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Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
2
Introduction
There are a number of ...
Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
3
3. Acting or feeling as if the trau...
Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
4
Cognitive Behavioral Therapy for PT...
Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
5
trauma survivors to become alert to...
Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
6
to the client by the therapist so t...
Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
7
The Therapeutic Relationship
Cognit...
Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
8
than 50 times”), 5-point duration (...
Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
9
personal relations. This measuremen...
Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
10
therapy. In a similar study, 50–60...
Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
11
for future research is to examine ...
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PTSDCBT

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  1. 1. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 2 Introduction There are a number of techniques for the treatment of Post-Traumatic Stress Disorder (PTSD). However, Cognitive Behavioral Therapy (CBT) is one of the only evidence-based treatments available for PTSD. CBT is a broadly used therapy for a multitude of mental disorders especially anxiety related disorders, such as Post-Traumatic Stress Disorder. The use of CBT with war veterans has been increasingly popular due to the effective treatment strategies that CBT encompasses. CBT has been shown to be the most effective and evidence based practice for the treatment of PTSD regardless of the type of trauma. CBT has also been shown to be equally effective in the treatment of PTSD in children and adults and men and women. Post-Traumatic Stress Disorder Diagnostic Criteria Post-Traumatic Stress Disorder or PTSD, according to the Diagnostic Statistical Manual IV (2000), can be defined as, “is a psychological condition that reflects the development of characteristic symptoms following exposure to extremely devastating traumatic events.” The DSM IV (2000) states that the diagnostic criteria for PTSD is as follows, A. The individual has been exposed to a traumatic event, which the following are present, 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person's response involved intense fear, helplessness, or horror. NOTE: In children, this may be expressed instead by disorganized or agitated behavior. B. The traumatic event is persistently re-experiences in one or more of the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. 2. Recurrent distressing dreams of the event. NOTE: In children, there may be frightening dreams without recognizable content.
  2. 2. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 3 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5. Physiologic reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 1. Effort to avoid thoughts, feelings, or conversations associated with the trauma. 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma. 3. Inability to recall important aspects of the trauma. 4. Marked diminished interest or participation in significant activities. 5. Feeling of detachment or estrangement from others. 6. Restricted range of affect. 7. Sense of foreshortened future D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following: 1. Difficulty falling asleep. 2. Irritability or outbursts of anger. 3. Difficulty concentrating. 4. Hyper vigilance. 5. Exaggerated startle response. E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of function. Specify if: Acute: If duration of symptoms is less than three months Chronic: If duration of symptoms is three months or more With Delayed-Onset: If the onset of symptoms is at least six months or more after the stressor occurred.
  3. 3. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 4 Cognitive Behavioral Therapy for PTSD Cognitive Behavioral Therapy for Post-Traumatic Stress Disorder aims to alter the behaviors and cognitions that developed in response to trauma and maintain PTSD. CBT emphasizes a shared partnership between the client and the therapist; and therefore, it therapy begins with education about the underlying principles of CBT and treatment, so that client can be an educated participant in treatment. Treatment also looks at avoidance behavior and unrealistic or unhelpful thinking, which according to the CBT model are key features for the maintenance of PTSD. A number of variants of CBT for PTSD have been developed. Different forms can be labeled by their core components (e.g., cognitive restructuring or exposure), or they may be referred to by specific names such as cognitive processing therapy or prolonged exposure (Foa & Rothbaum, 1998). However, most forms of CBT for PTSD consist of three main mechanisms which emphasized: psychoeducation, exposure, and cognitive restructuring. Briefly stated, psychoeducation provides patients with information about the cognitive behavioral formulation of PTSD and it facilitates patients’ understanding of the treatment foundation. The establishment of a collaborative understanding of PTSD will also assist in the building of a working relationship between the client and the therapist. Exposure targets avoidance and involves positive encouragement by the therapist while the client approach feared stimuli, so that they learn that feared situation or stimuli does not need to be avoided. Exposure can take a number of forms: imaginal, in vivo, and interoceptive exposure. Imaginal exposure, a client repeatedly recounts trauma memories, where during in vivo (live) exposure, the client confronts specific situations or stimuli in real life. During interoceptive exposure the client experiences the avoided physical sensations. Cognitive restructuring teaches
