By Chris Palmer

It is estimated that 50 – 70% of adults in the United States have experienced at least one traumatic event in their lifetime [i] [ii]. Approximately 15% of these people will go on to develop post-traumatic stress disorder, which can be a serious and sometimes disabling illness [iii]. In any given year, about 3.6% of the US population suffers from PTSD [iv]. Symptoms can include recurrent memories of the traumatic event(s), nightmares, trying to avoid things associated with the trauma, feelings of detachment or depressionsleep disturbances, and being easily startled. Sadly, PTSD often goes unrecognized. Only about 50% of people with the disorder are getting treatment [v], and even the people who do get treatment often don’t get appropriate treatment for PTSD – instead, they get treatment for depression, anxiety, and other disorders, and the trauma history goes unrecognized.

Many people with a trauma history don’t want to talk about it. They get intrusive thoughts and nightmares about the trauma, and they want them to stop. They are afraid that talking about it will only make it worse. Sometimes, they’re afraid that talking about it will only make them lose control of their emotions – start crying or get angry in front of someone – so they avoid the topic. They are trying desperately to put it in the past and keep it there, but they just don’t know how to do that.

Sometimes being traumatized takes a toll on a person’s self-esteem, and some victims of abuse or trauma engage in dangerous behaviors. Suicidalthoughts and suicide attempts can be common among trauma survivors, and some engage in purposeful self-injury – things like cutting or burning themselves in order to relieve emotional pain. This can be especially common in those who were abused as children. Alcohol and drug abuse can also be common in trauma survivors, with estimates of 50-66% of people with PTSD having problems with addiction [vi]. Some speculate that this is a way to numb the pain, but nonetheless, it ends up posing risks to the person’s health and safety. 

Up until recently, a paradigm for working with trauma survivors was “safety first,” meaning that  survivors had to be able to refrain from reckless use of alcohol and drugs and refrain from suicide attempts and self-injury before they were allowed to deal with the trauma. There is no question that talking about trauma is stressful. The concern was that facing the trauma – talking about it, or doing the evidence-based work of Prolonged Exposure Therapyfor PTSD – would  make the suicidality or substance abuse even worse.

Clinicians didn’t want to harm their patients. “Seal, don’t peel” was a common phrase heard on the specialty PTSD unit in which I worked years ago. It meant focus on functioning and safety in the here and now and “seal” in those memories—don’t “peel” away the outer defenses and allow them to come out. This all made sense at the time, and it’s still a paradigm practiced by many clinicians to this day.

The problem is that some people never got to the point of being safe enough to talk about the trauma, and so it never got talked about. Victims were told over and over that it wasn’t safe to talk about until they could maintain their safety. But this risked sending another kind of message: “You’re not strong enough to talk about it.” “The trauma is too powerful and awful for you to deal with.” Many of these people still aren’t better to this day. They need to face their trauma.article continues after advertisement

Prolonged exposure (PE) therapy exposes people to their traumatic memories over and over again until those memories begin to lose their power, and simply become memories of bad things that happened, as opposed to overwhelming thoughts and feelings that victims often try to avoid. This treatment can be done is as few as 6-12 sessions. The therapist guides the client to talk about details of the traumatic event(s), and this part of the session is often recorded. The therapist also teaches skills that will allow the client to remain safe and present in his/her environment. The client is then asked to listen to the recording over and over again until the next session, in order to decrease, or extinguish, the fear response that the memories trigger.

Research by Denise Hien and colleagues shows that people with PTSD and active substance abuse can engage in prolonged exposure therapy for PTSD and get better, without increasing their use of substances. [vii] Not only was combination treatment for both PTSD and substance use just as safe as substance use treatment alone, but the PTSD symptoms improved much more in the combined treatment group.

Martin Bohus in Germany is working with women who are diagnosed with both borderline personality disorder (BPD) and PTSD who are frequently engaging in suicidal acts or self injury. He did a study of 74 women and assigned half of them to a residential treatment unit where they received DBT for PTSD, a combination treatment of dialectical behavior therapy (DBT)—commonly used for BPD—and exposure therapy for their PTSD. The other half received treatment as usual. [viii] He did not exclude women who were actively self-harming. At the end of the study, women who received the PTSD treatment had significantly more improvement in their PTSD symptoms than the control group, and they did not show an increase in self-harming behaviors.

Bohus shared some of the women’s reflections that after years of running from traumatic memories, finally confronting them brought much relief.  Some remarked that they wished they had been offered this treatment years earlier, because they suffered unnecessarily for all of those years and can’t get them back now. 


[i]Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27

[i]Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27

[ii] Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of traumatic stress, 26(5), 537-47.

[iii] National Center for PTSD, retrieved from

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  1. Thanks for this Erin. PE is similar to one of the approaches I take with PTSD and other trauma based problems. It’s important to establish a reliable means for the patient to return to present-centred awareness before PE starts. I would be interested in your thoughts on how EMDR and PE compare in your experience. Hope you’re well, Stephen

    • Hi Stephen

      I would not have been capable of engaging with PE due to the extremeity of my trauma. I would just have dissociated immediately if I were to have engaged in exposure. I suffer from severe flashbacks which are usually followed by switching to an alter. (I have Dissociative Identity Disorder due to my abuse). EMDR works best for me. Somehow the trauma is brought up in a controlled way by the rhythmic movement of the fingers and the psychotherapist is able to process the particular trauma that way. I do not remember what happens under EMDR. She tells me afterwards and we talk about it and this happens over several sessions until it is fully processed. It is a very successful form of therapy for me. It does not re-traumatise me. Exposure therapy would re-tramatise me.

      Hope all’s well.


      • Thank yoy for clarifying that Erin. I’m glad it’s working for you and hope that it brings you real peace. Take care

I would love to hear from you so please leave a comment. All feedback is much appreciated. Thank you. Erin

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