What are the most effective therapy approaches when working with trauma?
Working with people who suffer with PTSD is often a mysterious and complicated process: they may show symptoms of avoidance, dissociation and magical thinking. Getting past these symptoms and into the internal world of the client is one of the skills that counsellors and therapists need to learn. This article considers the effectiveness of different theoretical approaches that are practised with clients who present with PTSD and looks at recommended treatment methods. I then offer a case example of working with a client who was severely traumatised as a young child. Research into the best methods for treating PTSD has been found to be contradictory. There is a need for robust, reliable data and proofs, something that is often difficult to provide in psychology, which is not a pure science. Quantitative research methods can be constraining when the research goals are to explore participants’ sense of their own worlds and their perceptions of their traumas. But in the medical model, quantitative methods are essential.
Quantitative or Qualitative?
I will first set out some of the pros and cons of quantitative and qualitative research methods, before considering the different kinds of research into the treatment of trauma. The strengths of quantitative research include replicability, ease of analysis, consistency and reliability from a scientific standpoint. Its limitations are its inability to portray complex issues, or human factors, such as a client or researcher’s opinions. Quantitative research methodologies are question-specific and tend to present data in the form of graphs or charts. A quantitative approach therefore may be limited when it comes to researching the details of personal experience, such as a person’s feelings and thoughts.
Qualitative research looks at personal experience in greater detail and depth. Qualitative research is more flexible and can provide a richer picture of the research topic than quantitative research. The researcher and her/his opinions and observations are instrumental. The relationship between the researcher and the participant is taken into consideration as an important part of the research process. The researcher uncovers the participant’s story and presents it to the world. In the words of Kim Etherington, ‘Storytelling is a social activity that requires an audience, whether that is a therapist, researcher, friend or other interested persons.’ (2009:232). One of the main limitations of qualitative research is reliability. The interviewee may want to comply with the researcher and provide responses to coincide with the research questions, which is known as researcher-biased research. A skilled researcher will spot this and overcome it. Due to its in-depth aspect, the collection and analysis of qualitative data can be time consuming. Confidentiality can also be a potential issue because the client’s narrative may be recognisable (Etherington, 2009).
I believe both quantitative and qualitative research methods have a part to play in the research into PTSD. We need qualitative research in order to capture the individual experience of trauma in as much depth as possible, and we need quantitative research to give us a good indication of how a particular intervention is working in order to establish robust, proven methods of working with PTSD. I will now give an overview of some of the research that is currently available in relation to the effectiveness of PTSD treatments.
Different approaches to treating PTSD
In 2005, the National Institute for Health and Care Excellence (NICE) recommended Cognitive Behavioural Therapy (CBT) for the treatment of PTSD (Bisson and Andrew, 2005). This recommendation was based upon a quantitative research study. NICE looked not only at effectiveness, but also at the good use of funds. CBT is very suitable for evaluation by quantitative research because it employs treatment methods that gather data, such as measurement scales and questionnaires that ask questions without narrative input, and tends to avoid in-depth exploration.
NICE recommended CBT as the first-line therapy for the treatment of PTSD (Kar, 2011). A meta-analysis of randomised treatment studies for PTSD conducted by Bradley et al (2005) reported a large effect size based on pre-treatment to post-treatment change. The study found that 67 percent of people who completed the treatment no longer met the criteria for PTSD (Bradley et al, 2005). The study listed CBT as helpful for certain conditions, including PTSD, but did not provide data on long-term effectiveness nor the effectiveness of other types of therapy to complement CBT. In a separate study, Hollon and Beck (2013) reported that the effects of CBT were short in duration.