  4. 4. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 5 trauma survivors to become alert to and modify obstructive thoughts. The client will learn to detect their thoughts, to recognize and confront maladaptive thinking, and to devise adaptive responses. Other CBT Interventions There are a multitude of approaches to CBT. Some of these approaches includes, but are not limited to; Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. According to Jongsma and Peterson (2006), the most effective Cognitive Behavioral approaches to help people with PTSD include psycho-education, relaxation and biofeedback, deep breathing, thought stopping, communication skills, guided self- dialogue, and cognitive restructuring: The goal of Psycho-education is to ensure that the patients understand the nature of PTSD and how the disorder individually affects them. There is often an immediate benefit when gaining an understanding of their symptoms, as the patient is relieved to learn that their symptoms fit into a coherent syndrome. Patients frequently feel as if they are losing their minds and through education, the patient will realize that they are not, in fact, losing their minds. Relaxation and Biofeedback are often used on a daily basis through the use of a professional relaxation tape. Biofeedback is useful for showing the connection between the way the client thinks ultimately effects the way they not only behave, but also how they feel. Deep (diaphragmatic) breathing is a way to calm the patient prior to and during in vivo (real life) exposure to the patient’s most feared situation. This technique is taught
  5. 5. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 6 to the client by the therapist so that the client can use the breathing exercise in and out of treatment. Thought Stopping is used to stop negative thoughts, which may contribute to the anxiety levels. With regular practice, this Thought Stopping can help to minimize the effects of negative thought processes. Communication skills can be used to speak of the incident in a controlled and healthy manner. Frequently PTSD sufferer will avoid discussing the traumatic event, however it is shown to be helpful with the recovery process. Guided self-dialogue, also referred to as positive self talk, provides a personalized self-help script for the clients to use when they feel anxious prior to, during, or after exposure sessions. Cognitive restructuring is the modification of the client’s thought processes and beliefs about themselves, their world, and their future. Cognitive restructuring is useful in restoring an optimistic outlook about the client’s future. CBT includes sensitive and thorough discussions to measure the patient’s response to certain stressful situations, not only with regard to the particular stressful event but also for other equally traumatic events. The objective is to prepare the patient by rehearsing coping skills, and by testing their reactions to real life events via in vivo exposure. Each client who is diagnoses with PTSD will be in need of tailor made services and interventions. That being said, not all of the above interventions are necessary for each client, where as some clients may need even further assistance to adequately treat their symptoms.
  6. 6. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 7 The Therapeutic Relationship Cognitive behavioral treatment puts an extreme emphasizes on the idea that therapy is based on the collaboration of the therapist and the client. Meaning that both of the client and the therapist work together to determine their goals, assignments, and means for success (Deville, 1999). A positive therapeutic relationship is vital to the success of CBT for the therapist to carefully cultivate the therapeutic alliance and pay attention to any tear within the relationship (Power, Brown, Buchannan, et al, 2002). Therapeutic relationships can be achieved a multitude of ways. Mainly, through collaboration the therapist can work with the client, by bringing skills, knowledge, emotion, and techniques that would assist the client throughout the process. Another way is through formulation, which are the organization of the presenting problems or situations, which will allow the client to incorporate information from assessments of the therapist. Third, the therapist uses the Socratic dialogue or guided discovery, which involves probing or questioning the client’s ideals. It explores and reflects on the client’s ways of reasoning and thinking differently. Finally, the therapist can assign homework to the client, so that the client can practice what they have learned during their therapy sessions. With the above methods, the therapeutic relationship between the client and the therapist can be established. Outcome evaluation methods The methods to assess the success of the use of CBT for the treatment of PTSD Keane,T., Fairbank, J. & Zimering, R (1989) developed the Combat Exposure Scale. The CES scale is a seven-item self-report that assesses wartime stressors experienced by soldiers. The items are rated on a 5-point frequency (1 = “no” or “never” to 5 = “more
