Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT)

We all know our brains are complex – our thought processes, emotions and behaviours are all delicately interwoven together. When you have PTSD however, a serious event or prolonged exposure to stress has left you with extremely sensitive or misaligned connections between these brain functions. This can mean that your thoughts, emotions and behaviours can be very hard to control when you have PTSD.

This is why a technique called Cognitive Behavioural Therapy (also called CBT) is such a widespread way to treat PTSD (read more about it’s effectiveness further down the page). It also has a strong track record for treating Complex Post-Traumatic Stress (C-PTSD) too. You can read some case studies of people who’ve been through successful CBT treatment for PTSD and C-PTSD here

So, what does Cognitive Behavioural Therapy mean?

‘Cognition’ is the word that sums up our thought processes, and the way we constantly analyse input from our senses and memory, to make decisions on how to behave.

As far back as the early 1900s, an Austrian psychotherapist called Alfred Adler identified that focusing on resolving unpleasant emotions and thoughts could result in successful psychotherapy. As with many of the techniques we use today, this initial basic concept has been developed and combined with other theories and practices to create something really powerful and effective.

This is now a widely used therapy. It focuses on that link between thoughts, feelings and action in one-to-one sessions, or you can have CBT in a group of people with the same challenges. There are also CBT online therapists.

How does CBT work?

CBT addresses the here and now of PTSD symptoms, it doesn’t necessarily go back over the initial cause of the PTSD. That is something other types of therapies can explore with you. CBT helps you to adjust and re-align negative thoughts, feelings and behaviours that stop you from enjoying a good quality of life.

This is achieved by breaking down the big issues that affect your day, then creating small, achievable changes, including coping strategies or new ways of thinking and acting.

‘Trauma-Focused CBT has several main components, which are often represented by using the acronym PRACTICE.

  • P – Psychoeducation and Parenting: The therapist educates the person and help them realise what trauma is and what its effects are, including the behavioural and emotional responses that it tends to trigger in people. This also involves helping them with behaviour management strategies.
  • R – Relaxation Methods: The therapist teaches the individual effective and healthy relaxation methods to reduce and manage stress. These relaxation techniques may include breathing exercises, guided imagery and progressive muscle relaxation.
  • A – Affective Expression and Regulation Skills: Trauma frequently causes intense emotions including anger, fear and sadness. The therapist addresses this by assisting the person in learning to identify and express these overwhelming emotions. The therapist also helps them develop healthy ways to soothe anxiety and other negative emotions on their own.
  • C – Cognitive Coping Skills and Processing: People often find trauma to be quite confusing, and they may have a tough time processing things in a healthy way. Therapists can help them understand the link between behaviours, thoughts and feelings along with recognising and rectifying inaccurate thoughts about it.
  • T – Trauma Narrative and Processing: Sharing the traumatic event and its effect can be done through verbal, written, artistic or symbolic narratives. This offers the person a way to express and process the trauma and connected experiences. The therapist guides them in creating their narrative by using exposure exercises.
  • I – In Vivo Exposure: One of the most effective ways to overcome fear and anxiety is through exposure instead of avoiding anything that is linked to the trauma. In vivo exposure involves gradually exposing the individual to things that remind them of the trauma. This approach helps decrease their negative emotional responses to those reminders. It also helps them find ways to manage their emotional reactions to unexpected or future reminders.
  • C – Conjoint Therapy Sessions: These therapy sessions concentrate on creating and maintaining a healthy relationship within a family setting. It gives both parties an opportunity to practice communication skills and talk about the trauma in a therapeutic environment.
  • E – Enhancing Personal Safety and Future Growth: It is crucial for individuals who have experienced trauma to develop personal safety skills and learn how to form healthy relationships. Ways to avoid future trauma and stay safe, as well as means to keep healing and growing, are all discussed.’

There are other types of specialist talking therapy that put the emphasis on other aspects of healing, such as counselling which gives you a safe place to discuss a wider range of thoughts and emotions. Or Interpersonal Talking Therapy, which focuses on your relationship with family and friends.

A typical CBT session

What happens during a CBT session depends on the nature of your challenges. However, it would usually focus on:

  • A problem you face, such as a difficult situation that’s happening now or an event in the future causing you concern.
  • What your thoughts and emotions are, and how these affect you physically. (Such as poor sleep, pain, or digestive issues.)
  • How you are behaving in response to the above.

The central feature of CBT is that the therapist doesn’t tell you how to dismantle the interrelationship between these things. Instead, they guide you, on self-resolution and self-management.

This involves highlight unhelpful connections and supporting you in finding helpful ones. Things you can put into practice every day.

You find a solution that dismantles a negative cycle, involving steps that are practical and achievable after the therapy session.