In 2005, Counselling and Psychotherapy Research published a systematic review of CBT and psychodynamic approaches for the treatment of PTSD (Bradley et al, 2005). The research analysed the results of 12 reviews and included participant samples from seven countries. Three studies found that Psychodynamic Therapeutic Intervention (PTI) treatments were an effective form of treatment for PTSD. Kellet & Beail (1997), Abbas & Macfie, (2013) and Lampe et al., (2014) also reported research that found the same. Out of the 12 reviews, two directly compared CBT and PTI treatments for PTSD. The studies reported PTI to be equally as, or more effective than CBT. D’Andrea and Pole (2012) also found PTI was associated with greater reductions in the effects of PTSD than CBT. But other research comparing PTI and CBT has found the opposite: Gilboa-Schechtman et al (2010) reported that CBT led to a larger mean reduction in PTSD symptom scores compared to PTI treatment.
The Clinical Psychology Review (Kline et al, 2018) published research into the long-term efficacy of psychodynamic psychotherapy for PTSD. The initial treatment was followed up with long-term interventions of at least six months duration. Effect sizes were significantly larger for active psychotherapy conditions relative to control conditions for the period from pre-treatment to the long-term follow-up. All active interventions demonstrated long-term efficacy.
PTI has been studied less frequently than CBT for the treatment of PTSD. Ehlers et al (2010) state that there is insufficient rigour in the current research to determine the effectiveness of PTI. But Ponniah and Hollon (2009) found that although some studies examining PTI for the treatment of PTSD are limited, others have demonstrated its effectiveness. Exploring patient preferences for PTSD treatments, Markowitz et al (2015) reported that 50 percent of patients preferred a psychodynamically oriented treatment, whilst 26 percent preferred CBT. Does this mean that patients prefer to tell their stories than tick boxes? This is an area where more research is needed (Bradley et al, 2005; Ulrich et al, 2016).
The International Society for Traumatic Stress Studies carried out a survey of 25 experts in complex PTSD and 25 experts in classic PTSD regarding the most appropriate treatment methods (Cloitre et al, 2011). Eighty-four percent of the experts endorsed a phase-based or sequenced therapy as the most appropriate treatment for PTSD. They said this required interventions tailored to specific symptom sets. First‐line interventions matched to specific symptoms included emotion regulation strategies, narration of trauma memory, cognitive restructuring, anxiety and stress management, and interpersonal skills.
Currently, systematic reviews offer the best available evidence for effective treatments for PTSD. The weight of the evidence is in favour of trauma-focused CBT. Overall, the evidence shows that a wide range of psychological therapies are effective in treating PTSD in a range of contexts. A meta-analysis by Benish et al (2008) suggests that there are equivalent effects for a range of psychological therapies. However, Ehlers et al (2010) argue that the selection procedure of the available evidence used in Benish et al’s meta-analysis introduces bias. They argue that the analysis and its conclusions fail to take into consideration the researchers’ need to demonstrate that treatments for PTSD are more effective than natural recovery. Ehlers et al (2010) recommend further research into the active mechanisms of therapeutic change, including treatment elements commonly considered to be nonspecific.
I have a personal interest in trauma and have researched what could be the best psychotherapeutic fit to address it. Although my own training and chosen orientation is person-centred psychology, I do not rule out using CBT. I recognise, and the research evidence suggests, that CBT has validity and could help assess the extent of my clients’ distress. I will now give an example of how I have integrated a CBT-type intervention with my usual person-centred approach in working with PTSD.
Trauma affects our development and functioning and help is needed in order to recover from it. This case study is fictitious and has been created from my experiences of work with clients suffering from PTSD. I have decided to use a fictitious story to ensure confidentiality. As a young child, the client lost both parents in traumatic circumstances. The client had poor recall of the event. He could remember his parents through flashes of memory, but not streams of memory, and could feel the effects of the shock of the loss in his body. I noticed that his breathing was shallow and high up in the chest, and that he sometimes held his breath. Bowlby would understand the client’s responses to the loss of his parents as signs of ‘separation anxiety’ (Bowlby, 1998:50).
