1. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
Jennifer E. Kaufman
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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.

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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. Cognitive Behavioral Therapy for the Treatment of Post-Traumatic
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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

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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

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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.

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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

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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

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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

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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

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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.