PTSD treatment

TraumaRecoveryReview8 Keys to Safe Trauma Recovery: Take-Charge Strategies to Empower Your Healing.
Babette Rothschild. 2010. W.W. Norton, New York.  174 pages.

Living with persisting trauma memories is tough. Involuntarily triggered by events, or people, or places, or thoughts, or feelings . . . well, anything can be a trigger, actually . . . these intrusive, searing memories will turn one’s life inside out. Recovery from traumatic experience is tough as well, and achieving a sense of safety is essential to successful recovery. Rothschild’s brief, personable, and accessible book directly targets safe, successful recovery in a way that compels and convinces the reader. If trauma memories impact your life or that of someone you know or treat in a healthcare setting, you need this book. Because of the importance of this material, and because I want this to be a bit more than a mere review, I will be discussing this book in a two-part post. My format is both book review and a discussion of key concepts central to Rothschild’s book in the context of my own clinical experience.

People in trauma recovery can change the course of their recovery

Rothschild has herself recovered from posttraumatic stress disorder (PTSD), so her instructions will have special relevance to trauma victims—she’s “been there.” Her special focus is reducing the trauma of recovery itself. For many reasons, trauma psychotherapy too often is more painful than it has to be. As a therapist, I lay significant accountability for this at the feet of my peers. Many are still learning how to deal effectively with psychological trauma. Others believe they are doing well, but are using treatment models which not only are not research-validated but also are known not to be effective—such as group therapy, or old-style talk therapy. The idea of evidence-based psychotherapy has yet to reach all corners of the professional trauma-treatment world, with the result that therapy intended to resolve the effects of traumatic experience results in needless emotional, social, and financial pain more often than it should.

Personally, I deeply regret that many in my profession remain significantly uninformed about psychological trauma phenomena. However, there is little doubt that the situation is improving—at least for civilians. In the military? Well, take a number, then take your prescription to be filled, then take your pills . . . and I’m sorry to report that this is simply not a validated treatment for PTSD on any known planet. I’ll be blunt: our military health system needs more money from Congress, then they need to prioritize training people to properly treat trauma.

Regardless of your situation, Rothschild proposes that your life in relation to trauma memories can be dramatically improved by focusing on just eight specific skills. This proposition is not likely to overwhelm. What’s utterly wonderful is the eight skills she has chosen: not only are they highly varied, but each of them, in her account, appears to offer such benefit as to be essential. In truth, we ALL need these skills—that was my thought after examining this book. However, she emphasizes that for some people certain skills may be much more useful than others. Learning how YOU work and responding to your personal needs is the point, here.

There is a secret promise in this book: If you’re in therapy, your therapist’s skills are not something you can control, but YOU can get your own skills in better shape, and if you do there’s every reason to expect that this will seriously improve your chances of success in therapy. A simple idea, with the promise of an improved chance of a life-changing outcome. Want to know more? Keep reading.

1: Self-awareness (mindfulness)

I ask you to consider something simple, yet profound: To navigate any difficult terrain, you must be aware. You cannot respond to what you do not see. Because therapy is about YOU, that’s where your awareness must focus. While there has been a growing interest in mindfulness meditation as a practice of great relevance to psychotherapy, the fundamental skills needed by those in recovery from trauma don’t rise to the level of formal meditation. Rothschild asks us simply to develop body-awareness, feelings-awareness, and thought-awareness.

Body-awareness is basic. From the beginning, Rothschild emphasizes that we are not all the same, so it should make sense that what happens in one person’s body as a result of trauma may differ in important ways from the responses seen in another person. What does not differ is the simple fact that if you pay attention to how your body changes in different situations, you can better manage your life as you recover. Zombies inhabit dead bodies, but we really should not!

However, it may be more useful to you to focus on your mood (your overall level of energy and pleasure in life). Closely related to this are your feelings—which will change more dramatically and quickly than your mood. Both mood and feelings are affected by a wide range of things, and how this all connects for you can be important knowledge in your recovery

Thought-awareness is given little attention in her excursion into mindfulness. It receives much more in the book’s final section, as well as the section on flashbacks. For now, the notion is to notice where your thinking takes you—what images arise in your mind. From that content will arise feelings. If you don’t like the feelings, track them back to the thoughts and images which brought them about.

2: Time and place: Where are you? WHEN are you?

Trauma memories distract. As a result, Rothschild reminds us, you will repeatedly lose your orientation to place and time. The “posttraumatic” part of PTSD points to the fact that the trauma is over. You survived. And if you’re like most trauma survivors you’ll forget this again and again! As I routinely point out to my clients, one problem is that since all feelings are real, when you are having feelings in relation to triggered memories, you ARE in a real moment. It’s confusing: the memory is of THEN, but the feelings are NOW. Pretty tricky, yes?