The client was a young man when I started to work with him. He suffered from nightmares and anxiety and struggled to commit to relationships. I sensed him as being dissociated at times, still in shock after all these years, suffering prolonged grief and displaying a disorganised attachment style (Bowlby 1988). Attachment theory helps me to understand my clients’ ways of relating, the ineffective coping mechanisms that they may have developed and gives me a deeper understanding of my clients personal emotional difficulties. Spring (2017) explains that disorganised attachment is not an attachment ‘style’ in its own right: “children display DA behaviour under specific conditions of activation but their overall attachment pattern resolves into one of the three organisations as soon as the specific threat that led to their disorganised behaviour disappears” (Spring, 2017). I assessed this client as suffering from PTSD. Because the traumatic experience of losing his parents was never adequately processed, the “threat” that led to his disorganised behaviour never disappeared.
I am an integrative, relational therapist and I have some CBT training. I draw on the person-centred approach in my work by using the core conditions of empathy, understanding the client from his frame of reference, and unconditional positive regard, whereby I accept him exactly as he presents and allow the work to go at his pace. By modelling a helpful relationship, I hope that my clients can take some of this experience into their lives for future relationships. Since this client had lost the essential caring characters from his life at a young age, there were some gaps in his upbringing. He needed to learn what it was to relate to others; for a long time, he had avoided close contact with others. The shock of loss was still in the room many years after the event.
I assessed this client carefully and slowly, asking questions about his present as well as his past life. When I saw that he was either suffering too much, or dissociating, I stopped and considered what he had told me. I avoided overwhelming him and asked him to let me know if this was what was happening. My prime concern with this client was not to retraumatise him, so I worked very slowly. When I felt he was able trust me, we took small steps to examine the trauma that had brought about the PTSD. I assessed the client using both a CBT method and relationally. For the latter, I explored his past behaviours in relationship and how he presented to me in the room. I noted his eye contact, his tone of voice, how he sat on the chair and positioned himself so that we would not physically connect. For the CBT method, I accessed a scale sheet and asked my client to rate his fears on a scale of 1 to 10. We then explored his answers.
In combining these two methods, I was able to explore more of my client’s story without retraumatising him as he told it. We worked at a safe and steady pace and I attuned to my client’s relational need to have physical space in the room. I believe that healing comes about by going over the details of the client’s story many times until its power became diffused and the client is able to cope with the awfulness of the loss. But that comes in time. I cannot rush clients into that. When working with trauma and grief of this kind, I have learned to be patient. In this process, I believe the use of the less personal CBT, which avoids in-depth exploration, combined with an empathic approach, can facilitate a process of healing that avoids retraumatising the client.
An integrative approach
While research has been instrumental in informing my practice, I don’t have a preference for a ‘best’ way to treat PTSD. I aim to ensure that the client’s needs are first and foremost. Therefore, I adjust the relationship between us to meet the client’s specific needs. I feel that a combination, an integration, of two or three methods when required works well. The vignette of my practice shows that CBT can be successfully integrated with a person-centred, relational approach. The setting in which the therapy takes place also influences the choice of treatment. I work in private practice, so I do not have the same considerations around cost as I would if I was working in the NHS. My case example did not include cost as a criterion for efficacy. I accept that NICE is an organisation that has to take cost into consideration, because it informs the NHS which has a limited budget. In terms of recommending models of treatment, this is a weakness in my opinion. If the NHS had bottomless funding, this would not be a problem.
In my private practice, I am finding a way of working with trauma which is necessarily long term and slow. That is expensive. But in my experience, treating trauma takes time. The use of CBT tools was helpful, but I also recognise their limitations. What is important in my case example is that the loss of caring relationships caused dreadful trauma, which damaged the client’s capacity to relate. The method I believe to correct this is, over time, to rebuild the person’s capacity to engage in relationships. This means attempting to go back to the start of the trauma pattern and to create a different ending, an ending where the relationship can provide a “secure base” (Bowlby, 1988).
Lynds O’Connor (MBACP accredited) trained at Southwark College, Bermondsey and works at Action For Family Carers (AFFC) in Essex (website: https://affc.org.uk/). She is currently doing a BA Hons in Counselling & Psychotherapy at Anglia Ruskin University. Email: [email protected]/ [email protected]
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