Cognitive behavioral therapy (CBT) is a psychotherapy treatment focused on problem-solving and actions-based solutions to mental health issues. CBT can be effective for PTSD because it can help a person understand and challenge unhealthy thought processes and emotions brought on by PTSD, reducing symptoms and improving quality of life. CBT generally occurs for about 12-20 sessions, with weekly sessions lasting about 50 minutes.
How Does CBT Help With PTSD?
Cognitive behavioral therapy is a positive and effective treatment for post-traumatic stress disorder (PTSD).2 CBT helps those with PTSD by challenging the unhealthy thought processes and emotions connected to someone’s trauma. Challenging these thought processes allows the patient to acknowledge the reality of the trauma. In addition, CBT can help by increasing someone’s emotional insight through exploring responses to reminders of the trauma.
By increasing insight to the connection between someone’s 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.2
Common CBT Interventions for PTSD
While there are a variety of techniques in the general CBT toolbox, specific approaches exist to help reduce symptoms of PTSD, such as cognitive restructuring and stress inoculation training.
Common CBT techniques and interventions for PTSD include:
Negative and maladaptive thought processes can impact someone’s memories and emotions connected to the traumas they’ve experienced. Cognitive restructuring 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.2,3
Those experiencing PTSD may engage frequently in avoidance of people, places, sounds, and other things that remind them of their previous trauma. Exposure therapy introduces individuals to increasing levels of the stress-related stimulus. They will begin to learn how to cope with these until their anxiety levels lower and, ideally, become non-existent when confronted with the stimuli.
Cognitive Processing Therapy
Cognitive processing therapy is a form of CBT specifically for people with 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.6,8,9
Stress Inoculation Training
Stress inoculation training for PTSD can be provided independently or with other treatments. It focuses on teaching coping techniques to help lower anxiety when experiencing stress-related stimuli in PTSD. Healthier coping techniques, such as breathing sessions, progressive muscle relaxation skills, and communication skills are used to increase clients’ ability to cope during times of stress or triggers.2,3,9
Eye Movement Desensitization & Reprocessing (EMDR)
Eye movement desensitization and reprocessing (EMDR) is a newer treatment in the CBT world that focuses on talking about the traumatic event or memories, processing this information, and giving attention to a back and forth movement with the eyes. 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.1,5,9
Acceptance & Commitment Therapy (ACT)
Acceptance and commitment therapy is a newer model of 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 reduces the power that the trauma event has on the individual. ACT is an offshoot of mindfulness-based and CBT-based specific treatments that continues to be developed. Mindfulness techniques help to provide coping skills to reduce anxiety related to PTSD.1,3,6,9
Is CBT Effective for PTSD?
While cognitive behavioral therapy research continues to grow, it is one of the most widely-researched psychotherapy treatments and has been found to be effective in short- and long-term approaches as well as with a variety of populations, ranging from PTSD in young children to older adults.2,4
Here are several studies highlighting the effectiveness of CBT for PTSD:
- CBT has been researched and observed to be as effective as a number of other therapy types, and research indicates that it has been culturally validated across a variety of populations.4
- Compared to a placebo, CBT was reported to be moderately helpful in treating anxiety-related disorders. The researchers did note that drop out rates were higher in PTSD samples, especially in the exposure therapy group, which infers a need for more specialized types of CBT for PTSD.11
- A research review notes that CBT can be an appropriate, safe, and helpful intervention in the presentation of acute and chronic PTSD for people of any age.4
- Research noted a significant improvement and significant reduction in symptoms of PTSD, in addition to feelings of depression and anxiety.12
- After reviewing clinical trials ranging from 1980 to 2005, researchers noted that CBT had significantly maintained healthy behaviors after treatment in comparison to EMDR and therapies that are more supportive. CBT was equal to exposure therapy and cognitive therapy in reducing PTSD symptoms and the maintenance of healthy behaviors.13
Examples of CBT for PTSD
There are a variety of CBT treatments that exist to help someone dealing with PTSD. Everyone experiences mental health differently and PTSD is not an exception to this.
Here are a few examples regarding specific treatment options as well as how they apply to each example’s experience of PTSD:
CBT for PTSD in a Veteran
Jamie, a 36-year-old Iraq war veteran, reports having had symptoms of PTSD for the past six and a half years. He continuously avoids 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 traveling to another base.
Jamie reports a history of difficulties attending work for a number of days out of the week, repeated nightmares of the event, higher levels of depressive moods along with some irritability, and difficulty feeling connected with his spouse and other family members.
Jamie goes to 12 to 16 sessions of cognitive behavioral therapy with a focus on prolonged exposure to process these emotions and thoughts to reduce avoidance. During these sessions, the therapist assigns Jamie weekly homework assignments to regularly practice coping skills. The therapist encourages Jamie to journal his anxiety levels each day to increase awareness of stress, anxiety, and his other symptoms. In doing so, Jamie’s therapist hopes that he will increase self-expression about how he is feeling to be able to rely both on himself and a support system. This helps Jamie to monitor and reduce the impact of his symptoms by becoming aware of his warning signs and the need to initiate his coping skills.
CBT for PTSD From Witnessing Violence
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, and she avoids the place where her brother died and thoughts about her brother’s death. She reports continuous increasing ruminative thought and guilt surrounding her lack of protection of her brother, as well as irritability and depression throughout the year.
Sarah’s PTSD symptoms 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.
Sarah begins seeing a therapist to process her symptoms and her traumatic experience. Her therapist begins challenging her in each session to use more healthy thinking patterns and to engage in coping techniques. When Sarah’s anxiety levels rise, the therapist helps her by pointing out the unhealthy thought or increased stress response and allowing her time to practice restructuring her thoughts and engaging in a breathing activity or to relax her muscles.