To shift your focus to where and when you really are—here and now, will likely require persistent effort. You need reminders and repeated correction. I suggest that you get other people to assist you with this. You can also leave reminders stuck on your refrigerator. There a plenty of other simple things you can do, as well. Rothschild’s point is that recapturing your life after trauma means knowing where you actually are, and this is a question that can, and should, be addressed now.

It is assumed, in dealing with this issue, that the environment in which your trauma occurred is gone. It may not be. Rothschild recognizes this special problem, but addresses it in the next section of the book (pp. 48–48).  However, let me say plainly at this point: if you are still in a traumatizing situation (exposure to domestic violence threats is one of the most common such situations), your therapy will be especially likely to fail. You must come in out of the rain if you are to dry off. If you cannot, this next section, while important to all, will be especially relevant for you.

3: Focus on managing symptoms first, then consider the option of processing trauma memories

To fully recover from traumatic events, research has shown that confronting the memories of the events is essential. It is a realistic fact, however, that this is not possible for everyone, or at least not immediately possible. This is especially true for those challenged by Complex-PTSD or Dissociative Identity Disorder (DID). It can also be especially true for those whose PTSD began in childhood. The decision about whether or not to go forward with trauma memory processing is NOT an immediate decision in therapy—although some clients and therapists are unwisely in a hurry to get to that part of therapy.

As do a great many trauma therapists, Rothschild embraces a model of trauma treatment that is not new at all, and that means that it’s had a lot of testing on the front lines of trauma treatment. It requires that (a) good management of symptoms be achieved before going on to (b) confront trauma memory, and says that the final stage is (c) integration of your life into the larger world. What needs to be understood is that “good management of symptoms” takes exactly as long as it takes, and not less. For some people, this will be years. For others, 2–3 weeks will be sufficient. You must simply be honest with yourself about your situation, and not try to grow roses in three days.

As Rothschild puts it (p. 43), “the first goal of trauma recovery must be to improve your quality of life on a daily basis.” In focusing initially on symptom management and reduction, you will be working directly to achieve this goal. Know that improving your quality of life is a good and attainable goal for almost everyone. Furthermore, she suggests that the commonly accepted last stage of trauma therapy—re-integration back into the larger world—can be addressed as part of the goal of improving symptom management. This is especially relevant for those with any ongoing risk of trauma, but the real question is whether you ought to move on to the stage of trauma memory processing, and Rothschild’s book is particularly strong in its addressing of this question (pp. 48–56). The key idea is that it should be YOUR decision, made when you feel ready, if ever.

Rothschild’s final comment is worth emphasizing: the present is always more important than the past. If you have trauma symptoms but no memories (which occurs, for example, with trauma stored in implicit-memory, a topic she doesn’t take up), don’t go on fishing expeditions in your mind, and don’t let anyone lead you on one either. Focus instead on getting your present life to work.

4: Flashback management: You can do it

Intrusive noxious memories which provoke real and disturbing feelings in the present—these are flashbacks, and they are the cardinal symptom of posttraumatic stress and of PTSD. Trying to avoid them is also a key symptom of PTSD, and for good reason. Rothschild wants you to improve your skills both at avoiding them and at shutting them down when they occur – an excellent idea, and quite doable for many people.

We all talk to ourselves internally—part of this is imagined dialogs and part is our thoughts. She urges that you pay attention to your thought-talk. Often, for traumatized people, this talk does not reflect current reality. If you notice your thought-language, have a chance to make some changes. There’s a large difference between “I’m in danger of being assaulted again!” and “I was assaulted, in the past, and I still feel unsafe, but no one here is a real threat to me!” Present reality, and its essential safety, is only present in the second version.

You can make these corrections repeatedly in your flashback moments, and over time they will become more and more automatic. You need to do this because trauma causes impaired function in our middle brain—the part that creates new learning and a sense of present time. So, remind yourself, “I’m having a memory!” In this way, you can accomplish by intention what your brain is no longer able to do automatically.

A key part of this involves getting NEW sensory information into your brain: awareness of where you are NOW, and that things are NOT like they were in former times. Rothschild is right on target in stressing that traumatized people repeatedly get snatched out of present time by their symptoms. Fight back against this in the ways she suggests and you’ll see a reduction in your symptoms. A simple proposition with a major effect.

[Part 2 of this review will address dealing with forgiveness of self and with shame; avoiding overwhelm by thinking small; improving mental resilience by exercising your body; and improving your mood and feelings by changing your thinking. I will then offer a glimpse at research supporting the value of these skills.]

