Combined with SSRI medications Zoloft or Paxil the most effective first line treatment for PTSD is cognitive behavioral therapy (CBT). CBT is a combination of behavioral and cognitive psychology and focuses on challenging and changing unhelpful cognitive distortions (e.g. thoughts, beliefs, and attitudes) and behaviors using focused coping strategies that improve emotional regulation. “CBT is based on a model or theory that it’s not events themselves that upset us, but the meanings we give them. If our thoughts are too negative, it can block us seeing things or doing things that don’t fit – that disconfirm – what we believe is true. In other words, we continue to hold on to the same old thoughts and fail to learn anything new.”[1]
Using the basic principles of both approaches CBT takes focus on current problems (cognitive distortions and maladaptive behaviors) and devises action oriented protocols for addressing and changing them with new processing and coping strategies. Symptoms that produce distress like anxiety, depression and intrusive thoughts, flashbacks and nightmares can be reduced when the patient learns what coping strategies work and replaces what doesn’t work. The goal of cognitive behavioral therapy is not to diagnose a person with a particular disease, but to look at the person holistically and decide what thoughts and behaviors can be changed.
CBT protocol as designed by Kanfer and Saslow [3] has SIX phases:
The steps in the assessment phase include:
Interventions include distraction, imagery, motivational self-talk, relaxation and/or biofeedback, development of adaptive coping strategies (like minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, goal setting and mindfulness.
Interventions can be focused on cognitive restructuring (process of learning to identify and dispute irrational or maladaptive thoughts) or it can be behaviorally oriented through exposure therapy.
CBT may be delivered in conjunction with a variety of diverse techniques such as talk therapy, stress inoculation, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy, and mindfulness therapy that promotes self-awareness.
What to Expect
Your therapist will encourage you to talk about your thoughts and feelings and what's troubling you. Don't worry if you find it hard to open up about your feelings. Your therapist can help you gain more confidence and comfort.
CBT generally focuses on specific problems, using a goal-oriented approach. As you go through the therapy process, your therapist may ask you to do homework activities (like reading, journaling, repeating positive affirmations or mindful meditation) to build on what you learn during your regular therapy sessions. These activities encourage you to apply what you're learning in your daily life.
Through sessions you will:
CBT isn't effective for everyone. But you can take steps to get the most out of your therapy and help make it a success.
Length of therapy
CBT is generally considered short-term therapy — ranging from about five to 20 sessions. You and your therapist can discuss how many sessions may be right for you.
- Behaviorism or Behavioral Psychology is a systematic approach to understanding that the behavior of humans are either reflexes produced by a response to a specific stimulus in the environment or a consequence of that individual's history, especially in the area of reinforcement and punishment. Behaviorists, however, are more concerned with environmental stimuli that influence current thoughts and behaviors opposed to historical.
- Cognitive psychology is the scientific study of mental processes such as attention, language use, memory, perception, problem solving, creativity, and thinking.
Using the basic principles of both approaches CBT takes focus on current problems (cognitive distortions and maladaptive behaviors) and devises action oriented protocols for addressing and changing them with new processing and coping strategies. Symptoms that produce distress like anxiety, depression and intrusive thoughts, flashbacks and nightmares can be reduced when the patient learns what coping strategies work and replaces what doesn’t work. The goal of cognitive behavioral therapy is not to diagnose a person with a particular disease, but to look at the person holistically and decide what thoughts and behaviors can be changed.
- Cognitive distortions are symptoms of distorted thought and can include self defeating responses like overgeneralizing, magnifying negatives, minimizing positives, and catastrophizing. They are either a pseudo-discrimination belief or an over-generalization of something. Other distortions include all-or-nothing thinking (splitting), magical thinking, and emotional reasoning.
- Maladaptive behaviors are dysfunctional actions that may provide short-term relief but are non-productive because they do nothing to alleviate the root of the problem. In PTSD behaviors are disassociation (avoidance, withdrawing, self harm, suicidal ideation, or risky behavior like substance abuse) or inappropriate responses to distress like irritability, aggression, and misplaced or misdirected anger.