Sarah’s therapist also assigns her weekly homework of journaling her anxiety and symptom levels; she is encouraged to keep practicing thought restructuring and coping mechanisms outside of sessions and to log them as well. As Sarah and her therapist work on these tasks together, Sarah begins to communicate more about her emotions and become more aware of how blaming herself impacts her thoughts.
CBT for PTSD Caused by Abuse
Bill, a 40-year-old who was physically abused by his parents until he was 18, 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, constant tenseness in his body, and significant anger with people in his life.
At around 17 years old, Bill began drinking alcohol 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 of beer in a day, and has been arrested for disorderly conduct. He works infrequently but in the last three months has been unsuccessfully attempting to cut back on drinking and find regular work.
Bill agrees to complete an assessment with a local therapist who is trained in trauma and substance use treatment. The therapist diagnoses Bill with PTSD and an alcohol use disorder and informs Bill that they would like to try applying acceptance and commitment therapy (ACT) in their sessions. Bill’s therapist helps him by encouraging him to accept feelings or thoughts that come up during sessions; he hopes that Bill will begin to be able to do this at home, becoming accepting of himself in and out of session.
Bill and his therapist regularly practice mindful meditation and muscle relaxation in each session, especially if Bill’s therapist notices that he’s tense, talking about drinking cravings, or having difficulty calming his anger and anxiety in session. Over time, the therapist helps Bill to become more comfortable talking about the events of his past and his feelings. Bill begins to regularly engage in coping techniques independently in and out of session; he has begun to engage in more healthy self-expression instead of letting his anger explode onto others, and reducing his drinking as his avoidance symptoms have begun to reduce by using coping techniques.
4 At-Home CBT Exercises for PTSD
While it’s always best to find a licensed therapist if you’re experiencing PTSD symptoms, the therapist may recommend some at-home exercises to keep your symptoms under control.
Here are four CBT exercises you can use at home to reduce symptoms of PTSD:10
1. Try Practicing Cognitive Restructuring on Your Own
It can be helpful to challenge or reframe your thinking in the moment on a regular basis. It can be difficult, but it’s important to challenge negative thoughts as they come up. You can also start to notice when these thoughts come up to learn what may be triggering your PTSD symptoms.
2. Practice the ABC Technique
The ABC Model allows you to explore more about how or where a negative or maladaptive belief began.
Here are the first three steps:
- Identify the (A) activating event: The trigger that would lead to a significant emotional response or maladaptive thinking
- Identify the (B) belief: The negative thought that you experienced during this trigger or event
- Identify the (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 trigger or belief that influenced the consequences. By engaging in this practice in a journal, you can actively track the cognitive restructuring in a more structured manner, giving you the opportunity to challenge a belief or emotional response that may have started following a traumatic event.
As a follow up, keeping a journal of your thoughts, feelings, and behaviors each day may be helpful. Through writing and monitoring your thoughts and beliefs, you may begin to learn more about yourself, about the ABC’s that may be a trigger for your PTSD symptoms. You may also identify ways that have helped manage your symptoms in the past.
4. Meditation & Progressive Body Relaxation
Meditation has become highly popular in the last few years in the physical and mental health fields. When dealing with PTSD symptoms, it may be common for you to struggle with constant tenseness in your body that you feel like you can’t release.
By engaging in guided meditations, guided breathing, grounding exercises, 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.
How to Find a CBT Therapist for PTSD
Choosing a therapist can be challenging, but an online directory can be a good place to start, or you can ask your primary care provider for a referral. Many therapists now offer teletherapy which has enabled people to get CBT online and expanded the number of therapists people have access to.
How Much Does It Cost?
CBT sessions typically range from about $100 to $200 per session, generally falling around $125 if you are paying out of pocket. Most CBT therapy styles are covered by insurance, although this does depend on the type of insurance you have. With coverage, CBT session copays can range from $25 to $75 dollars if you are doing individual sessions. In addition, there are mental health professionals who are generally willing to provide income-based or sliding scale fees for sessions.
What Are the Alternatives to CBT for PTSD?
While cognitive behavioral therapy is a common therapy style for treating PTSD, there are other approaches that may work better for others. These options are also evidence-based treatments and have been studied on their efficacy in treating PTSD symptoms.
Alternatives to CBT for PTSD include:
- Eye Movement Desensitization and Reprocessing (EMDR): EMDR occurs by directing eye movements with lights to stimulate the brain to reassess and process trauma. It increases the individual’s ability to re-process the emotions and memories related to their trauma and learn to cope with them more effectively. A number of research studies indicate that EMDR can be effective on a short-term basis in PTSD treatment.14
- Cognitive processing therapy: CPT teaches individuals to acknowledge and identify, challenge, and eventually change irrational or unhealthy thoughts—that could later impact behaviors—related to their trauma history. CPT allows people the opportunity to increase flexibility in their thought process and belief system so that they do not become stuck in negative thoughts and emotions, especially in relation to their trauma.16
- Exposure Therapy: Exposure therapy works through exposure through images, sounds, or in real life to things that can increase panic, anxiety, or similar symptoms, working to desensitize the person to their triggers. Research indicates that exposure therapy can be effective in reducing PTSD symptoms, especially in lowering panic and anxiety symptoms and increasing the individual’s ability to cope with stress-inducing situations.15
- Narrative Therapy: Narrative therapy can be helpful in allowing someone to tell the story of their trauma and the context around it. In turn, it can help by allowing the individual to take ownership and re-write their own story in such a way that they can heal, increase feelings of self-esteem, and increase post-trauma growth and understanding.17
There are also several alternative and complementary therapies that can help someone process difficult flashbacks and emotions, like brainspotting and EFT tapping.
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, it can make a world of difference in how you feel.