If you were to have a traumatised client, which type of therapy would you choose to treat them? On what would you base your decision? Research tells us that there is choice. Psychotherapeutic interventions for PTSD have significant empirical support. One meta-analysis of 26 studies (1535 subjects) employing different psychotherapeutic approaches found that four out of five clients (79 percent) completed treatment. Two-thirds (67 percent) of the completers no longer met criteria for PTSD. In a further meta-analysis of 17 studies (690 subjects), psychotherapeutic treatment was found to be effective, with symptomology significantly decreased (Sherman, 1998, in Knauss & Schofield, 2008).

Whichever therapy is selected, traumatised clients are severely distressed; thus, the therapist must have highly developed relational and supportive skills in addition to knowledge about treatment methods that will be appropriate and effective. The job of the professional working with such clients is to contain and deal with the trauma. A solid therapeutic alliance and positive client expectations towards the treatment are positively associated with treatment outcome (Australian Centre for Posttraumatic Mental Health, 2013a).

While the therapy-types on offer to treat PTSD abound, three different types of psychotherapeutic approaches come up again and again in the literature as workable and appropriate for trauma. These are: cognitive-behavioural therapy (CBT), eye movement de-sensitisation and reprocessing (EMDR), and psychodynamic psychotherapy. In this article, we explore the use the CBT and CBT-related therapies to treat trauma.

Cognitive behavioural therapy (CBT) for trauma

The most widely studied therapy of all, CBT, has demonstrated efficacy (in its multitudinous forms) as a treatment for PTSD. As trauma-focused cognitive-behavioural therapy (TFCBT), its effectiveness has been reported in several reviews and meta-analyses (American Psychiatric Association, 2004; Australian Centre for Posttraumatic Mental Health, 2013a; Bisson & Andrew, 2007; Schnyder, 2005). Trauma-focussed therapy involves direct engagement with the traumatic memory. Although it often includes psychoeducation and symptom management strategies (notably arousal reduction), the “variations on a theme” are predominantly characterised by different emphases on exposure to traumatic memories and/or cognitive restructuring. These psychological interventions are short-term and structured; the techniques include: exposure therapy/prolonged exposure (PE), systematic de-sensitisation, cognitive processing therapy (CPT), cognitive therapy, narrative exposure therapy (NET), stress inoculation therapy (SIT), a suite of anxiety management techniques (including relaxation training, distraction techniques, and positive self-talk) and EMDR (which we will include under its own subheading). All of them aim to address the cognitive, emotional, and behavioural sequelae of exposure to traumatic events.

The recent literature review of the Australian Centre for Posttraumatic Mental Health identified 29 studies comparing TFCBT to waitlist or control conditions, and a further 38 studies which compared TFCBT to treatment as usual or another intervention. Six studies compared EMDR to waitlist controls and a further 9 studies compared EMDR to treatment as usual or another intervention (see Australian Centre for Posttraumatic Mental Health, 2013a).

We can summarise the wide literature base on CBT’s effectiveness through these simple remarks:

Each of the above types of trauma-focussed therapies has shown significant positive treatment effects for adults with PTSD, with cognitive behaviour therapy that incorporates imaginal and in vivo exposure as well as cognitive restructuring having received the most attention.

Multiple trials indicate that trauma-focussed therapies result in greater reduction in PTSD symptoms than supportive counselling, thereby providing solid evidence that it is a relatively stronger intervention than generic psychotherapeutic support (Australian Centre for Posttraumatic Mental Health, 2013a).

So what, exactly, are CBT-based, trauma-focussed therapies trying to do?

Goals of CBT-based therapies

CBT helps clients to weaken the connections between troublesome thoughts and situations and the clients’ habitual reactions to them. Cognitive therapies teach clients how certain thinking patterns may be the cause of their difficulties by giving them a distorted picture or making them feel anxious, depressed, or angry. Traumatic experiences typically impede emotional processes because they conflict with pre-existing conceptual schemas. Cognitive dissonance occurs because clients cannot reconcile thoughts, memories, and images of the trauma with their current meaning structures; the result is severe distress. Clients need to match new information with inner models based on older information until they agree, in a psychological drive for completion.

