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Life After Trauma: Is Cognitive Behavioral Therapy an Effective Treatment for Post Traumatic Stress Disorder?

Katie Guess

October 5, 2009


Trauma can come in all shapes, sizes, and severities, leaving sufferers with long-lasting physical, mental, and emotional scars. From follow-up appointments to rehabilitation, the recovery process does not always end the moment a trauma patient is discharged from the hospital or the instant the last wound heals. For some patients, the recovery process doesn't even end after the last doctor visit. Instead, many patients experience a time during which they may struggle with the acceptance of their recent traumatic event and be forced to undergo emotional healing in addition to their physical recovery. If not addressed or treated properly, this struggle may develop into the anxiety disorder referred to as Post Traumatic Stress Disorder or PTSD.

According to the National Center for PTSD (NCPTSD), "5.2 million adults have PTSD during a given year," and "8% of the population will have PTSD symptoms at some point in their lives" (NCPTSD). Today, many treatment options including psychotherapies, medications, and combinations of the two are being developed to treat PTSD (NIMH). One form of psychotherapy gaining recognition as a viable treatment option for PTSD is Cognitive Behavioral Therapy (CBT). Many sources such as the NCPTSD claim that the therapy is the "most effective type of counseling for PTSD" (NCPTSD), and studies testing its effectiveness in treating the symptoms of the disorder continue to be tested daily.

What is Post Traumatic Stress Disorder?**http%3A/**http%3A/ to the National Institute of Mental Health, "Post Traumatic Stress Disorder is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened" (NIMH-PTSD).  According to the National Center for PTSD, "These events can include: combat or military exposure, child sexual or physical abuse, terrorist attacks, sexual or physical assault, serious accidents such as a car wreck, or natural disasters such as a fire, tornado, hurricane, flood, or earthquake" (NCPTSD).

 Four basic symptoms outline warning signs associated with PTSD in both adults and children. These include reliving the event, avoiding situations that are reminiscent of the event, avoiding emotions, and feeling hyper aroused (NCPTSD ).  For example, "seeing a car accident can remind a crash survivor of his or her own accident"(NCPTSD) or watching a movie with an abundant amount of violence can remind an abuse victim of his or her assault. These flashbacks may result in "nightmares, a renewed and heightened sense of horror or fear, or make the victim feel as though the event is taking place all over again" (NCPTSD). Patients may also avoid situations that remind them of their trauma. For example, these individuals may evade discussing their experience with others or reading newspapers or books in fear of triggering memories of the event. Next, individuals demonstrating PTSD symptoms may also "feel numb" or "find it had to express feelings" (NCPTSD), and because of this, they may not enjoy the same activities they have in the past and "may stay away from relationships" (NCPTSD). Finally, patients may exhibit signs of "feeling keyed up"**http%3A/ Individuals demonstrating this symptom may "feel jittery, have a hard time sleeping,  have trouble concentrating, or fear for his or her safety" (NCPTSD) . Other common symptoms of PTSD in adults or teens may include "drinking or drug problems, employment problems, physical signs of distress, or depression" (NCPTSD).

Both life experiences before the traumatic event and during the recovery process can increase the risk of a patient developing PTSD. For example, the chance of acquiring PTSD increases if a patient has frequently been exposed to other traumatic events throughout of his or her lifetime and has developed emotional problems such as depression as a result of those events (NCPTSD). Additionally, the degree of pain experienced and the sense of life threat caused by the incident can also play a role in the progression of PTSD (NCPTSD). In children, the possibility of developing the sickness rises if the child is separated from his or her parents during the experience,**http%3A/ no support from family members during the recovery process, or receives no "positive peer support" during the recovery process (NCPTSD). Finally, gender can also play a role in the disorder's progress. Research shows that women are more susceptible to the disorder than men. According to the U.S. Department of Veterans Affairs, 9.7% of women and only 3.6% of men will experience PTSD during their lifetime (NCPTSD).

How is PTSD diagnosed?**http%3A/ of PTSD is made by a mental health professional. Psychiatrists, psychologists, and clinical social workers specifically trained to assess psychological problems are all qualified to diagnose patients with PTSD (NCPTSD). In order to formally make the diagnosis, a patient must demonstrate the symptoms that may "cause significant distress and affect the individual's ability to function socially, occupationally, or domestically" for over one month (NCPTSD).

