Cognitive Behavioral Therapies for PTSD

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The treatments covered in this section fall into one of the three (behavior, cognitive, or CBT) categories listed in the preceding section to one degree or another. However, most therapies are combined. In order to simplify things a bit, we will discuss the various treatments or therapies separately as behavior, cognitive, or CBT where appropriate and helpful. That is, if a therapy is primary behavioral, it will be discussed as a behavioral treatment, and so on. Table 12.1 might help with classifying the various treatments.

Student Alert

In order to Learn the actual nuts and bolts and step-by-step procedures for each therapy, please see the various treatment manuals that exist for each, the scope of which goes well beyond the space we have here.

TABLE 12.1

Components of Cognitive and Behavioral Therapies

Behavior Therapies

Cognitive Therapies

Cognitive-Behavioral Therapies

Direct exposure therapy

Cognitive therapy

Stress-inoculation training

Systematic desensitization

Thought stopping

Cognitive processing therapy

Breath control

Cognitive restructuring

Imagery-based exposure


Guided self-dialogue

Assertiveness training

Relaxation training

Dialectical behavioral therapy

Covert modeling

Role play

Behavior Therapies

Conceptually, from a behavior therapy perspective, PTSD is viewed as a specific form of conditioned emotional (fear) reaction. The natural emotional reaction is paired with particular stimuli and other related stimuli, which ultimately serve to maintain the conditioned behavior and responses over time. Successful behavior therapies for PTSD work to break the conditioning between the traumatic event and the conditioned emotional responses through subsequent learning episodes or trials. They also seek to increase behaviors that are incompatible with the high levels of arousal in PTSD, such as teaching breath control.

Exposure Therapies

Exposure therapy involves a patient being exposed to trauma-inducing stimuli on purpose and for a significant period of time. It works on the principle of extinction. A patient is encouraged to essentially relive the traumatic experience and to reexperience the full arousal and related images associated with the trauma. As arousal and fear are maintained, they eventually remit as the patient learns that the original trauma is not going to happen and is not actually occurring despite the high arousal. It is as if the therapist is saying, "See, you are scared, but you are not going to die and therefore there is nothing to be afraid of!"

Zoellner, Fitzgibbons, and Foa (2001) address the therapeutic mechanism in exposure therapy. They cite that it has long been believed that emotional engagement with traumatic memories is a core feature of recovery. In turn, it is thought that avoidance of such engagement only serves to maintain symptoms. A critical component of exposure therapy is not engaging in escape and avoidance behavior or mechanisms. This is sometimes referred to as escape prevention. It plays a critical role in diminishing escape and avoidance behavior as escape and avoidance behaviors are thought to be negatively reinforcing in Anxiety Disorders and work to maintain symptoms. Zoellner et al. (2001) state that ultimately, "The beliefs that particular situations are unsafe and that escape is necessary for anxiety reduction are disconfirmed" (p. 170). Empirical support exists for exposure therapies (Rothbaum, Meadows, Resick, & Foy, 2000a, b).

Direct exposure is one of the therapies that is sometime more cognitive than behavioral in that the act of reexperiencing often involves imagining the traumatic event. However, a patient is often directly exposed to fear-inducing stimuli and triggers in the extinction process. Imaginal exposure will be discussed in the CBT section that follows.

Case Illustration: In Vivo Exposure

A patient's daughter was born premature and suffered severe complications during the birth process. The child nearly died but was saved by aggressive intervention by hospital staff. She was eventually discharged and scheduled for a follow-up appointment in a couple of weeks. The patient was unable to take the child to the appointment, and after several reschedules the treating pediatrician consulted with a psychologist. The mother agreed to see the psychologist and, after several sessions, was finally able to take her daughter to the hospital for her follow-up visits. Here is an excerpt from the treatment:

Therapist: Your homework assignment is to put your daughter in the car and drive toward the hospital. Don't go all the way there; just go a few miles down the freeway toward the hospital, and then go home.

Client: Don't worry; I won't go all the way. I can't go without my husband.

Therapist: That's fine.

Client: I think I can do that. But what if I start having a panic attack?

Therapist: Just start using the breathing techniques we practiced, and pull off the road until you calm down. Then you can either proceed or head home for another trial the next day. I want you to do this three times before I see you again.

Systematic Desensitization

Joseph Wolpe developed systematic desensitization as a means to desensitize an individual to stimuli that is initially very arousing. It is a practice- or learning-based technique in which a desirable behavior that is incompatible with the undesired behavior is first established (Blake & Sonnenberg, 1998). Then, while engaged in the incompatible and positive behavior, typically a state of calm or relaxation, the patient is exposed to arousing or fear-inducing stimuli while attempting to remain calm and relaxed. Eventually, arousal in reaction to previously arousing stimuli will subside and be replaced by a relaxed state. A patient can then encounter arousing stimuli without the arousal reaction. Systematic desensitization is sometimes done with imagery exposure, making it more cognitive, but it is often used with real life stimuli, thus putting it in the behavioral camp. An anxiety hierarchy is developed in which a patient establishes how specific stimuli rank in terms of how much arousal they induce. Relaxation training is then undergone. Exposure then begins, moving through the hierarchy until all the stimuli on the list can be tolerated to the patient's satisfaction. Rothbaum et al. (2000a, b) cite that systematic desensitization has some research support of its effectiveness but is generally considered unsupported. They state that it has generally been replaced by exposure and relaxation techniques.