Yet in the acute phase of the trauma, cognitive accord is sorely lacking. Trauma survivors typically fluctuate between hyperarousal and inhibition. Attempting to comprehend and integrate the traumatic experience, the survivor normally replays the event that has been stored in active memory. Each replay, however, distresses the traumatised person, who may inhibit thought processes in an attempt to modulate the active processing of the traumatic information. When this inhibition is observed, it gives the sense that the client has disengaged from processing the traumatic memory. Some client-survivors, therefore, display withdrawn and avoidant behaviours until the traumatic thoughts can no longer be inhibited, and become intrusive, expressed as hyperarousal symptoms of flashbacks (when awake) and nightmares (when asleep). The observed result is a swinging between denial/numbness and intrusion/hyperarousal. The psychological completion can be achieved when the client re-appraises the event and revises the cognitive schemas previously held, coming to hold a point of tension between the two (Dass-Brailsford, 2007). Accordingly, CBT techniques used in trauma treatment tend to focus on the following:

• Learning skills for coping with anxiety (such as breath retraining or biofeedback)
• Using cognitive restructuring to change negative thoughts
• Managing anger
• Preparing for stress reactions (stress inoculation)
• Handling future trauma symptoms
• Addressing relapse prevention and other substance abuse issues
• Communicating and relating effectively with people (interpersonal skills)
• Addressing thought distortions that usually follow exposure to trauma
• Relaxation training and guided imagery (Dass-Brailsford, 2007)

Here are some snapshot views of the various trauma-focused therapies based on CBT.

Exposure therapy/prolonged exposure

In exposure therapy, long held to be an effective treatment for a range of anxiety disorders, clients are encouraged to confront the fear-inducing memory at varying levels, either imaginally or in vivo. Therapists doing exposure therapy (also called prolonged exposure) work with the notion of habituation, which posits that if people can be kept in contact with the anxiety-provoking stimulus long enough, their anxiety around it will inevitably decrease. Thus, gradually and repeatedly, clients are guided through a vivid and specific recall of traumatic events until, in the safe, controlled context of the therapy rooms, clients’ emotional reactions decrease. This can happen with an exposure session (in-session habituation) or via a series of sessions (between-session habituation). Exposure therapy began with early desensitisation sessions with war veterans and developed into the prolonged exposure that is the contemporary cornerstone of PTSD treatment.

Central to exposure therapies is the notion of grading the exposure (typically using a hierarchy) to expose the client to both traumatic memories and also avoided situations and activities related to the trauma. The client confronts ever-more-threatening situations, repeating and prolonging the exposure until it evokes only minimal anxiety (Australian Centre for Posttraumatic Mental Health, 2013a; Dass-Brailsford, 2007).

In some cases the practitioner may use flooding, a related technique which encourages clients to confront all their memories or reminders of trauma at once. This technique should only be offered if the client is given a robust opportunity to refuse treatment, as the technique is not well-tolerated by some populations, notably veterans with chronic combat-related PTSD. In one study most of the veterans dropped out rather than continue the treatment (Foa, Keane, & Friedman, 2000). Empirical studies demonstrate, however, that exposure therapy is effective with other groups, such as rape survivors (Foa et al, 2002).

PE up close

PE is typically conducted in 9 to 12 sessions lasting 90 minutes each. It has been used to treat PTSD after sexual assault, combat, childhood abuse and sexual abuse, motor vehicle accidents, and natural disasters (Chard & Gilman, 2005). While individual sessions are more common, group PE has also been found to be effective. The therapist first educates the client about PTSD and the treatment rationale through psychoeducation, then moves into a phase of repeatedly asking the client to describe the traumatic event as if it were occurring. During, say, 45 to 60 minutes of exposure, the therapist frequently asks the client to rate his or her distress, thus identifying “hot spots” in the account to which they will return. At this stage, the therapist is not necessarily challenging cognitive distortions (e.g., “No one can be trusted”).

Through the continuing exposure, the client habituates to the pathological “fear network”, coming to enhance self-control and personal competence and decreasing generalisation of fear to non-trauma stimuli. Thus, a returned veteran who once had to disembark on a beach and walk toward combat through land-mine-studded fields may have been up until the PE re-traumatised by a walk in the park with the family. Through in vivo exposure, such clients can face associations between environmental cues and their trauma, learning to modify the fears associated with the cues. The result is improved personal and social functioning (Australian Centre for Posttraumatic Mental Health, 2013a; Chard & Gilman, 2005).