Evaluation procedures for adults include structured interviews of the patient with detailed questions about the traumatic event or symptoms. For adults, these include the Clinician Administered PTSD Scale (CAPS) which consists of an interview about the frequency and intensity of symptoms, the Anxiety Disorders Interview (ADIS), the PTSD Checklist (PCL), or the Posttraumatic Diagnostic Scale (PDS). For children, evaluation is performed using the Screening for Early Predictors of PTSD (STEPP) which identifies "children (and their parents) in the acute care setting who are at risk for traumatic stress reactions to injury" (NCPTSD).

What is Cognitive Behavioral Therapy?

View ImageAccording to the National Institute of Mental Health (NIMH), "Cognitive Behavioral Therapy is a form of psychotherapy designed to help a person develop a more adaptive response to a fear" (NIMH-CBT). The NIMH states that "Cognitive Behavioral Therapy (CBT) is a blend of two therapies: cognitive therapy (CT) and behavioral therapy (BT)" (NIMHs-CBT). CT concentrates on "a person's thoughts and beliefs, and how they influence a person's mood and actions" (NIMH-CBT). In doing so, the therapy "aims to change a person's thinking to be more adaptive and healthy" (NIMH-CBT), and BT strives "to change unhealthy behavior patterns" (NIMH-CBT).  As a combination of the two, CBT "emphasizes the important role of thinking in how we feel and what we do" (NACBT).

While undergoing this form of "'talk therapy,"' patients learn to identify thoughts that make them upset, afraid, guilty, or angry and learn to cope with these thoughts by replacing them with positive, "more accurate, and less distressing thoughts" (NCPTSD). According to the British Association for Behavioral and Cognitive Psychotherapies (BABCP), five factors influence the effectiveness of CBT treatment. These include building a "therapeutic relationship" between the patient and the CBT therapist, "collaboration" efforts between the two parties, "formulation" of an assessment plan based on "CBT framework," a form of questioning used by the therapist which leads to changes in behavior and ideas called "Socratic dialogue," and "homework" completed by the patient (BABCP) . Two-way communication is a key component in developing a CBT treatment plan and implementing that plan. In order for this communication to begin, the patient must feel comfort with and trust in his or her therapist. Therefore, a "trusting, safe therapeutic alliance" (BABCP) must be developed between the individuals before treatment can begin. The "Collaboration" component of treatment is based on the fact that the relationship between therapist and patient is an "equal partnership" in which both parties bring their own skills and experiences (BABCP). For example, the therapist brings his or her own psychological training, and the patients are "experts in their own experience and bring their own resources" as well (BABCP).

Next, "formulation" of a treatment plan based on the patient's fears or anxiety is developed by "drawing upon theory and evidence based practice" of CBT (BABCP). For example, during the treatment process, the CBT therapist may use "exposure therapy" (NIMH-CBT) with the patient. This technique "works by helping a person confront a specific fear or memory while in a safe and supportive environment" (NIMH-CBT), and the treatment focuses on giving the patient the "tools" needed to cope with their "fears or traumatic memories" and teaching them that the anxiety they are experiencing decreases with time (NIMH-CBT). Another form of treatment used in CBT in which therapists "encourage survivors to talk about upsetting (often incorrect) thoughts about the trauma, question those thoughts, and replace them with more balanced and correct ones" is known as "cognitive restructuring" (NIMH-CBT). Finally, "stress inoculation training," a method that "teaches anxiety reduction techniques and coping skills to reduce PTSD symptoms, and helps correct inaccurate thoughts related to the trauma" (NIMH-CBT) may also be used.

Throughout this process, "Socratic dialogue" also known as "guided discovery," a process in which the therapist uses a specific style of questioning to "probe for people's meanings and to stimulate alternative ideas," is also utilized (BABCP). This practice "involves exploring and reflecting on styles of reasoning and thinking and possibilities to think differently" (BABCP). Finally, in order to help integrate the skills developed and learned during therapy sessions, the patient is assigned "homework" through which the he or she puts "what has been learned into practice" (BABCP). "Homework" may include reading assignments (NACBT), implementation of practices or techniques learned (NACBT), and behavioral experiments (BABCP).

Who is promoting the use of CBT in the treatment of PTSD?