[revised 2013.11.20]

GuidelinesResearch on traumatic stress disorders grows more voluminous and complex almost daily. While this is a very good thing, it does present an ongoing problem for treatment professionals. How are they to confidently summarize current knowledge so as to be assured of providing state-of-the-art care? A parallel problem exists for consumers of psychotherapy services: how are they to know that the treatment they are getting is the best available?

Treatment guideline summary recommendations, traditionally issued from time to time by major governmental agencies and professional organizations, address this need well[1]. Now we have a new and important guideline publication to guide professionals and consumers alike—the Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder, published late this summer by the Australian Centre for Posttraumatic Mental Health (ACPMH), a non-profit corporation originally devoted to trauma issues of military veterans but now also including the civilian population in their scope of concern.


An “update, revision and expansion of the original Guidelines” (ACPHC, 2013a, p. 2) published in 2007, the most significant change in this new edition of the Guidelines is the inclusion of recommendations for children and adolescents. Conveniently, it is published in four separate documents: a primary detailed statement of the Guidelines (ACPHC, 2013a), an extensive and lengthy set of appendices (ACPHC, 2013b), a special summary statement focused on children (ACPHC, 2013d), and an overall summary statement (ACPHC, 2013c). All are available for download in PDF format, which may be easily subjected to full-text search using common software. (See References below for details and download links.)

These non-prescriptive (ACPHC, 3013a, p. 2) Guidelines are derived from a systematic review of relevant literature, focusing on 24 specific research questions given to reviewers (ACPHC, 2013b, pp. 25-26). Recommendations are qualified by a grading system developed by the Australian National Health and Medical Research Council  (ACPHC, 3013a, p. 2):

  • Grade A: Available evidence can be trusted to guide practice.
  • Grade B: Available evidence can be trusted to guide practice in most situations.
  • Grade C: Available evidence provides some support for recommendation(s) but care should be taken in its application.
  • Grade D: Available evidence is weak and recommendation(s) must be applied with caution.

In cases where there was no research evidence for a recommendation, Consensus Points (CP) were assigned, based on the consensus opinion of the reviewers if such evidence had been expected, and Good Practice Points (GPP) in cases where no such evidence was expected to exist and none was looked for.

Treatment recommendations

Significantly stronger evidence was found for recommendations for adults than for children. In addition, it is important to realize that “posttraumatic mental health problems manifest in many different ways, and that ASD and PTSD are only two of the issues encountered by health professionals when helping individuals affected by traumatic events” (ACPHC, 2013c, p. 4).

Overall recommendations may be succinctly summarized: Do not medicate potentially traumatized children; do not use “psychological debriefing” at all. For adults, medication should not be used in preference to psychotherapy; in those cases where medication is indicated, the preferred choice is selective serotonin reuptake inhibitor (SSRI) antidepressants.

The single strongest recommendation (Grade A) is for trauma-focused cognitive behavioral therapy (TF-CBT) or eye-movement desensitization and reprocessing (EMDR), with TF-CBT alone being the recommendation for children.

Psychological interventions for adults

  1. Individuals exposed to potentially traumatizing events should not be offered a psychological “de-briefing” intervention [Grade B].
  2. Individuals who are displaying symptoms consistent with Acute Stress Disorder (ASD) or Posttraumatic Stress Disorder (PTSD) in the four weeks after exposure to potentially traumatizing events should be considered for individual TF-CBT, if this is indicated by a thorough clinical assessment [Grade C].
  3. Individuals diagnosed with PTSD should be given TF-CBT or EMDR [Grade A] (ACPMH, 2013a, p. 3).

Pharmacological interventions for adults

  1. Drug treatments should not be used as a blanket intervention for groups of people exposed to potentially traumatizing events [Grade D].
  2. Drug treatments should not be routinely used for individuals with ASD and early PTSD (within first 4 weeks of symptom emergence) [Grade C].
  3. For PTSD, drug treatments should not be used as a first treatment, in preference to TF-CBT pr EMDR [Grade B].
  4. For PTSD, when drug treatments are considered, the first choice should be SSRI antidepressants [Grade C].
  5. SSRI antidepressants should be considered in situations where an individual has not benefited from trauma focused psychological therapy, or has pre-existing conditions (details are given) which interfere with participation in such therapy [GPP] (ACPMH, 2013a, p. 4).

Psychological interventions for children and adolescents

  1. Children exposed to a potentially traumatic event should not be offered “psychological debriefing” [Grade B].
  2. Children of at least school age who have PTSD should be considered for developmentally appropriate TF-CBT [Grade C].
  3. Children exposed to a potentially traumatic event, with symptoms of PTSD, when exposed to the same event, should be considered for a school-based TF-CBT intervention to reduce symptoms [Grade C] (ACPMH, 2013a, p. 4).

