Mental Health

The Center for Treatment and Study of Anxiety (CTSA) at the University of Pennsylvania is at the forefront in research for the treatment of post traumatic stress disorder (PTSD). Prolonged Exposure (PE), formulated by pioneering researcher and clinician Dr. Edna Foa, is now a widely used treatment protocol in the United States and throughout the world in treating wide-ranging incidence of PTSD. This model has been adopted in the U.S. Armed Forces as a treatment option for returning veterans, and the model is widely applicable to people suffering from PTSD due to many different traumatic events.

Many of our rehab patients enter treatment as a result of trauma. Practitioners can play a vital role in educating themselves about PTSD, recognizing the signs and supporting patients to seek the appropriate treatment as needed.

What is PTSD?

The world is now a complex place with more frequent threats to safety, both natural disasters - flood, fire, hurricanes - and human caused events - accidents, assault, increasing incidence of public violence.

PTSD is a severe anxiety reaction that can develop right after a traumatic event, within 3 to 6 months of the event or, in some situations, several years after the incident has passed. But Dr. Elna Yadin, PTSD supervisor of the CTSA, explains that "it is not a given after trauma. Some people who may have very good social support, for example, may adapt and be able to adjust. For the people that don't adapt, it is because the natural recovery process has not occurred."

Signs of PTSD

The hallmark of PTSD, unlike a specific phobia (e.g., fear of dogs) or an anxiety with a specific trigger (e.g., fear of falling in the winter), is the inability to let go of the experience. Common symptoms can include:

• Re-experiencing: a repeated re-living of the event, with flashbacks or nightmares, which inhibits daily functioning;

• Avoidance: fear-driven behaviors that slowly narrow one's life - dating, looking for work, going out in public, etc.;

• Emotional numbing: a process of emotional detachment that can manifest in loss of interest in goals or social connections; and

• Arousal: exaggerated responses or a chronic sense of hypervigilence.

Yadin explains, "With PTSD there is an intrusive quality - you are trying hard to push away the memories, but you can't. Some people may not recognize that what they are experiencing is PTSD. They may feel it's normal to be fearful and think that it will right itself, or that they deserve to feel this way. PTSD does not right itself; patients need to be encouraged to seek treatment."

Prolonged Exposure

At CTSA, prolonged exposure (PE) is an evidence-based 9-12-week cognitive-behavioral weekly treatment (sessions 90-120 minutes) targeted to assist patients with processing traumatic experiences so the memory of the trauma does not continue to re-traumatize them. PE treatment interventions generally have several components:

Psycho-education on trauma: "In PE we do a lot of education on what is a traumatic reaction. There is often a misconception that PE is a mechanical process; it's much deeper than that. PE is process of new learning, that new behaviors help the healing process," says Yadin.

Dr. Elna Yadin is clinic supervisor of the Center for Treatment and Study of Anxiety at the University of Pennsylvania in Philadephia.

Talking about the event: Yadin clarifies that processing the trauma does mean one has to go back to the physical place where he experienced it or confront the person or situation.

"PE helps a patient think about the incident and learn that thinking about it is not the same as re-living or re-experiencing it, and to not be so easily beset with the same fear or degree of physical arousal," she says.

"In other words, we can go back to that memory, but from the present - a safe place. We may have sadness or grief about the memory, but we are not re-living it in the present," she explained.

Coping with arousal: Through a variety of relaxation and cognitive techniques (identifying dysfunctional beliefs), coping skills training, building a mind-body connection, stress management and medication interventions (SSRIs or anti-anxiety medications), patients learn how to tolerate distressing affects and learn to de-escalate from the habituated reactions that a traumatic memory may generate.

Building mastery: In-vivo exposure is another aspect of PE. In this approach, a therapist would help a patient come up with a list of activities, both mastery activities (such as going shopping) and pleasure activities (speaking with a friend by phone) to begin the process of re-engaging with life.

"We look for those functional tasks that they have been avoiding - going to the supermarket, going to a family gathering, detachment from social roles, avoiding parent/teacher conferences," says Yadin. "Also, we put activities on the list that will activate them behaviorally - going to the gym, calling a friend. The key is to find what steps feel safe. We teach them that it is the patient and the therapist against the disorder, and we find that patients come back and say, 'It's not as hard as I thought it would be,'" says Yadin.

Meaning-making: Traumatic experiences assault the mind-body and also a person's place in the world on an existential level. Yadin explains that meaning making is a critical part of PE.

"In PTSD counseling we help patients acknowledge what happened, put it in the past, and gain perspective on the situation," she says. "We don't just revisit the memory; we process its meaning. What does it tell them about life? What does it mean to survive? What have they learned about people? Some patients come to value the importance of each day. Sometimes they acknowledge that there is evil in the world - and [discover] how to live with it, co-exist with it and not let it be all of our life."

Post Traumatic Life

Although the program at CTSA is a structured, time-limited program, the adjustment and recovery to post traumatic life is a personal and highly individualistic one and is also dependent on a variety of personal characteristics - resiliency, values, beliefs and social support.

Yadin advised that it is critical to educate family members about PTSD. "Patience is really important when your loved one is recovering," she said. "They will need a lot of support and energy to recover; they will also need the time and space to practice the exercises. You would want to treat this the same way as a physical injury."

Yadin added that recovery from PTSD does not mean that a patient may not look back at a traumatic event without complicated feelings. "We have good memories, neutral memories and bad memories," she said. "The goal is to not allow the trauma to inform all your decisions in the present or generalize it to all situations - thoughts such as 'all males cannot be trusted' or 'all hospital staff are uncaring.'"

The treatment team at CTSA is a collective group with hope in the PE treatment model. "It is nourishing for us to watch patients get their lives back, return to school, switch jobs, and the best validation. When some of our patients finish their treatment, they volunteer to be of support to another patient who has just started the process of recovering from PTSD." 

Dr. Reji Mathew is a psychotherapist/clinical instructor at New York University. She is a disability advocate and freelance writer. The main focus of her work is to promote coping skills education for persons with chronic illness and disability. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via e-mail at her website: rejimathewwriter.com.