The National Institute of Mental Health (NIMH-CBT), the National Center for PTSD (NCPTSD), British Association for Behavioral and Cognitive Psychotherapies (BABCP), and the National Association of Cognitive Behavioral Therapists (NACBT) are just a few of the organizations promoting the use of CBT as a treatment for PTSD. In fact, as stated previously, the NCPTSD states that CBT is "the most effective type of counseling for PTSD" used today (NCPTSD). On their websites, the NIMH and NCPTSD outline the symptoms of the disorder, methods of diagnosis, the treatment options available, and provide links to other resources such as videos, therapists, and links to the websites of other various trauma organizations. These sights target patients with PTSD, patients who believe that they might have the disorder, family and friends of individuals with the disorder, therapists, and researchers interested in learning more about PTSD and CBT, and the general public. The sites for the BABCP and NACBT define CBT, outline the procedures through which therapists work with patients and also provide links to CBT resources such as books, tapes, and therapists, and these sites are targeted to both the public and to CBT therapists.  All of the sites indicate the effectiveness of the treatment, and in addition to their explanations about the disorder and treatment, they provide links to scientific publications verifying their claims.**http%3A/ Scientific Research Support These Claims?





Cognitive Behavioral Group Therapy for Sexually Abused Girls

Luísa Fernanda Habigzang et al. (2009) conducted a non-randomized study on female children and adolescent victims of sexual abuse to determine the effect that CBT plays on the symptoms of PTSD. In her study, the participants with PTSD were first individually assessed to determine the severity of their symptoms using the "semi-structured interview" (Habigzang et al., 2009, p. 2), Children's Attributions and Perceptions Scale (CAPS), Child Depression Inventory (CDI), Children's Stress Inventory (ESI), Trait-State Anxiety Inventory for Children (IDATE-C), Trait-State Anxiety Inventory for Children (IDATE-C), and a "structured questionnaire based on DSM-IV for assessing post-traumatic stress disorder" (p. 3). Analysis determined the participants' "symptoms of depression, anxiety, post-traumatic stress disorder and dysfunctional beliefs concerning sexual abuse" (Habigzang et al., 2009, p. 3).  Next, the children were assigned to group therapy and later exposed to 16 sessions of CBT during which "semi-structured activities were carried out" (Habigzang et al., 2009, p. 3). These sessions were conducted by psychologists specially trained to treat children and teenagers who have been victims of sexual assault. At the end of the therapy sessions, the children were again individually assessed using the same diagnostic tools as in the original assessment. From the final evaluation, the investigators concluded that "there was a significant decrease in the number of PTSD symptoms in the three symptom categories: reliving the trauma, avoidance and numbness and hyper vigilance"  (Habigzang et al., 2009, p. 5). Therefore, according to this study, CBT appears to be an effective treatment method for young girls with PTSD who have been sexually abused. However, while this study did make use of common PTSD diagnostic techniques and CBT procedures, it did not investigate the effects of CBT on young boys with PTSD who had been sexually abused or children who had survived other forms of trauma. Additionally, it did not precisely entail what forms of CBT were used in treatment.

Group Cognitive Behavior Therapy for Chronic Posttraumatic Stress Disorder: an Initial Randomized Pilot Study

            J. Gayle Beck et al. (2008) conducted a study in which adults, ages 22-69, who had previously developed PTSD following a motor vehicle accident (MVA) that involved "actual or threatened death or serious injury" (Beck et al., 2009, p. 84)  were given group cognitive behavioral therapy in order to determine the effects of the treatment. These individuals had experienced MVA "at least 6 months prior to assessment and their emotional response included intense fear, helplessness, horror, or the perception that they would die" (Beck et al., 2009, p. 84). The Clinician-Administered PTSD Scale (CAPS) was conducted to evaluate the participants' PTSD symptoms, and during the 14-week investigation, exposure therapy was used for treatment. At the end of the sessions, the CAPS was administered again to determine the effectiveness of the treatment.**http%3A/ to the results obtained, "88.3% of patients receiving GCBT did not satisfy criteria for PTSD" (Beck et al., 2009, p. 82) after undergoing treatment. Therefore, the study concluded that group cognitive behavioral therapy is effective in treating the symptoms of PTSD in adults who have experienced MVAs. However, at the end of the study, the investigators reported the limitations of the experiments. These include the fact that the study group was small, follow-up was conducted over a short period of time, the investigation was conducted strictly on survivors of MVAs, and the investigation "conducted by its developers" (Beck et al., 2009, p. 90).   