PE session by session

A set of 9 to 12 PE sessions might be conducted as shown below:

1. Session 1
   1. Education
   2. Treatment rationale
   3. Review of PTSD symptom response
   4. Introduce breathing retraining
2. Session 2
   1. Review handouts of common reactions to trauma
   2. Introduce Subjective Units of Distress*
   3. Create fear hierarchy for in vivo exposure
3. Session 3
   1. Provide rationale for imaginal exposure
   2. Conduct imaginal exposure
   3. Assign in vivo exposure homework
4. Sessions 4-8
   1. Conduct imaginal exposure
   2. Discuss in vivo exposures
5. Sessions 9-12
   1. Conduct imaginal exposure
   2. Suggest continued in vivo exercises
   3. Termination

*Measurements used to describe an individual’s level of suffering or grief associated with painful memories (Jonas: Mosby’s Dictionary of Complementary and Alternative Medicine. (c) 2005, Elsevier)

Source: Foa & Rothbaum, 1998.

Systematic de-sensitisation

This therapeutic approach, developed by Wolpe (1958, in Dass-Brailsford, 2007), works well for clients who prefer gradual recall rather than immediate total recall of traumatic memories. In systematic desensitisation, clients are supported through deep muscle relaxation techniques and diaphragmatic breathing, which are taught before treatment is administered and used whenever a client’s anxiety increases. Early tasks in this approach centre on establishing a hierarchy of fear-inducing stimuli and gaining competence in using the relaxation techniques to overcome the situations in the hierarchy. Clients begin by recalling the least upsetting situation, the least distressing aspects of the traumatic experience. If the client has a negative reaction, the therapist induces relaxation. They gradually return to the hierarchy, ascending to the next (slightly more) distressing stimulus. Thus clients systematically work to overcome and integrate their fears (Dass-Brailsford, 2007).

Cognitive processing therapy

A particular form of cognitive therapy refined specifically for the treatment of PTSD, cognitive processing therapy was created originally to treat trauma and related symptoms in rape survivors. Thus it first appeared as a 12-session manualised treatment that systematically addressed key posttraumatic themes, including safety, trust, power and control, self-esteem, and intimacy. Sessions can be group, individual, or combined, depending on client needs and clinic resources. The length of the program can go up to 17 weeks in some cases of work with survivors of domestic violence, child sexual abuse, and war veterans, with sessions being added/deleted/adapted to the needs of the particular population being addressed. CPT is also useful for PTSD from motor vehicle accidents (Chard & Gilman, 2005).

CPT treatment, based on information processing theory, helps the person to: (1) identify unhelpful thoughts and beliefs (“stuck points”) about self, others, and the world; (2) challenge them; and (3) replace them with rational alternatives in an adaptation of standard cognitive therapy approaches. The stuck points, or distortions, are sometimes called “rules”; they are gradually replaced with more adaptive, healthier beliefs. Because CPT systematically identifies key themes and issues associated with reactions to the trauma, it is especially suitable for addressing the complex psychiatric sequelae found in the PTSD of returned troops from recent military conflicts. It has a smaller exposure component than imaginal exposure therapy (clients merely write an account of the experience), which makes it more appealing to veterans and practitioners looking for alternatives to purely exposure-focussed treatments.

Traumatised individuals typically feel out of control or hopeless. Thus the above-mentioned focal themes of safety, trust, control, self-esteem, and intimacy also have the advantage of helping to address associated problems such as depression, guilt, and anger. Modules on assertiveness, communication, and social support can also be added (Australian Centre for Posttraumatic Mental Health, 2013a; Chard & Gilman, 2005).