Pharmacological interventions for children and adolescents

  1. Pharmacotherapy should not be considered as a blanket therapy for groups of children exposed to a potentially traumatic event [Grade D].
  2. Pharmacotherapy should not be given preference over TF-CBT for children with PTSD [Grade D].
  3. Pharmacotherapy should not be routinely used as an adjunct to TF-CBT for children with PTSD [Grade D]  (ACPMH, 2013a, p. 4).

Development Process and publication formats

The Guidelines are presented very attractively at the ACPMH website, hosted by the University of Melbourne. Four groups are addressed at the website—children, adolescents, adults, and mental health professionals. This largely reflects the focus of the Guidelines (ACPHC, 2013a, p. 1):

“The Guidelines have been designed to be used by: a) the range of general and mental health practitioners planning and providing treatment across clinical settings; b) people affected by trauma making decisions about their treatment; and c) funding bodies making service purchasing decisions.”

The quickest access to this large and significant work is the Guidelines Summary (ACPHC, 2013c). The main Guideline statement (ACPHC, 2013a) will be the focus of professionals, and some consumers; it’s well organized and easy to read into. For children and professionals, there is a brief summary “practitioner guide” statement (ACPHC, 2013d). Finally, for scholars, researchers, and those who wish to examine the basis for these guidelines, there is a separately published very substantial set of Appendices.

Of likely interest to professionals, Appendix 2 offers documentation of the process by which the Guidelines were developed. Key concepts relevant to this process are defined. Of particular interest is this statement concerning limitations of this effort:

“The Guidelines are principally limited to forms of distress consistent with the constructs of ASD and PTSD. They do not seek to address the full range of possible responses to traumatic exposure, including those known as Complex PTSD or Disorders of Extreme Stress Not Otherwise Specified (DESNOS). The original Guidelines were limited to adults; however, the revised version will also include children and adolescents.” (p. 4)

Then, concerning the question of who should actually use the Guidelines:

“There is insufficient evidence available in either the research or clinical practice literature to allow an authoritative specification of competencies required for particular interventions, and so the individual practitioner should be guided by his or her own professional code of conduct with regard to this issue.” (p. 5)

As it was a specific charge given to the Working Group that their recommendations be based on “a systematic review of the literature” (p. 13), the overwhelming bulk of the Appendices document is devoted to Appendix 3, which is the “Evidence Report” commissioned by the ACPMH and undertaken by the Adelaide Health Technology Assessment group, University of Adelaide. Addressed are ASD and PTSD, people “exposed to trauma”, school based interventions, psychological interventions, psychopharmacology, exercise and physical therapies, combined interventions, comorbidities, and “child-specific questions”. Appendix 3 has also several potentially useful sub-appendices. Appendix 5 (p. 592ff) is a complete specification of the DSM-5 Diagnostic Criteria for PTSD.


This is clearly a serious effort to guide treatment practices. That it is NOT focused solely on a military population is significant, given that, contrary to general public perception, most people with traumatic stress disorders are civilians. The explicitness of recommendations provides well-focused guidance for professionals concerned with providing best-practices care. The extensive and thoroughly documented accounting of the literature review upon which the recommendations are based is a model of transparency well-articulated thoughtfulness.

I find this 2-year large-scale effort fully deserving of respect by both professionals and the general services-consuming population. A large number of contributors, specialists in their fields working closely with each other and with many check and balances, produced what is offered here. In all regards, this is a definitive statement of best-practices treatment for traumatic stress disorders (ASD and PTSD) at this point in time.


1. I am assembling a fairly complete list of such guidelines, and expect to have it completed soon after this present review is published.


Australian Centre for Posttraumatic Mental Health. Acute Stress Disorder & Posttraumatic Stress Disorder in Children & Adolescents: A Practitioner’s Guide to Treatment. Melbourne, Victoria, Australia: ACPMH, 2013. (7 pp) [download:]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder. Melbourne, Victoria, Australia: ACPMH, 2013a. (177 pp) [download:]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder – Appendices. Melbourne, Victoria, Australia: ACPMH, 2013b. (596 pp) [download:]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder: Guidelines Summary. Melbourne, Victoria, Australia: ACPMH, 2013c. (50 pp) [download:]

—. Australian Guidelines for the Treatment of Adults with Acute Stress Disorder & Posttraumatic Stress Disorder. Melbourne, Victoria, Australia: ACPMH, 2007.  Downloaded 2013.03.20 from