of mastery has been achieved by way of the brief exposure strategy. The emotion
focused coping skills are again applied while the client reviews distress-producing
memories, worries, thoughts, images, sensations, objects, and situations for prolonged
periods of time. The exposure exercises are conducted first in imagination and then later
in real life. Prolonged exposure emphasizes rational thinking and assimilation strategies
to manage the distress of prolonged exposure. Assimilation, like rational thinking, is a
cognitive reframing strategy employed to help clients correct their faulty appraisals and
underlying beliefs regarding themselves and their world. However, assimilation strategies
are more philosophic in nature and more often target a client's overarching beliefs. Both
types of cognitive reframing strategies utilize metaphors, Socratic questioning and
straightforward teaching maneuvers to correct their faulty appraisals and beliefs.

The two desired outcomes for both types of exposure are Desensitization and Coping.

Desensitization is defined as the reduction of client's distress upon exposure to traumatic
memories, thoughts, worries, images, objects, sensations, or situations. This reduction is
experienced as occurring outside of the individual's control. Coping effects, on the other
hand, are defined as an increase in the ease and quickness with which clients can calm
themselves down using the emotion focused coping skills. This reduction is experienced
under the individual's control. It is thought that prolonged exposure strategies produce
stronger desensitization effects than brief exposure, and that brief exposure strategies
produce stronger coping effects than prolonged exposure. Thus, it is important to
integrate and apply both forms of exposure to maintain treatment gains.

By learning anxiety management skills and gaining the benefits of exposure strategies
PTSD sufferers can overcome their pervasive sense of vulnerability, the tendency to
devalue their problem solving ability and exaggerate the degree of threat in a problematic

James Stabler, MSW, RSW, RCC is Psychotherapist in private practice and specializes
in the treatment of Stress and Anxiety Disorders.

For more information about PTSD.... Anxiety

By way of reading material we recommend:
Smyth, Larry. Overcoming Post-Traumatic Stress Disorder. Client Manual New Harbinger Publications, Inc
Mataskis, Aphrodite. A Handbook for Trauma Survivors-I can't Get Over It. New Harbinger Publications Inc.
Other helpful books about CBT- Beck, Aaron & Emery Gary-Anxiety Disorders and Phobia. Basic book 1985
Greenberger, Dennis & Padesky, Christine-Mind Over Mood. The Guilford Press 1995