INTERVENTIONS

Caring for the patient diagnosed with PTSD involves establishing patient-centered goals and expected outcomes, setting priorities, and choosing interventions according to the urgency of each problem. Urgency is measured by patient safety, patient desires, and nature of the treatment.

Interventions for PTSD are generally divided into psychotherapy and pharmacology, with psychotherapy being the primary choice for most adults. There are several treatment modalities, and while some patients respond well to one modality, others may require a combination of modalities.

Trauma-Focused Psychotherapies

Trauma-focused therapies focus on the trauma and its subsequent effects on the patient consistently throughout treatment. This modality helps the patient to correct flawed perceptions and decrease symptoms through exposure to reminders of the traumatic event.

COGNITIVE BEHAVIORAL THERAPY (CBT)

Cognitive behavioral therapy is based on the idea that our thoughts and behaviors are interwoven. This means that if one’s thoughts are changed, then behavior will also be impacted. CBT targets maladaptive behaviors and beliefs that cause distress and impair ability to function. Following trauma, a person is left with extremely negative beliefs about themselves, others, and the world. A CBT therapist works with these individuals to help them learn how to identify, assess, and modify negative perceptions and actions that result in distress (Porter & Fuller, 2023).

COGNITIVE PROCESSING THERAPY (CPT)

Cognitive processing therapy is a form of CBT developed specifically to treat trauma. It is a structured approach that typically occurs over 12 sessions and includes both psychoeducation and the development of coping skills. A therapist explores how a patient’s trauma has affected their mind and body, both during and after the event, and then uses cognitive restructuring to help the person identify, assess, challenge, and change rigid maladaptive thoughts related to the trauma (Porter & Fuller, 2023).

BRIEF ECLECTIVE PSYCHOTHERAPY (BEP)

Brief eclectic psychotherapy for PTSD combines aspects of CBT with psychodynamic therapy. BEP aims to change painful thoughts and feelings resulting from a traumatic event. While incorporating many elements found in cognitive behavioral therapy, BEP also incorporates a psychodynamic approach with an emphasis on the emotions of shame and guilt and the relationship between patient and therapist. Throughout treatment sessions, the person learns about trauma and how to employ relaxation exercises while discussing the trauma (Porter & Fuller, 2023).

PROLONGED EXPOSURE THERAPY (PE)

Prolonged exposure therapy is used to address PTSD avoidance behaviors. Patients who have experienced trauma typically avoid reminders of that trauma in order to protect themselves from being overwhelmed by fear and emotional pain. This only further reinforces that fear and pain.

Throughout PE treatment, typically provided over a period of about three months, the therapist utilizes systematic desensitization techniques through prolonged exposure to stressful trauma cues, which leads to gradual disappearance of symptoms. More specifically, the therapist teaches patients relaxation and grounding techniques during a session while the patient is being exposed to distressing reminders, including imaginal exposure and in vivo exposure.

Imaginal exposure occurs with the patient describing the event in detail in the present tense followed by a discussion and processing of emotions. The patient is recorded during the event for use between sessions to further process the emotions and practice associated breathing techniques.

In vivo exposure is assigned homework that involves the confrontation of feared stimuli outside of therapy. Both patient and therapist together identify a range of possible stimuli and situations connected to the traumatic fear. They then agree on which stimuli to confront and devise a plan to do so between sessions (Porter & Fuller, 2023).

Virtual reality exposure is a method found to be well suited for recreating scenarios to help facilitate exposure. Virtual reality exposure therapy uses a head-mounted computer display to present the patient with the visual, auditory, tactile, and other sensory material that stimulate traumatic memories and affective response (Stein & Norman, 2021).

NARRATIVE EXPOSURE THERAPY (NET)

NET is a short-term approach specifically for survivors of complex trauma and which can be done individually or in small groups. Narrative exposure therapy involves having the patient write about the traumatic event in response to specific prompts. As they write, they are asked to notice their thoughts, emotions, and physical sensations in the present moment (Stein & Norman, 2021).

EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)

EMDR is a form of psychotherapy that incorporates components of CBT and exposure therapy along with saccadic eye movements (rapid, jerk-like movement of the eyeball) to abruptly change the visual focus on an object.

The technique involves having the patient imagine a scene from the trauma and focus on the accompanying cognition and arousal. The therapist simultaneously moves two fingers across the patient’s visual field and instructs the patient to track the fingers. This sequence is repeated until anxiety decreases, at which point the patient is instructed to generate a more adaptive thought. An example of a thought initially associated with the traumatic image might include, “I’m going to die,” while the adaptive thought might end up being “I made it through, and it’s in the past” (Stein & Norman, 2021).

Non-Trauma-Focused Psychotherapies and Psychosocial Interventions

Some types of non-trauma-focused therapies have been shown to be effective in reducing symptoms of PTSD, but their effects are lesser than trauma-focused interventions. Trauma-focused therapies also are not always available and not always desired by patients.

PATIENT-CENTERED THERAPY (PCT)

Patient-centered therapy is a time-limited treatment for PTSD that focuses on increasing adaptive responses to current life stressors and difficulties that are directly or indirectly related to trauma or PTSD symptoms. PCT has been shown to result in greater reductions in PTSD symptoms than inactive controls but lesser reductions than trauma-focused cognitive-behavioral therapies (Stein & Norman, 2021).

INTERPERSONAL THERAPY (IPT)

Interpersonal therapy has been found to be effective for patients who are not willing to undergo an exposure-based therapy. IPT is a present-based therapy that focuses on the interpersonal consequences of trauma rather than on the trauma itself, distorted cognitions, or behavioral habituation. IPT includes a time-limit, and goals are the resolution of interpersonal conflict and mobilization of social support (Stein & Norman, 2021).

CASE

Alex (continued)

Several times during his hospitalization, Alex met with a social worker, who provided education about the PTSD symptoms he was experiencing and explained how treatment could help him restore control over his life. During his sessions with the social worker, Alex began to develop an awareness of thoughts and feelings that he had not previously understood were related to his trauma.

The multidisciplinary team’s plan of care involved Alex participating in cognitive-behavioral therapy. Two forms of CBT therapy were determined to be good choices for Alex—cognitive processing therapy and prolonged exposure therapy, which are two of the most common CBT methods used to treat PTSD.

In the first session, a psychologist met with Alex and discussed the theory behind PE therapy to help him understand why he would be asked to do something as scary as reliving his trauma. He was told he would be talking about and reacting to the memories of his traumatic experience, but in the absence of any danger.

During the next session, Alex struggled at first, but with the psychologist’s promptings and urgings began talking about the accident and how his best friend, Loren, had been killed. Alex remembered his frantic efforts to try to reach his friend and help him out of the car. Again, he felt the fear and frustration with the difficulty he experienced trying to get Loren out of the car and onto the riverbank.

During the telling of the event, Alex experienced intense distress and fear and responded physiologically as if he were actually living through the trauma again. He cried softly as he described the death of his friend. He repeatedly said, “I’m sorry, I’m so sorry, Loren! I should have saved you. I wish it had been me.” During this session, the psychologist recorded his description of the trauma and emotional response. Alex was instructed to listen to this recording sometime during the remainder of the day and told that they would repeat the session again the following morning.

Alex also began attending group sessions with an occupational therapist. He learned about the struggles other patients with posttraumatic stress were having trying to move forward to assume normal activities of daily living and responsibilities. He began opening up and talking more freely. The occupational therapist made an appointment with Alex to complete an assessment of the effects PTSD has had on his ability to work.

With continued treatment, Alex gradually experienced less and less fear, anger, and guilt. He was able to remember his experience without reacting to it negatively and began the slow process of incorporating the event into his other lifetime memories.