  7. 7. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 8 than 50 times”), 5-point duration (1 = “never” to 5 = “more than 6 months”), 4-point frequency (1 = “no” to 4 = “more than 12 times”) or 4-point degree of loss (1 = “no one” to 4 = “more than 50%”) scale. Clients are asked to answer based on their exposure to various combat situations. The total CES score (ranging from 0 to 41) is calculated by using a sum of weighted scores, which can be classified into 1 of 5 categories of combat exposure ranging from “light” to “heavy.” The CES has been shown to be useful in both research and clinical settings. CES should be administered at the start of therapeutic intervention and at post-therapy to ensure the treatment has been effective. Another evaluation, The Stressful Life Events Screening Questionnaire (SLESQ), is a 13-item self-report measure that assesses lifetime exposure to traumatic events. Eleven specific and 2 general categories of events, such as a life-threatening accident, physical and sexual abuse, witness to another person being killed or assaulted, are examined. For each event, respondents are asked to indicate whether the event occurred (“yes” or “no”), their age at time of the event, as well as other specific items related to the event, such as the frequency, duration, whether anyone died, or was hospitalization, etc. The SLESQ has been recommended for research and general screening purposes. (Goodman, Corcoran, Turner, Yuan, Green, 1998). The Traumatic Stress Schedule or TSS interview measures essential information about potentially traumatic events. The TSS assesses ten events such as combat, robbery or motor vehicle accident. For each of the events, there are twelve questions that examine the dimensions of loss, scope, threat to life and physical injury. TSS also assesses the event that changed an important aspect of life such as residence, job or
  8. 8. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 9 personal relations. This measurement can be used for clinical and research purposes. (Norris, 1990). Although there are a number of scales to measure the effectiveness of CBT for the treatment of PTSD the above scales seem to be the most widely used at this time. These three scales can assist in the evaluation, both pro and post therapy, of whether the therapeutic interventions have been effective by comparing the pre and post evaluations. The scales can also be useful to monitor the client’s progress through out therapy. Current Research The study of the treatment of PTSD has received considerable attention due to the effects of wars during our time. Studies have looked at a number of different therapies, from psychoanalytic to Behavioral Therapy to Cognitive Behavioral Therapy to the use of a number of medications. Through out the numerous studies one thing remains clear; Cognitive Behavioral Therapy has shown to be the most effective in the treatment of PTSD. One study conducted by the Veteran’s Association (2009) concluded that cognitive-behavioral therapy is responsible in reducing symptoms of PTSD by 60% to 80%. Another study done by the Institute of Medicine (2007) evaluated 90 studies on PTSD treatment techniques and found that exposure-based therapies were the only treatments solidly backed by evidence. Foa and Freedman (2010) found that individuals suffering from PTSD who completed CBT were 65-80% were free of a PTSD diagnosis at follow up. Where as less then 40% of individuals were free of PTSD diagnosis that had completed supportive
  9. 9. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 10 therapy. In a similar study, 50–60% of participants who began treatment with CBT were PTSD diagnosis-free compared to 20% of those who began supportive counseling. Bryant (2002) looked at Civilian trauma survivors who had been diagnoses with acute stress disorder. The subjects were randomly assigned to either cognitive behavior therapy (CBT) or supportive counseling (SC). In a four-year follow up of the long-term effectiveness of the study’s treatments, the data showed that clients that received CBT only 8% met the PTSD criteria where as the 25% of clients who received SC met the criteria for PTSD. The study also found that clients who received CBT reported less intense PTSD symptoms, and particularly less frequent and less avoidance symptoms, verses clients who received SC. Overall, these findings reveal that early use of CBT in the month after trauma has long-term benefits for people who are at risk of developing PTSD. The research not only shows that Cognitive Behavioral Therapy is the most effective treatment for PTSD compared to other therapeutic interventions, but that it is considered to be the only evidence based practice for the disorder. CBT is effective for all types of PTSD, whether it be from sexual assault, combat, or a natural disaster. CBT is also shown to be equally effective among children and adults, and men and women. Recommendations for Future Research Future research should look at the different techniques within CBT to assess which techniques is the most useful and at what time the individual technique will be most effective. More research should also be done to evaluate the effectiveness on CBT within the different types of trauma. For instance, examining whether CBT is as effective on soldiers verses its effectiveness on civilians’ within a war torn country. Another idea
  10. 10. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic Jennifer E. Kaufman 11 for future research is to examine which techniques within CBT are the most effective depending on age and/or sex of the individual. I believe that future research on the above areas will enable therapists to not only treat the clients more effectively but also is a more time limited fashion. Conclusion Post-traumatic stress disorder is a debilitating and serious mental disorder which can effect almost any individual with whom has experienced a traumatic situation; be it war, a natural disaster, an untimely death, rape, etc. This disorder is especially relevant at this time due to the war our country is in and has been in for a number of years. That is why it is extremely important to research the best treatment possible for the treatment of PTSD. Cognitive Behavioral Therapy has been shown to be effective in the treatment of PTSD in a magnitude of studies through out the years, as has the use of psychotropic medications. However, every study has its limitations and those must be addressed to truly see whether a treatment is applicable to the majority of the population. Future research is necessary, as it is for any therapeutic technique, to ensure the technique is the more effective and timely intervention possible for those with the diagnosis of PTSD.

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