Exposure-Based Cognitive-Behavioral Treatment of PTSD in Adults with

Schizophrenia or Schizoaffective Disorder: a Pilot Study

            B. Christopher Frueh et. al. (2009) studied the effect of Cognitive Behavioral Therapy on the symptoms of PTSD in adults with either schizophrenia or schizoaffective disorder. During this study, 13 participants with either of these disorders were studied, and the intervention methods included "psycho-education, anxiety management therapy, social skills training, and exposure therapy" (Frueh et al., 2009, p. 667) and lasted for 22 weeks. The participants were evaluated with the CAPS and PTSD Checklist both before and after treatment. At the conclusion of the study, "12 of 13 completers no longer met criteria for PTSD or were considered treatment responders" (Frueh et al., 2009, p. 673), therefore, proving the effectiveness of CBT in treatment of PTSD in individuals mentally ill with schizophrenia or schizoaffective disorder. However, this study was limited because of its small experimental groups and because only two mental illnesses were investigated in conjunction with CBT.



Psychological Treatment of Post-Traumatic Stress Disorder (PTSD

Jonathan Bisson and Martin Andrew (2009) reviewed 33 studies that tested the effects of the use of "any psychological treatment designed to reduce symptoms of PTSD" in adults displaying symptoms of PTSD for three months or more. The treatment types reviewed were Trauma Focused Cognitive Behavioral Therapy (TFCBT), "Stress management/relaxation" (Bisson and Andrew, 2009, p. 3) or any psychological treatment that used non-trauma focused CBT techniques, TFCBT Group Therapy, Non-trauma focused CBT group therapy, Eye movement desensitization reprocessing (EMDR), and "Wait list/usual care" that "ranged from no intervention at all to undefined psychological input and/or drug treatment that was not fully described" (p. 3). In the studies, the Clinician Administered PTSD Symptom Scale, Impact of Event Scale, the Beck Depression Inventory, and the Spielberger State Trait Anxiety Inventory were used to measure the outcomes. Additionally, participant drop-out rates, PTSD diagnosis after treatment, and increased PTSD symptoms were also measured. After reviewing previous investigations, Bisson and Andrew concluded that "there was evidence individual TFCBT, EMDR, stress management and group TFCBT are effective in the treatment of PTSD" (p. 2). Additionally, they concluded that "other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly" (p. 2). The reviewers acknowledge a need for further analysis and research that would include "well-designed trials of psychological treatments…that consider boundary issues (e.g. predictors for treatment effects), large EMDR trials, further comparison studies of one type of psychological treatment against another, trials that consider adverse events in more detail, and the role of psychological treatment in combination and as an alternative to medication" (Bisson and Martin, 2009, p. 19). Therefore, while the researchers are indicating that investigations done in the past have demonstrated that forms of CBT are effective treatment options, they cannot conclude that they are the most effective because they have not been compared solely to another treatment option.**http%3A/







Life After Trauma

Scientific Research seems to agree with the information that can be found on the NIMH, NCPTSD, BABCP, and NACBT websites. CBT appears to be an effective treatment option for patients with PTSD. The studies previously noted indicate that the treatment can be in effective in decreasing PTSD symptoms in children, mentally ill adults, and other non-mentally ill adults. However, all studies also indicate that further investigation needs to be conducted comparing the efficacy of CBT to other treatment options to determine if it is the most helpful choice because no study concluded that the treatment was "the best" or "the most effective."

Life after trauma is never easy, and PTSD can worsen the after-effects of a traumatic event in the lives of patients, family members, and friends of the patient alike. However, according to the research, with therapies such as CBT and the many other treatment options that are available today, patients with PTSD can learn to accept their past traumatic experiences and move forward. With a little assistance, the transition can be made.












Web Sources:






Academic Sources:

1.    Habigzang, L. F., Streher, F. H., Hatzenber, R.,Cunha, R. C., da Silva Ramos, M., &

       Koller, S. (2009). Cognitive behavioral group therapy for sexually abused girls.    

       (2009), Rev Saúde Pública, 43, 1-9.

2.    Beck, J. G., Scott, F. C., Foy, D. W., Keane, T. M., & Blanchard, E. B. (2008). Group

        Group cognitive behavior therapy for chronic posttraumatic stress disorder:

        an initial randomized pilot study. Behavior Therapy, 20, 82-92.

3.    Frueh, B. C., Grubaugh, A. L., Cusack, K. J., Kimble, M. O., Elhai, J. D., & Knapp, R.

        G. Exposure –based cognitive-behavioral treatment of PTSD in adults with

        schizophrnia or schizoaffective disorder: a pilot study. Journal of Anxiety

        Disorders, 23, 665-675.

4.    Bisson J, & Andrew M. (2007).  Psychological treatment of post-traumatic stress

         disorder (PTSD). Cochrane Database of Systematic Reviews 2007, 3, 1-105.




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