(continues)

Psychopharmacology

First-choice PTSD treatment can involve therapy, medication, or a combination of both. PTSD is considered by many to be a psychological disorder; however, evidence has shown it to be related to changes in the brain that are linked to a person’s ability to manage stress. People with PTSD have different amounts of specific neurotransmitters in the brain than people without PTSD. Certain medications have been found to be successful in treating PTSD by putting these neurotransmitters back in balance.

Two types of antidepressant medications have been found to be most effective for PTSD—selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). These include:

Sertraline (Zoloft), FDA approved for PTSD
Paroxetine (Paxil), FDA approved for PTSD
Fluoxetine (Prozac), off-label use

Other off-label medications may be helpful, but the evidence is not as strong as for SSRIs and SNRIs. These include:

Nefazodone (Serzone), a serotonin reuptake inhibitor (SRI)
Imipramine (Tofranil), a tricyclic antidepressant (TCA)
Phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI)
Topiramate (Topamax), an anticonvulsant
Minipress (Prazosin), an alpha-adrenergic blocker used for nightmares
(NCPTSD, 2023a; Stein, 2023)

Occupational Therapy

PTSD can be debilitating, with negative impacts in many areas of a person’s life, making it difficult to carry out the normal activities of daily living. Broad areas affected can include health and safety, money management, self-care, transportation, work, school, relationship duties, and community participation. PTSD also affects a person’s executive planning abilities such as time management and concentration or paying attention. Overall reduction of PTSD symptoms has been found to be associated with improvement in these instrumental activities of daily living.

Access to occupational therapy early in the recovery process can prevent loss of routines, habits, and roles. Occupational therapists (OTs) assist in identifying areas of development and functional performance that may have been impacted by stressful and traumatic experiences. OTs are able to enhance functional coping strategies, environmental adaptations, and other aspects that optimize daily functioning. Therapists enable a person with PTSD to experience life more meaningfully and to achieve a more satisfying inclusion within society (AOTA, 2018).

Occupational therapists work with patients who have PTSD across the lifespan and in all phases of recovery. Following a comprehensive and collaborative evaluation to identify the individual’s strengths and barriers to occupational performance and their causes, OTs provide individual and group therapy sessions that are often done in collaboration with other professionals. They may offer treatment options that include self-reflection (for both adults and children), using expressive therapies (such as dance, drawing, or role-playing), and focusing on empowerment and promotion of health and well-being (Edgelow, 2019; Punski, 2023; AOTA, 2018).

OCCUPATIONAL THERAPISTS AS QMHPs

Occupational therapists are considered qualified mental health providers (QMHPs) in many states and Puerto Rico. Occupational therapists in these jurisdictions are also permitted to be classified as QMHPs for purposes of Medicaid reimbursement (Wilburn et al., 2021).

CASE

Mickey

Mickey, an Army veteran, returned home from Iraq, where he drove trucks in combat zones. He was diagnosed with PTSD as a result of this combat experience. Since his return, he has been involved in two minor automobile accidents and received a citation for inattentive driving when he was straddling two lanes on the highway.

His psychiatrist was aware that many returning combat veterans have difficulty returning to civilian driving, and their behaviors often were viewed as “road rage” or thrill-seeking. Increasingly, however, these driving behaviors have been identified as symptoms of either a traumatic brain injury or PTSD. For this reason, the psychiatrist referred Mickey to the North Central Rehabilitation Center for assessment and assistance with driving in a civilian setting.

Carlos, an occupational therapist who is also a certified driving rehabilitation specialist, received the referral and met Mickey for the first time a few days later. At this initial meeting, Mickey learned that the goal of the following sessions would be to conduct a routine assessment and a comprehensive driving evaluation, which was expected to take approximately three hours to complete.

The first part of the evaluation was done in the office. During the initial session, Carlos conducted an examination of Mickey’s physical, visual, and mental abilities required for safe driving, including his reaction time, basic visual acuity, and decision-making.