CPT session by session

Twelve CPT sessions might be conducted as shown below:

1. Session 1
   1. Education
   2. Review of symptoms
   3. Introduce “stuck points”/rules
   4. Write Impact of Event Statement (IES)
2. Session 2
   1. Review IES
   2. Identify stuck points
   3. Introduce A-B-C sheets (from the ABC paradigm*)
3. Session 3
   1. Review A-B-C sheets
   2. Assign writing of traumatic account
4. Session 4
   1. Read traumatic account
   2. Identify stuck points
   3. Rewrite the account
5. Session 5
   1. Read rewritten account
   2. Identify stuck points
   3. Introduce worksheet on challenging questions
   4. Assign writing of next-most-traumatic incident and work through challenging questions
6. Session 6
   1. Review challenging questions work
   2. Assign review of faulty thinking patterns work
7. Session 7
   1. Review faulty thinking patterns work
   2. Assign safety module and challenging beliefs worksheets on safety
8. Session 8
   1. Review challenging beliefs worksheets on safety
   2. Assign module on trust
9. Session 9
   1. Review challenging belief worksheets on trust
   2. Assign module on power/control
10. Session 10
    1. Review challenging beliefs worksheet on power/control
    2. Assign module on esteem
11. Session 11
    1. Review challenging beliefs worksheets on esteem
    2. Assign module on intimacy
    3. Rewrite IES
12. Session 12
    1. Review challenging beliefs worksheet on intimacy
    2. Read both impact statements
    3. Address remaining areas of concern
    4. Termination

*From Albert Ellis’ Rational-Emotive Therapy (the forerunner of CBT), the A stands for Activating Event, the B is for Beliefs (often irrational), C is for the emotional consequences of A and B. Later, Ellis added D, for Disputing irrational beliefs, and E, for Effects – cognitive and emotional – of revised beliefs (Dewey, R., 2007. The A-B-C-D-E Mnemonic, retrieved from: www.intropsych.com).

Source: Resnick, & Schnicke, 1993).

Cognitive therapy

Needing a treatment for depression in the 1970s, Aaron Beck introduced cognitive therapy; Albert Ellis’ Rational-Emotive Therapy (later Rational-Emotive Behavioural Therapy) and other similar therapies were in their hey-day at the time. Anxiety disorders, some psychoses and personality disorders, and other emotional conditions have been successfully treated with cognitive therapy since then. In treating PTSD, cognitive therapy helps clients to identify, challenge, and modify any biased or distorted thoughts or memories of the traumatic experience, as well as any later-developing maladaptive or limiting beliefs they may hold about themselves and the world (Australian Centre for Posttraumatic Mental Health, 2013a). Note that cognitive therapy does not emphasise exposure processes, which may limit its effectiveness with some populations, yet appeal more to others, such as veterans.

Narrative exposure therapy (NET)

Narrative exposure therapy is adapted from both mainstream exposure approaches and testimony therapy, which was first used with survivors of torture and civilian casualties of war. Standardised and short-term, NET was originally developed for the dual purposes of treating survivors and documenting human rights violations. The intervention asks clients to construct a narrative of their life, from the early years to the present, detailing the traumatic event(s) and elaborating on related thoughts and emotions. NET proponents posit that the therapy works in two ways: (1) promoting habituation to traumatic memories through exposure and (2) reconstructing the individual’s autobiographic memory (Australian Centre for Posttraumatic Mental Health, 2013a).

Stress Inoculation Therapy (SIT)

Originally developed by Meichenbaum (1994) for anxious clients, SIT is a commonly used anxiety management treatment which incorporates psycho-education and skill-building techniques such as relaxation, thought stopping, breath retraining, problem-solving, role-playing, covert modelling, and guided self-dialogue, and seems to be particularly effective in relieving the fear, anxiety, and depressive symptoms associated with traumatic experiences (Chard & Gilman, 2005). SIT has yielded encouraging results when used with female rape victims. It is also thought to be most helpful with PTSD related to physical assault and motor vehicle accidents (Chard & Gilman, 2005).
In a well-controlled study combining SIT with prolonged imaginal exposure and supportive counselling, it was found to significantly reduce symptoms (Foa, Rothbaum, Riggs, & Murdock, 1991).

Anxiety management

Clients diagnosed with PTSD may not know how to manage anxiety when confronted with anxiety-provoking situations related to their traumatic experience. Thus anxiety management works to develop skills in this area through specific anxiety-reduction techniques such as relaxation training, positive self-talk, and distraction techniques. Like SIT, anxiety management has been successfully used to treat PTSD in rape survivors (Foa et al, 1991).

This article was adapted from Mental Health Academy’s upcoming professional development course, “Working with Trauma”.

References

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• Australian Centre for Posttraumatic Mental Health. (2013a). Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. ACPMH, Melbourne, Victoria.
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