Cognitive behavioral therapy is a psychotherapy treatment that takes a problem-solving and actions-based perspective to mental health concerns. CBT generally occurs for about 12 sessions, with weekly sessions lasting about 50 minutes. CBT for PTSD is effective because it can help a person understand and challenge unhealthy thought processes and emotions brought on by PTSD.
Central Concepts of Cognitive Behavioral Therapy
Cognitive behavioral therapy is based on the connection between emotions, thoughts, and actions. It posits that the difficulties one experiences with mental health symptoms are attributed to disruptions in one or any of these areas, impacting the ability to stabilize in the others.1 This type of therapy focuses on the thought process that leads to certain emotions and significant behaviors.2 The main goal is to help gain a better understanding of one’s thoughts, worldviews, and emotions to reduce negative thoughts and unhealthy behaviors.
CBT is also based on structure and outside applications of what one is learning in session. Each week, one can expect to receive a suggestion for “homework” to improve insight to their thoughts. CBT is also highly structured, which encourages one to apply what they have learned in session and see how it works in their daily life to better increase their functioning.
How Can CBT Help With PTSD?
Cognitive behavioral therapy is considered a positive and effective treatment for post-traumatic stress disorder (PTSD).3 CBT for PTSD helps by challenging the unhealthy thought processes and emotions connected to one’s trauma. Challenging these thought processes allows the patient to acknowledge the basic reality of the trauma. In addition, CBT can help by increasing one’s emotional insight through exploring responses to reminders of the trauma.
By increasing one’s insight to the connection between their responses and emotions, CBT can help people with PTSD reduce the negative impacts of their panic responses in their daily life and reduce the severity of these responses. CBT can also help to reduce avoidance behaviors. This aspect of CBT can reduce isolation and withdrawal as well as trigger responses in those with PTSD. Overall, CBT is useful to help those with PTSD to have a higher level of functioning in their daily life.3
Common CBT Techniques Used for PTSD
CBT uses a number of different techniques, models, and applications to help individuals with PTSD. While there are a variety of techniques in the general CBT toolbox, specific approaches exist to help reduce symptoms in those experiencing PTSD.
Some common CBT techniques and models for PTSD include:
Cognitive Restructuring
As mentioned above, negative and maladaptive thought processes can impact individuals’ memories and emotions connected to the traumas themselves. This tool is a main piece of CBT as it is used in helping one to explore, challenge, and ideally begin trading these negative thoughts with more positive and healthy ones grounded in reality.3,4
Exposure Therapy
Those experiencing PTSD may engage frequently in avoidance of people, places, sounds, and other things that remind them of their traumas. Exposure therapy introduces individuals to increasing levels of stress-related stimulus. They will begin to learn how to cope with these until their anxiety levels lower and, ideally, become non-existent to the stimuli.
There is a variety in the exposure therapies offered, but more common ones in the treatment of those with PTSD include graded (ranking one’s levels of stress-related stimuli and beginning at the lowest and working up to reduce anxiety levels) and prolonged exposure (exposure to images of stress-related stimuli over time to decrease related anxiety levels).1,3,4,7,9
Cognitive Processing Therapy
Cognitive processing therapy is a form of CBT specifically for those experiencing PTSD. Individuals are encouraged to consider how the event happened and how it changed their thoughts. They are challenged to consider the factual basis of these thoughts or if they have formed negative or maladaptive thoughts as a result.7,9,10
Stress Inoculation Training
This training is a tool that can be provided independently or with other treatments to teach individuals with PTSD. It focuses on teaching coping techniques to help lower anxiety as they experience stress-related stimuli in PTSD.
Healthier coping techniques, such as breathing sessions, progressive muscle relaxation skills, and communication skills are used to increase their self-expression about their concerns.3,4,10
Eye Movement Desensitization & Reprocessing (EMDR)
Eye movement desensitization and reprocessing (EMDR) is a newer treatment in the CBT world that focuses on talking about stress-related stimuli (i.e. the trauma event or memories), processing this information, and giving attention to a back and forth movement with their eyes.
Some suggest the exposure itself is effective, but others have reported EMDR to be effective in treating PTSD. Ideally, the purpose is to match the way you mentally process memories unconsciously to help reduce the amount of stress and anxiety related to the memories.1,6,10
Acceptance & Commitment Therapy (ACT)
Acceptance and commitment therapy is also a newer model in CBT. It focuses on acknowledging and accepting one’s thoughts and emotions surrounding the stress-related stimuli and memories of the traumas instead of necessarily controlling or challenging one’s thoughts.