CBT protocol as designed by Kanfer and Saslow [3] has SIX phases:
- Assessment or psychological assessment;
- Reconceptualization;
- Skills acquisition;
- Skills consolidation and application training;
- Generalization and maintenance;
- Post-treatment assessment follow-up.
The steps in the assessment phase include:
- Identifying critical behaviors
- Determining whether critical behaviors are excesses or deficits
- Evaluating critical behaviors for frequency, duration, or intensity (obtain a baseline)
- Attempting to decrease frequency, duration, or intensity of behaviors in the event of excess
- Attempting to increase frequency, duration, or intensity of behaviors in the event of deficit[3]
Interventions include distraction, imagery, motivational self-talk, relaxation and/or biofeedback, development of adaptive coping strategies (like minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, goal setting and mindfulness.
Interventions can be focused on cognitive restructuring (process of learning to identify and dispute irrational or maladaptive thoughts) or it can be behaviorally oriented through exposure therapy.
- Cognitive restructuring helps people make sense of bad memories. They often remember their trauma differently than how it happened (like not remembering certain parts of the trauma, remembering it in a distorted way). It is common for people to feel guilt of shame about aspects of their trauma that were not actually their fault. Cognitive restructuring helps people look at what happened with fact to get a realistic perspective on the trauma.
- Exposure therapy is safely exposing the patient to the anxiety source - without the intention to cause any danger - to help overcome the anxiety or distress surrounding it. It is direct confrontation of feared objects, activities, or situations. For example, a rape victim who fears the location where she was assaulted may be assisted by her therapist in going to that location and directly confronting her fears. Exposure or confrontation leads to the harmful conditioning being "unlearned” returning a sense of control, self-confidence, and predictability to the patient while reducing escape and avoidance behaviors.
CBT may be delivered in conjunction with a variety of diverse techniques such as talk therapy, stress inoculation, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy, and mindfulness therapy that promotes self-awareness.
What to Expect
Your therapist will encourage you to talk about your thoughts and feelings and what's troubling you. Don't worry if you find it hard to open up about your feelings. Your therapist can help you gain more confidence and comfort.
CBT generally focuses on specific problems, using a goal-oriented approach. As you go through the therapy process, your therapist may ask you to do homework activities (like reading, journaling, repeating positive affirmations or mindful meditation) to build on what you learn during your regular therapy sessions. These activities encourage you to apply what you're learning in your daily life.
Through sessions you will:
- Identify troubling situations or conditions in your life.
- Become aware of your thoughts, emotions and beliefs about these problems.
- Identify negative or inaccurate thinking.
- Reshape negative or inaccurate thinking.
CBT isn't effective for everyone. But you can take steps to get the most out of your therapy and help make it a success.
- Approach therapy as a partnership. Therapy is most effective when you're an active participant and share in decision-making. Make sure you and your therapist agree about the major issues and how to tackle them. Together, you can set goals and assess progress over time.
- Be open and honest. Success with therapy depends on your willingness to share your thoughts, feelings and experiences, and on being open to new insights and ways of doing things. If you're reluctant to talk about certain things because of painful emotions, embarrassment or fears about your therapist's reaction, let your therapist know about your reservations.
- Stick to your treatment plan. If you feel down or lack motivation, it may be tempting to skip therapy sessions. Doing so can disrupt your progress. Attend all sessions and give some thought to what you want to discuss.
- Don't expect instant results. Working on emotional issues can be painful and often requires hard work. It's not uncommon to feel worse during the initial part of therapy as you begin to confront past and current conflicts. You may need several sessions before you begin to see improvement.
- Do your homework between sessions. If your therapist asks you to read, keep a journal or do other activities outside of your regular therapy sessions, follow through. Doing these homework assignments will help you apply what you've learned in the therapy sessions.
- If therapy isn't helping, talk to your therapist. If you don't feel that you're benefiting from CBT after several sessions, talk to your therapist about it. You and your therapist may decide to make some changes or try a different approach.[2]
Length of therapy
CBT is generally considered short-term therapy — ranging from about five to 20 sessions. You and your therapist can discuss how many sessions may be right for you.