Breath Control and Retraining, Biofeedback, and Relaxation Training

Diaphragmatic breathing is sometimes taught as a means for patients to calm themselves down and maintain relaxation during exposure and desensitization procedures. Therapists train patients and encourage them to use this out of session as a means to manage their anxiety. Homework as practice is assigned, to be practiced several times a day. Biofeedback and relaxation training can also be utilized to help patients develop stress- and arousal-control skills in the face of trauma stimuli and everyday stressors as well. The focus of these techniques is the control of physiological arousal. Deep muscle relaxation, a technique used to relax all the major muscle groups, is also employed. As PTSD-specific treatments, Rothbaum et al. (2000a, b) indicate that these techniques have not been found to be effective in and of themselves. These treatments can be used as adjuncts, however.

Cognitive Therapies

From the cognitive perspective, PTSD treatment is approached from an information processing perspective. Emotional reactions and mood states are produced by how a stimulus, situation, or event is interpreted and not by the stimulus in and of itself. Such interpretations can be fraught with bias and distortion and are sometimes referred to as automatic thoughts or maladaptive cognitions. A patient is taught to overcome the influence of these systematic biases and distortions in the processing of information and thinking through exploration, examination, putting them to the empirical test and challenging them, and appropriately altering and changing them in order to produce more logical, more accurate and helpful ways of thinking. Other techniques, such as thought stopping, cognitive restructuring, and guided self-dialogue, are also used to bring automatic thoughts to a patient's attention and either stop them or alter them.

Traditional cognitive therapy was developed for treating depression, but adaptations for Anxiety Disorders and PTSD have been developed (Clark, 1986; Frank et al., 1988; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998). Rothbaum et al. (2000a, b) report that cognitive therapy for PTSD has been shown to be effective for reducing posttraumatic symptoms in two well-controlled studies.

Cognitive therapies are combined with exposure therapy. Its unique contribution is to focus on the identification and modification of "target core dysfunctional cognitions" (Moore, Zoellner, & Bittinger, 2004, p. 132). These dysfunctional cognitions and cognitive processes include disruptions in Janoff-Bulman's (1992) "fundamental assumptions about a safe and meaningful world" (Moore, Zoell-ner, & Bittinger, 2004, p. 130). Disruptions in Epstein's four beliefs that the self is worthy, people are trustworthy, the world is benign, and the world is meaningful; and Foa and Rothbaum's (1998) dysfunctional cognitions that the world is a dangerous place, and the self is incompetent. Cognitive therapy through restructuring might also focus on the process identified by Ehlers and Clark (2000) in which an individual maintains the perception of current environmental threat by misinterpreting the physiological symptoms of PTSD, such as arousal and numbing, and taking them as threat signals. That is, a person might be keyed up or on edge because of the ongoing state of arousal of PTSD, yet they may interpret this as proof that there is, in fact, danger present. This is akin to the cognitive account of panic attacks and Panic Disorder.

Moore et al. (2004, p. 144) also propose that cognitive therapies should focus on dysfunctional information processing in PTSD, stating that PTSD is necessarily associated with "deficits in the automatic and strategic processing of information." These errors include the quick and unconscious processing of information seen with intrusive thoughts. They emphasize the therapeutic importance of helping patients develop an understanding of these automatic processes and helping them frame and contextualize the symptoms, rather than misinterpreting them.

Cognitive-Behavioral Therapies

Cognitive-behavioral therapies combine both behavioral and cognitive orientations, theoretical rationales, and techniques to produce some of the most effective treatments for PTSD.

Stress-Inoculation Training

Donald Meichenbaum developed stress-inoculation therapy (SIT) for the management of anxiety. Stress-inoculation therapy consists of helping patients identify stressors or stressful stimuli, learning adaptive coping while confronting it, and practicing the coping techniques while being faced with the stimuli. Coping techniques used while in the face of a stressor may include self-talk, deep breathing, or thought stopping. The goal is to reduce avoidance and reduce excessive arousal. In 1982, Kilpatrick, Veronen, and Resick modified SIT for treatment of rape trauma. Rothbaum et al. (2000a, b) cite that SIT has been found effective by at least two well-designed studies, but only for sexual assault victims. Kilpatrick et al.'s (1982) program and subsequent programs consist of education; the acquisition of coping skills; and the application of coping skills, including deep muscle relaxation, breathing control, communication skills and assertiveness training, covert modeling (imagery based modeling), thought stopping, and guided-self dialogue consisting of identifying one's internal dialogue and generating and substituting positive ones.