Some examples are:

  • Distorted Beliefs:Once you identify the distortions you hold, you can begin to explore how those distortions took root and why you came to believe them. When you discover a belief that is destructive or harmful, you can begin to challenge it. For example, if you believe that you must have a high-paying job to be a respectable person, but you’re then laid off from your high-paying job, you will begin to feel bad about yourself. Instead of accepting this faulty belief that leads you to think negative thoughts about yourself, you could take an opportunity to think about what really makes a person “respectable,” a belief you may not have explicitly considered before.’

  • Play the script until the end: ‘This technique is especially useful for those suffering from fear and anxiety. In this technique, the individual who is vulnerable to crippling fear or anxiety conducts a sort of thought experiment in which they imagine the outcome of the worst-case scenario. Letting this scenario play out can help the individual to recognise that even if everything he or she fears comes to pass, the outcome will still be manageable’

  • ‘Socratic’ Questioning: ‘This technique can help challenge irrational or illogical thoughts. On a piece of paper, you write “What I’m Thinking”. You write down a specific thought, usually, one you suspect is destructive or irrational. Next, you write down the facts supporting and contradicting this thought as a reality. What facts about this thought being accurate? What facts call it into question? Once you have identified the evidence, you can make a judgment on this thought, specifically whether it is based on evidence or simply your opinion. These Socratic questions encourage a deep dive into the thoughts that plague you and offer opportunities to analyse and evaluate those thoughts. If you are having thoughts that do not come from a place of truth, this can be an excellent tool for identifying and defusing them.’

  • Exposure therapy: ‘This type of intervention helps people face and control their fears by exposing them to the trauma memory they experience in the context of a safe environment. Exposure can use mental imagery, writing, or visits to places or people that remind them of their trauma. Virtual reality (creating a virtual environment to resemble the traumatic event) can also be used to expose the person to the environment that contains the feared situation. Virtual reality, like other exposure techniques can assist in exposures for treatment for PTSD when the technology is available. Regardless of the method of exposure, a person is often gradually exposed to the trauma to help them become less sensitive over time.’

  • Cognitive Processing Therapy (CPT) ‘is an adaptation of cognitive therapy that aims toward the recognition and reevaluation of trauma-related thinking. The treatment focuses on the way people view themselves, others, and the world after experiencing a traumatic event. Often times inaccurate thinking after a traumatic event “keep you stuck” and thus prevent recovery from trauma. In CPT you look at why the trauma occurred and the impact it has had on your thinking. It can be especially helpful for people who, to some extent, blame themselves for a traumatic event. CPT focuses on learning skills to evaluate whether you thoughts are supported by facts and whether there are more helpful ways to think about your trauma. There is strong research support showing the effectiveness for people recovering from many types of traumas.’

  • Stress Inoculation Training (SIT) ‘is another type of CBT that aims to reduce anxiety by teaching coping skills to deal with stress that may accompany PTSD. SIT can be used as a standalone treatment or may be used with another types of CBTs. The main goal is to teach people to react differently to react differently to their symptoms. This is done through teaching different types of coping skills including, but is not limited to, breathing retraining, muscle relaxation, cognitive restructuring, and assertiveness skills.’

How effective is CBT for PTSD and C-PTSD?

CBT is used to treat a lot of different mental health and behavioural issues, not just PTSD. That includes criminality, substance misuse, schizophrenia depression, anxiety, bipolar disorder, eating disorders, insomnia, anger and aggression management and even pregnancy stress.

You can read some case studies of people who’ve been through successful CBT treatment for PTSD and C-PTSD here

Figures on its success rate with PTSD and C-PTSD vary – this is as a result of the trauma itself, comorbidities (other conditions the person has), and other factors, however, some studies show 61% to 82.4% of participants treated with CBT lost their PTSD diagnosis.

This table (from Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review by Nilamadhab Kar) shows a small sample of studies which show the effectiveness of CBT (group, online, solo variations too) amongst various traumas.

Trauma/context

Therapy

Findings/outcome

Acute PTSD from various trauma

Brief CBT

Brief early CBT group had significantly fewer symptoms at one week post intervention, but the difference was smaller and not significant at 4 months. However, patients with baseline comorbid major depression and who were included within the first month of incident had significantly lower PTSD scores at 4 months.

Chronic PTSD

CBT

A 2-year follow-up study where CBT retained significantly more patients in treatment than ST, but its effects were equivalent to those of ST in the completers. CBT was better in the dimensional ITT analysis at post test.

PTSD patients in outpatient clinic

CBT

No differences in efficacy were detected between CBT and structured writing therapy.

