New Study Explores How Trauma-Focused Psychotherapy Works

Trauma-focused psychotherapy is widely accepted as the best treatment for post-traumatic stress disorder (PTSD), but due to a lack of data, it’s not entirely clear how it changes the brain to aid the recovery process.

A new study, published recently in Biological Psychiatry, may help shed some light on this. The researchers used neuroimaging to get a clearer look at exactly how psychotherapy changes the areas of the brain responsible for generating emotional responses to threats.

Functional magnetic resonance imaging (fMRI) scans helped the researchers identify how brain networks communicate with one another before and after trauma-focused psychotherapy treatment. They paid particular attention to the degree of communication or "traffic" (known as functional connectivity) between the parts of the brain that regulate emotion and the parts that control logic and thinking.

The researchers discovered that there was a reduction in traffic between these brain regions among patients who had undergone trauma-focused psychotherapy.

Plus, greater connectivity changes were associated with bigger symptom reductions, which indicates that the restructuring of brain communication may be a unique feature of PTSD recovery. The hope is that these findings will help develop new and better treatments for people with PTSD.

What Is Trauma-Focused Psychotherapy?

Trauma-focused psychotherapy is an umbrella term, which includes trauma-focused cognitive behavioral therapy (CBT) and eye movement desensitization reprogramming (EMDR). Trauma-focused CBT allows individuals to identify their anxiety pattern and combat this by reframing thinking and partaking in healthy behaviors, while EMDR couples eye movements with traumatic memories in an effort to diminish both the intensity and frequency of painful thoughts and images, explains Leela R. Magavi, MD, psychiatrist and regional medical director for California-based Community Psychiatry.

Another type of trauma-focused psychotherapy is exposure-based psychotherapy, which was the focus of the new study.

"Exposure-based psychotherapy helps trauma survivors decrease their tendency to avoid places, thoughts, feelings, and memories," Dr. Magavi says. "Individuals may imagine, recreate, or visit feared places or thoughts with the support of their therapist."

This type of therapy allows individuals to overcome their anxiety by safely exposing themselves to perceived fears. "Individuals who are traumatized may repress and suppress their emotions and memories for years at a time, which can adversely affect their cognition, self-esteem, and ability to engage in meaningful relationships," Dr. Magavi explains.

Commonly, mental health professionals recommend or use trauma-focused CBT to target PTSD symptoms. In Dr. Magavi's opinion, exposure-based psychotherapy can complement trauma-focused CBT, or follow it.

"Some individuals experience significant flashbacks when they engage in exposure therapy, and if they lack coping skills, which they would normally learn with trauma-focused CBT, this could lead to panic attacks and further avoidance," Dr. Magavi explains. "However, for some individuals, exposure therapy is warranted to bring out hidden memories."

Dr. Magavi says individuals can also "inoculate themselves" as much as possible against grief with exposure therapy. She advises patients to write down statements suggesting that their biggest fear will manifest, or record their own voice making these statements.

"Reading or listening to these statements repetitively could help strengthen individuals and increase resilience, which could consequently improve emotional response to grief," she explains. She also advises pairing exposure therapy with mindfulness activities and various coping skills.

"I explain to my patients that desensitization is a normal human phenomenon; after enduring something so many times, human beings become less likely to respond emotionally or to experience feelings of shock and despair," Dr. Magavi adds. "For example, I have friends who are oncologists and palliative care physicians who lose patients all the time. Every loss hurts, but over time, for most individuals, the response to pain diminishes."

It's important to recognize that everybody processes pain differently. "Individuals who are more thinking than feeling with regard to personality type are more likely to compartmentalize painful events such as death," Dr. Magavi says. "In this time of pain, many patients ruminate and question themselves and their moral compasses; this is what tragedy and trauma does to us human beings. We begin to doubt others and ourselves. We lose trust in the world and the future, and perhaps, experience existential and nihilistic thoughts, which can be significantly distressing over time."

How Do You Know If You've Been Through Trauma?

There are many ways in which people experience trauma. "Frankly, anyone who is struggling with unconscious reactions, mood dysregulation, unwanted or uncontrollable behaviors, would be helped with trauma-focused psychotherapy as they have probably experienced trauma in their lives," says psychiatrist and author Gayani DeSilva, MD. "Most, if not all, of our unconscious behaviors are due to defense mechanisms that have arisen because of our need to protect ourselves from trauma or the perceived threat of trauma (which I believe is traumatic also)."  

You can experience trauma at any age, of course, but therapy is different in general for adults and children, Dr. DeSilva explains—and a therapist needs to take into account the client's age, and well as their developmental stage and therapeutic needs, before starting therapy.

"Children are still developing in their ability to think, simply because of their cognitive development," Dr. DeSilva explains. "Plus, trauma additionally hinders brain development. These factors must be taken into account."

While adults' brains have essentially developed, they may have some cognitive issues directly due to the experience of trauma, depending on when it occurred. "An astute and skilled trauma-focused therapist will be able to assess their client's needs and adjust accordingly to understand and help their client heal," Dr. DeSilva says. "Young children do well with play therapy and sand therapy, while adults mostly engage in a talk-based therapy. Both teenagers and adults do well with EMDR therapy."