At the following session, Carlos introduced Mickey to the driving simulator, a technology that provides the illusion of driving an actual vehicle. PTSD response triggers were programmed into two driving scenarios designed to elicit a reaction from the driver. In this instance, nine triggers were included in a simulated a rural/suburban drive and ten triggers included in a city/highway drive. The triggers were combat-related and included disabled vehicles, trash at the side of the road, dead animals, unexpected maneuvers made by other drivers, loud helicopter sounds, and engines backfiring.

In the following session during the simulated driving experience, Carlos recorded the number and types of errors Mickey made as well as the verbal responses he made in reaction to the triggers. Mickey’s most common errors were in lane maintenance and vehicle positioning. Following the session, Carlos and Mickey developed a plan of intervention strategies to help overcome Mickey’s combat mindset and improve the skills that are required for civilian driving.

Physical Therapy

Physical therapists are not involved in the primary treatment of PTSD, but they are heavily involved in the rehabilitation of patients with traumatic brain injury and comorbid PTSD.

Physical therapy can offer various forms of therapeutic exercise, which is a potent technique for helping those with PTSD to fight anxiety and depression. It promotes many changes in the brain, including neural growth, reduced inflammation, and new activity patterns that provide feelings of calm and well-being. It also boosts physical and mental energy, relieves tension and stress, and enhances well-being through the release of endorphins. Exercise can also serve as a much-needed distraction, allowing for time to break out of the cycle of negative thoughts that feed depression. In addition, exercise may also:

Help with sleep problems, allowing for a restful night’s sleep and feeling energized during the day
Give a sense of accomplishment as fitness improves and as goals are achieved
When performed as a shared activity with others, provide additional benefits of social connection

Stress and anxiety can result in tension in the body, and physical therapy can help to reduce or eliminate various types of muscle and joint pain. A physical therapist can evaluate a patient and administer an individualized treatment plan, which may include one of more of the following: strength training; stability, balance, endurance, and/or range of motion exercises; joint mobilizations; dry needling; and/or various types of targeted soft tissue work (such as myofascial release or other manual therapy techniques).

People with PTSD can react strongly to events that remind them of the traumatic experience, and this can lead to a rapid heart rate, chest tightness, shortness of breath and trembling. Breathing exercises can help them get through situations of stress, making it easier to self-manage an episode (Physiopedia, 2023).

Complementary and Integrative Approaches

A growing body of research supports the use of complementary and integrative treatment modalities for PTSD. Clinicians can employ modalities such as mindfulness-based interventions and yoga when treating patients with PTSD.

MINDFULNESS-BASED INTERVENTIONS

Regular mindfulness and meditation can lead to positive changes to neural functioning by helping the learning and memory processes, emotional regulation, and perspective-taking as well as reducing the volume of the right amygdala, which is involved in activating the “fight or flight” response.

Mindfulness practice has two key elements:

Paying attention to and being aware of the present moment
Accepting or being willing to experience thoughts and feelings without judgment

Present-centered awareness and nonjudgmental acceptance may function as indirect exposure to trauma-related stimuli, both internal and external, resulting in a reduction of behavioral avoidance and physiological arousal.

Present-centered awareness diminishes worry and catastrophic thinking, and through this training, the patient is able to gain an understanding that cognitions and beliefs are mental phenomena rather than facts (NCPYSD, 2023b).

YOGA

Yoga involves a combination of physical postures, controlled breathing, meditation, and yogic ethics and philosophy. Yoga has been associated with improvement in depression, anxiety, and stress, with few to no side effects.

With its combination of controlled breathing, relaxation, meditation, and movement, hatha yoga can shift autonomic balance towards the parasympathetic branch of the autonomic nervous system, which reduces the hyperactivation of the amygdala and elevated cortisol levels that often accompany PTSD.

Yoga is effective in easing tense muscles and improving the confidence of those with PTSD to go about daily life with less fear that they are likely to experience triggering episodes.