Comorbid PTSD and substance use disorders in women

Manualized CBT addressing both PTSD and substance abuse

Participants in both CBT conditions had significant reductions in substance use, PTSD, and psychiatric symptoms, but community care participants worsened over time. Improvement was maintained at 6- and 9-month follow-ups.

Comorbid PTSD in severe mental illness

CBT

CBT clients improved significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance.

Cardiovascular illness

CBT using imaginal exposure

Nonsignificant improvements in the CBT group, with a significant improvement in Clinical Global Scale-Severity and in PTSD symptoms in a subgroup of patients with acute unscheduled cardiovascular events and high baseline PTSD symptoms. CBT that includes imaginal exposure is safe.

Motor Vehicle Accident

CBT

CBT treatment proved to be highly effective in terms of PTSD symptom reduction, showed increases in post-traumatic growth subdomains “new possibilities” and “personal strength”.

Motor Vehicle Accident

Group-CBT

Group CBT showed significant reductions in PTSD symptoms, both in clinical interview and self-report measures. Among treatment completers, 88.3% of group CBT relative to 31.3% of the minimum contact comparison participants did not satisfy criteria for PTSD at post-treatment. Treatment gains were maintained over a 3-month period. Patients reported satisfaction with Group CBT.

PTSD in WTC disaster workers

Cognitive-behavioral exposure treatment

Relevance of a brief focused intervention comprised of CBT and exposure was established; the need to eliminate barriers to treatment retention was associated with income and education.

PTSD in service members following 9/11 or Iraq war

Self-management CBT

Self-management CBT led to greater reductions in PTSD, depression, and anxiety scores at 6 months. One-third of those who completed self-management CBT achieved high end state functioning at 6 months.

Refugees

CBT

Exposure therapy and CBT led to a 48% and 53% reduction on PTSD symptoms, respectively, with no difference between them on any measure; results were maintained at the 6-month follow-up.

Intimate partner violence

TF-CBT

Community TF-CBT effectively improves children’s PTSD and anxiety related to intimate partner violence

Female survivors of assault

Brief CBT

At postintervention, and at 3-month follow-up, participants in brief CBT reported greater decreases in self-reported PTSD severity than those in SC; however around 9 months post assault, all three interventions had generally similar outcomes.

Female survivors of childhood sexual abuse

CBT

CBT and PCT were superior to WL in decreasing PTSD symptoms and secondary measures. CBT had a significantly greater dropout rate than PCT and WL. Both CBT and PCT were associated with sustained symptom reduction.

PTSD in children and adolescents

TF-CBT

Individual TF-CBT was effective for PTSD in children and young people.

Sexually abused children

TF-CBT

Children treated with TF-CBT had significantly fewer symptoms of PTSD and described less shame than the children who had been treated with CCT at 6 and 12 months.

Sexually abused children

TF-CBT

TF-CBT group evidenced significantly greater improvement in PTSD at the 12-month follow-up.

Sexually abused children

TF-CBT

CBT compared with CCT, demonstrated significantly more improvement in PTSD.

Various trauma

Group CBT

Symptom reductions were similar in magnitude with CBT and acupuncture compared with WL; maintained at 3-month follow-up for both interventions.

Various trauma

Internet-based CBT

Internet-based CBT proved to be a treatment alternative for PTSD (effect size d = 1.40) and had sustained treatment effects. A stable and positive online therapeutic relationship could be established.

Various trauma

CBT variant (trauma treatment protocol)

Trauma treatment protocol was both statistically and clinically more effective in PTSD; and this was maintained and became more evident by 3-month follow-up.

Effective PTSD treatment, but not for everyone

One of the reasons it is offered to people with PTSD is that it can help them break down all their symptoms and difficulties into small, achievable goals, but CBT is not a quick fix, and it can take anything from a few weeks to six months to show substantial results. Some studies show that ‘nonresponse’ to CBT can be as high as 50%, but this depends on various factors, including comorbidity (other conditions the person has) and the nature of the populations studied.

For some people, negative and unhelpful connections between thoughts, emotions and behaviours can come back, or manifest in new ways. It can also be difficult for people to engage with if they are feeling severely depressed or anxious. Not least as it relies on the individual creating their own coping strategies and new connections between thoughts and actions. Not easy to do, when you are in a state of emotional arousal. In fact, a skilled therapist would need to be aware of times when exploring a situation in CBT is increasing your anxiety and depression, rather than finding positive adjustments. However, for many people, it is a valuable way to achieve sustainable recovery from PTSD.

How can you find a CBT therapist for PTSD?

Cognitive behavioural therapy is available from the NHS. So, your GP may refer you. Or, you can use the British Association for Behavioural and Cognitive Psychotherapies database to find local help.

You can read some case studies of people who’ve been through successful CBT treatment for PTSD and C-PTSD here

 

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