While it does involve CBT techniques, ACT is being developed to reduce the power that the trauma event has on the individual. ACT has an offshoot of mindfulness-based and CBT-based specific treatment that continues to be developed. These are where mindfulness techniques often come in to provide coping skills to reduce anxiety where one can acknowledge their feeling.1,4,7,10
Examples of CBT for PTSD
As one can see above, there are a variety of CBT treatments that exist. In addition, everyone experiences mental health differently and PTSD is not an exception to this. Below, one can see a number of examples regarding specific treatment options as well as how they apply to each example’s experience of PTSD.
Jamie
Jamie, a 36-year-old Iraq war veteran, reports the presence of symptoms of PTSD for six and a half years. He continuously avoided thoughts, memories, or images (even in media) that could be connected with the experience of his fellow unit members and himself driving over an explosive device while driving a truck between bases.
As time passed, Jamie reports a history of difficulties attending work for a number of days out of the week, repeated nightmares of the event itself that were consistent with the traumatic event, higher levels of depressive moods along with some irritability, and difficulty feeling connected with his spouse or their in-laws.
With every anniversary since his return and debriefing, Jamie has worsening PTSD symptoms. He reports a difficulty with coping with these symptoms as time occurs. He reports anger and irritability impacting his relationship, continuous sleep issues causing issues for his ability to focus in addition to the other symptoms. He does deny suicidal thoughts, but is concerned that they may occur in the future.
Due to the extent of his symptoms, the nightmares, the ruminative thoughts and continuous avoidance of his symptoms, Jamie would benefit from 12 to 16 sessions of cognitive behavioral therapy with a focus on prolonged exposure to process these emotions and thoughts, reduce avoidance and the impacts of this on his functioning, and regular homework to practice the coping skills and self-expression he is learning to express his needs regarding avoidance.
Sarah
Sarah, a 22-year-old who witnessed her younger brother’s murder by gunshot, has been experiencing symptoms of PTSD for 3 years. She has recurrent nightmares of the murder, although sometimes the nightmare is incorrect and shows Sarah stepping aside to allow her brother to be shot voluntarily. She avoids the place where her brother died and thoughts about her brother’s death.
However, she reports continuous increasing ruminative thought and guilt surrounding her lack of protection of her brother, as well as irritability and depression on a low level throughout the year. These feelings increase significantly around the anniversary of her brother’s death, and she is easily startled by the sound of gunshots, even in the media. She reports flashbacks if she does experience a trigger and often finds it difficult to connect with her family, her spouse, and her child.
Sarah expressed frustration with the continuous emotional disconnect as well as the PTSD symptoms that have begun to seriously impact her work relationships and with her family. After being assessed for comorbid symptoms of grief and depression in addition to PTSD, Sarah would benefit from about 12 sessions of a combination of CBT and cognitive processing therapy.
Due to her rumination, the inconsistency of the nightmares to the event itself, the grief and guilt related to the murder, and continuous difficulty in her relationships due to negative thoughts, Sarah would benefit from a focus on cognitive restructuring techniques, added stress inoculation training for coping, weekly homework, or journaling, and a structured schedule of the combined therapies above to reduce these symptoms.
Bill
Bill, a 40-year-old who was physically abused by his parents until he was 18 years old and reports a history of PTSD symptoms beginning in his early 20’s. He experienced a heightened startle reflex to any sudden movement, avoidance of talking about the abuse he experienced overall, constant tenseness in his body, and significant anger with people in his life, even if it’s over a smaller situation. He does not report flashbacks nor nightmares frequently but reports these can occur after he attempts to reconcile with his parents.
At around 17 years old, Bill began drinking alcohol when he could to cope with the abuse he was experiencing at home. This led to alcohol charges for a minor for which he was placed in juvenile detention. He now drinks daily, generally at least twelve 16-oz cans beer in a day, and has been arrested for disorderly conduct. He works infrequently but has been attempting to cut back unsuccessfully and find regular work within the last 3 months.
Bill reports anger with himself about the emotions related to his abuse (shame, guilt) and that he drinks to cope with the thoughts and the emotions surrounding his abuse. He is agreeable to treatment. After a complete assessment of comorbid alcohol use and PTSD symptoms, Bill would benefit from 12 to 18 sessions of acceptance and commitment therapy in addition to treatment with a therapist who is trained in substance use disorders and withdrawal protocol to begin processing the traumatic events and the emotions related to them. ACT would also help Bill develop coping mechanisms and potential mindfulness techniques to help reduce tension in his body, and to reduce the complete avoidance of these symptoms to increase his functioning.