Hatha yoga is also noted for helping reduce intrusive thoughts and anxiety and for facilitating autonomic balance by increasing heart rate variability (HRV), a measurement between sympathetic and parasympathetic nervous systems. Increased HRV is also associated with improved adaptation to changing environmental stimuli and physiological reactions to stress. Having a balanced HRV is important for emotional self-regulation, giving one the ability to calm oneself down (Park & Slattery, 2021).

Evaluation of Interventions

Identified goals and outcomes serve as a basis for evaluating the effectiveness of interventions for survivors of PTSD. The primary outcome is symptom reduction. Other goals include learning skills to deal with the trauma and restoring self-esteem. This is evaluated using clinician-rated and self-reported measures that address the symptoms the patient presented with, and asks if they have lessened, remained the same, or increased. Other goals to be evaluated include:

Have comorbid medical or psychiatric conditions been prevented or reduced?
Has there been an improvement in coping skills?
Have proper sleep patterns been restored?
Has there been improvement in relationships with others?
Has there been a remission of all symptoms?
Has the patient’s quality of life improved?
Has the patient effectively dealt with disability/functional impairment?
Has the patient returned to work or to active duty?
(Springfield Wellness Center, 2023)

CASE

Alex (continued)

Six months after he began treatment, Alex met with his healthcare provider. In evaluating his treatment, she determined that he has achieved the following goals:

He no longer has thoughts of suicide.
His symptoms have lessened to a great extent, and most days he is functioning well.
He has not reported any signs or symptoms of depression or anxiety.
His sleep has improved, and most nights he sleeps undisturbed for 6 to 7 hours.
He no longer feels angry and has not had any outbursts for over 3 months.
Alex has returned to his wife, and they are now involved in family counseling.
He is able to talk about the loss of his friend and has accepted his role without judgment.
Although he continues to have a drink now and then, he has refrained from abusing alcohol or other substances.
Alex reports he still has memories of the trauma, but he no longer responds physiologically to them. Emotionally he says that he “just feels sad” when he remembers.
Last month he began part-time employment at a local hardware store.

ASSISTING SUPPORT PERSONS

Primary support persons are family members or close friends who play the roles of advocate, confidant, and “cheerleader.” Healthcare workers are often involved with primary support persons, assisting them to help with treatment and cope with the patient’s symptoms as well as to take care of themselves. It is beneficial if support persons are assisted to:

Become educated about PTSD. The more support persons know about the symptoms, effects, and treatment options for PTSD, the better they can understand what the patient is going through and keep things in perspective. When support persons are involved in the treatment process, patients experience a reduction in symptoms and the family environment is improved.
Avoid exerting pressure but be willing to listen. Do not try to force the person with PTSD to talk. Support persons should understand that patients may have difficulty talking about their traumatic experiences, and in some cases, talking can make things worse. Support persons can be encouraged to be ready to listen when the patient is ready to speak.
Be patient. It is important for support persons to understand that the process of recovery takes time and that there are often setbacks; the important thing is to remain positive and be patient.
Recognize that withdrawal is part of the disorder. Often the patient may resist help. When this occurs, support persons should allow “breathing room” and let the patient know they are available when the patient is ready to accept help.
Offer to attend medical appointments. When a support person attends appointments along with the patient, it can increase understanding and assistance with treatment.
Encourage participation. Even though it may be difficult for the patient, it is important that support persons encourage the patient to return to a normal routine that includes socialization and celebrating with friends and family.
Encourage contact with family and friends. A support system can help the person get through difficult changes and stressful times.
Encourage physical activity. Exercise provides both physical and psychological benefits; it is important for health and helps clear the mind.
Make personal health a priority. By eating a healthy diet, getting enough exercise and rest, taking time to be alone or with others involved in activities that are rejuvenating, it is easier for support persons themselves to maintain a positive attitude.
Seek help if needed. Support persons who are having difficulty coping can seek help from family, support groups, or healthcare providers, who may refer them to a counselor or therapist.

(NCPTSD, 2022b)