Helping trauma survivors share their stories is intimidating, but not complicated

Working with patients as they share the worst story in their history is an honor bestowed only to therapists who have earned the trust of their patients. With this honor comes an obligation to ensure that we are using the best tools available in our field. Cognitive behavioral therapy has the strongest evidence-base for helping patients with posttraumatic stress disorder (PTSD), yet therapists commonly struggle with how to bring art and humanity to the science of CBT.

Few therapy experiences are more harrowing than sitting with a patient who is about to close their eyes and trust you to complete their first imaginal exposure. Imaginal exposure requires a tremendous amount of courage – to talk through the worst event that ever happened to a person feels almost unnatural at first, and to witness that description can be intimidating for therapists. The process of coaching a patient through imaginal exposure for the first time can be so aversive to therapists that most never get that far, or they might begin the process but cease it prematurely. However, to experience the transformational healing that emerges when a patient shares their story “seals the deal” for many therapists that CBT works and becomes the treatment of choice for patients with PTSD. The gap between considering imaginal exposure with a patient and witnessing healing can become a chasm for some therapists without objective consultation.

In consultation for CBT for PTSD, the focus is on optimizing the approach rather than teaching the therapist new skills. In fact, knowledge deficits are rarely an explanation for why a therapist pivots away from imaginal exposure practice. Experiential deficits play a more critical role. In consultation, therapists can have genuine and raw conversations about their fears in delivering CBT for PTSD. For instance, some therapists worry that they are pushing their clients too fast (it’s usually the opposite). Other therapists are reluctant to start CBT for PTSD because it never “feels like the right time.” In consultation, therapists can get objective feedback from an expert to help allay concerns and overcome barriers to implementing CBT for PTSD.

In my book, Optimizing CBT for PTSD, each of the critical components of the therapy are discussed with a goal of demystifying the process. I have provided consultation on CBT for PTSD for many years, and in so doing have noticed common patterns where clinicians can use more support. Nothing can replace the value of consultation with a human for enhancing confidence in delivering a therapy, but my hope is that this book will serve as a valuable supplement to reduce barriers to implementation of CBT for PTSD. In it, I discuss how to serve as an advocate for patients in their journey of healing from trauma and PTSD, all while delivering gold-standard therapeutic practices. Furthermore, Optimizing CBT for PTSD discusses common challenges that can derail CBT for PTSD, such as intersections with the legal system, navigating partner violence, and managing suicide risk in the context of trauma-focused treatment, all with a goal of helping therapists to stay true to the active ingredients of CBT while attending to the needs of the human sitting across from them in therapy.

Working with survivors of trauma in therapy is an extremely meaningful and rewarding profession. The most reinforcing aspect of delivering CBT for PTSD is witnessing patients heal on their own terms and grow their lives in directions of their choosing. Whether a provider is new to CBT for PTSD or desiring a refresh on the topic, case consultation and continued education can offer valuable perspectives to optimize patient outcomes.

Foa, Edna B., McLean, Carmen P., Brown Lily A., Zang, Yinyin, Rosenfield, David, Zandberg, Laurie J., Ealey, Wayne, Hanson, Brenda S., Hunter, Lora Rose, Lillard, Ivett J., Patterson, Thomas J., Rosado, Julio, Scott, Valerie, Weber, Charles, Wise, Joseph E., Zamora, Charles D., Mintz, Jim, Young-McCaughan, Stacey, Peterson Alan L. for the STRONG STAR Consortium: The effects of a prolonged exposure workshop with and without consultation on provider and patient outcomes: a randomized implementation trial. Implement Science, 15(1):59.