R.J.
R.J., a 33-year-old combat medical specialist who had completed two tours in Afghanistan, was recently honorably discharged from the Army branch. He reported PTSD symptoms that had become more severe while serving in his second tour; he reported difficulties with blowing up on people, difficulty managing his mood, frequent irritability, nightmares, a significant startle response, and flashbacks (if he experiences triggers).
R.J. has reported difficulty connecting with his support system since his return, which has made things difficult since his significant other is 3 months pregnant, and he fears he does not connect with his significant other and may be similarly numb with his unborn child.
R.J. would benefit from an EMDR referral- which his VA counselor provided- and will need to meet with his therapist twice a week for an hour, once a day. He will be working with this therapist on processing memories from his first and second tour, the triggers that bring out his current symptoms, and will be processing ways to handle these stress-related stimuli when they occur at later points.
Is CBT Effective for PTSD?
While cognitive behavioral therapy research continues to grow, it is one of the most widely searched psychotherapy treatment styles as it continues to apply to more populations. Overall, CBT has been found to be efficacious in short- and long-term approaches as well as with a variety of populations, ranging from very young children to adults.3,5
CBT has been researched and observed to be as effective as a number of other psychological treatments and research indicates that it has been culturally validated across a variety of populations.5 This being said, CBT is not easily accessed as therapists need to be trained- even briefly- in this field and it can be difficult for therapists in the needed populations to be able to access the needed training.7
How to Find a CBT Therapist for PTSD
For those struggling with PTSD, working with a certified CBT therapist may be helpful. It can be a difficult place but it is important to know you are not alone. It may feel like a daunting task but there are resources that can help with the process of helping you explore who may be the right fit for you and what is happening in your life.
It is important to remember that if you are specifically looking for a CBT therapist, it is important to ensure they are licensed in CBT when exploring them to find the best fit for you.. Choosing a therapist can be challenging, but directories of mental health professionals are a good place to start.
4 At-Home CBT Exercises for PTSD
Although the process to find a CBT therapist for your PTSD symptoms may be difficult, this does not mean there are no options out there available to you.
Here are four CBT exercises you can use at home to reduce symptoms of PTSD:
1. Try Practicing Cognitive Restructuring on Your Own
While it can be difficult, it is helpful to challenge or reframe your thinking in the moment to help you learn how to do this on a regular basis. Even if the thought is not based in guilt or anxiety, it is productive to challenge negative thoughts about yourself, if there is no truth in them, to help reduce negative emotions and increase knowledge of when you begin to engage in negative thought processes.2
2. Practice the ABC Technique
This technique refers to the irrational thought technique in CBT. It allows you the chance to explore more about how or where a negative or maladaptive belief began.
The first three steps include:
- Identifying the (A) activating event: The trigger that would lead to a significant emotional response or maladaptive thinking)
- Identifying the (B) belief: The negative thought that you experienced during this trigger or event),
- Identifying (C) consequences: The negative emotions or actions that happened as a result of A & B
This gives you the chance to challenge your interpretation of the event or belief that influenced the consequences. By engaging in this in a journal, you can actively track the above cognitive restructuring in a more structured manner but will give you the opportunity to challenge a belief or emotional response that may have started following a traumatic event.2
3. Journaling
As a follow up, keeping a journal of your thoughts, feelings, and behaviors each day can be helpful for you. Through your writing and monitoring, you may begin to learn more about yourself, about the ABC’s that may be a trigger for your PTSD symptoms, and identifying ways that have possibly helped manage your symptoms in the past.2
4. Meditation & Progressive Body Relaxation
Meditation has become highly popular in the last few years in the physical and mental health fields. In PTSD symptoms, it may be common for you to struggle with constant tenseness in your body that you feel like you can’t loosen or even influence easily being startled because your body is in physical fight or flight mode.
By engaging in guided meditations (available on youtube or meditation apps), guided breathing, grounding exercises, and/or guided progressive relaxation, you should be able to relax your body and maybe even your anxiety levels, especially if you’ve recently experienced a trigger. It has previously been proven to help with addictions, PTSD and other anxiety disorders, mood disorders, and other issues.2
Final Thoughts on CBT for PTSD
If you are struggling with PTSD symptoms, CBT can help with increasing your awareness of your physical basic status, your emotional status, and your thought process. While it may not be easy to reach out for help, even trying some coping skills for yourself can be useful in reducing how much your life may have been impacted by the traumatic events you may have unfortunately experienced. Cognitive behavioral therapy and other treatment styles are an option for the struggles you may be experiencing and you are not alone.