Cognitive Processing Therapy

Cognitive processing therapy was specifically designed for rape survivors. It is a combined approach using both cognitive therapy and exposure methods. Cognitive processing therapy combines cognitive therapy elements and exposure components. The cognitive aspects focus on self-blame and attempt to "mentally undo the event" and "overgeneralized beliefs emanating from the rape" (Rothbaum et al., 2000a, p. 65). The exposure component consists of writing an account of the rape and reading it to the therapist.

Cognitive-Behavioral Therapy-Exposure Treatments

Exposure therapies from a combined behavioral and cognitive perspective are considered one of the two most effective treatments for PTSD, next to pharmacological treatment with selective serotonin reuptake inhibitor (SSRI) medication. I use the word therapies in the plural deliberately because there is no single type or form of CBT-exposure-based therapy. Exposure therapies typically include an imaginal exposure component such as writing about or reading about the trauma (Taylor, 2004) and an in vivo or real-life exposure component to trauma reminders or classically conditioned trauma cues.

Imaginal or imagery-based exposure consists of various techniques in which exposure is achieved by imagination, within a role-play scenario, or some other form of non-real-life setting. Other techniques include telling the story of the trauma in a narrative format with the therapist, the therapist presenting a scene to the patient, or trying to imagine the event in all its detail in a manner akin to experiential therapy techniques.

Case Illustration: Imaginal Exposure

Therapist: I want you to tell me what happened, starting at the beginning.

Client: I can't, not without getting upset. But I'll try. I was in the park with my family, just barbecuing, having fun. It was sunny. I remember running and falling down, watching the guy with the gun approaching me.

Therapist: What are your tension and fear level ratings right now? Last time you told me the story, they were nine, and today they are a seven. That's improvement! Please continue.

Client: He just walked up and shot me in the face and chest. ALL I remember after that is waking in the middle of surgery, looking down and seeing my chest opened up and then feeling the most intense pain I have ever felt in my life. I knew I was going to die.

Therapist: What are your ratings now?

Client: They are a one hundred on a scale of ten, Doc!

Therapist: Okay. Let's stop for a minute.

Assertiveness Training

Assertiveness training is a skill-building intervention sometimes used in conjunction with other therapies. It is intended to be a coping skill that helps reduce arousal in tense or otherwise arousing situations that a PTSD sufferer may have otherwise avoided or overreacted to. It may also be viewed as a solid adjunct for helping a patient develop a stronger sense of self-efficacy and self-control. However, it is not considered a therapy or treatment in and of itself and is not considered a vital component of treatment overall (Rothbaum et al., 2000a, b).

Dialectical Behavioral Therapy

Marsha Linehan first developed dialectical behavior therapy (DBT) for Borderline Personality Disorder. Since then it has been developed for use with other disorders. However, its use with Borderline Personality Disorder may have, in fact, lent itself directly to a PTSD application, as some professionals believe that Borderline Personality Disorder is a form of complex PTSD in and of itself. Melia and Wagner (2000) state that DBT is a form of cognitive-behavioral therapy but different in two additional underlying, guiding theories: (1) the biosocial theory of emotional dys-regulation and (2) the theory of dialectics and its inclusion of Eastern philosophy and mindfulness practices. Dialectical behavioral therapy is suggested as one possible approach to those patients who have difficulty engaging in the more common therapies and whose lives are characterized by instability, chronic crises, and living difficulties. Dialectical behavioral therapy may be particularly well suited for these particular clients because of its emphasis on and varied methods for dealing with early engagement and treatment compliance. Posttraumatic Stress Disorder is characterized as a form of emotional dysregulation and as such can benefit from the DBT methods for addressing such dysregulated emotion. Dialectical behavioral therapy is unique in its high degree of structure and systematic approach to symptoms and behavior problems, including suicidal behavior and self-harm, and in its use and integration of Eastern philosophy and its use of dialectics. An underlying worldview in which reality is seen as a dynamic of opposing forces that are constantly changing is used to bring dichotomous thinking and behavior into a more flexible, fluid, and less black-and-white perspective. This helps clients work through rigid behaviors and beliefs and reduces overreactions. The dialectic technique is employed as a form of persuasion that works hand in hand with this philosophy in which change occurs through the simultaneous consideration of opposing viewpoints (Melia & Wagner, 2000). However, DBT has yet to be empirically evaluated or validated as a specific treatment for PTSD.

Before we wrap up, it is important to mention that, despite the powerful and numerous treatments discussed in this chapter, many people continue to suffer from PTSD after having been treated with such methods. Personally, I can attest to this fact as I have evaluated numerous PTSD sufferers for disability who are still symptomatic and still having functional difficulties, despite having been through treatment. Steven Taylor (2004) suggests that for individuals in which exposure therapy, cognitive therapy, or a combination of both does not work, perhaps other related issues of significance need to be addressed. These include trauma-related anger, utilizing virtual reality exposure intervention, improving social support, or utilizing interoceptive exposure, a method of deliberately, inducing PTSD-symp-toms. He cautions, however, that research still needs to be done before final, concrete suggestions are made, but his recommendations are well taken.

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