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Cognitive Behavioural Therapy for PTSD

Post-traumatic Stress Disorder is a condition that can affect anyone who has experienced a traumatic life event.  Flashbacks, Nightmares, feeling persistently anxious and avoiding reminders are all part of the condition which can have a considerable impact upon the lives on the sufferer and their loved ones.

This section focuses upon PTSD, highlighting the symptoms of PTSD, what processes keep PTSD going and, most importantly, how to treat it.  I cover two Cognitive Behavioural Treatment approaches to PTSD, detailing exactly what Cognitive Behavioural Therapy for PTSD looks like in practice, with a view to informing you about what to expect when you access help for Post-Traumatic Stress Disorder with Access CBT.

Through working in mental health services for over 10 years, I have seen that the quality and type of therapy offered to individuals with PTSD related problems can vary, and can deviate quite significantly from “best practice”.  After reading through this article, and the article on EMDR for PTSD, you will know what to expect from “gold standard” treatment.

CBT and EMDR are the only two types of treatment recommended by the National institute for Clinical Excellence for the treatment of PTSD in the UK.  If you have PTSD, then you should have Trauma focused CBT or EMDR.

Again, this is presented for information purposes and it is always recommended that you access treatment from an accredited CBT or EMDR therapist.  A good therapist will not only be able to deliver these techniques in an effective way, but will also make you feel safe, involved and supported throughout.  This is vitally important as working through Post-traumatic stress symptoms in therapy effectively can often be an intense emotional journey.

It’s important that your therapist is sufficiently skilled and is with you all the way.

What is Post-Traumatic Stress Disorder (PTSD) ?

Post-Traumatic stress disorder is a clinical term for a specific set of symptoms which can develop following a traumatic life event.

A traumatic event is as when a person experiences a real or perceived threat to their own life or safety, or witnesses (or hears about) a similar threat to somebody else. Common examples of traumatic events include natural disasters, road traffic accidents, illness and physical or sexual attack and abuse.

For somebody to be diagnosed with PTSD it means that they reach a certain “threshold” of having specific symptoms which are defined by one of two diagnostic manuals, the DSM-V and the ICD-10.  However, it is also common for people to not quite meet the clinical threshold of PTSD but still be troubled by related trauma symptoms.

The symptoms of PTSD include Flashbacks, feeling persistently anxious and on the look out for danger,  nightmares, avoidance of reminders of the event and emotional numbness.  All of these symptoms collectively serve to have a significant negative impact upon the individuals overall level of functioning and quality of life.

What are the symptoms of PTSD?

1.  Flashbacks

One of the most recognisable features of PTSD is the experience of having a “Flashback”.

What is a flashback?  A flashback is an extremely vivid re-experiencing of the traumatic event, with features that can make the individual believe that the event is happening all over again.

In a flashback, we can experience many of the elements of the original trauma (sights, sounds and smells, etc.) and our body responds with the same fear-based emotions that we experienced at the time of the event.

Some triggers for flashback memories can be extremely subtle which can make the experience even more fear provoking for the individual, almost as if the flashbacks are coming from out of nowhere, whereas others may have clear associations with the initial traumatic event.

2.  Nightmares

Whilst we will all have nightmares occasionally, studies show that people who have PTSD are more likely to have nightmares more often.

Nightmares, like flashbacks, are another part of the “re-experiencing” symptoms that occur within PTSD and occur as part of the brains desire to make sense of the traumatic event and process it into long term memory.  Of course, this leads to poor sleep, which can in turn lead to reduced functioning for the rest of the day.

Nightmares in PTSD can be specific to the traumatic event itself – e.g., replaying through what occurred during the traumatic incident – or can be about a more general sense of threat.

3.  Hypervigilance in PTSD

As part of your body’s “better safe than sorry” response to a traumatic event, people with PTSD will become hypervigilant to signs of danger. What this means is that sufferers can feel constantly on edge, always in fear that another traumatic event is going to happen.

We may observe what we call an exaggerated startle response, where the person is particularly jumpy in response to a related trigger.  You might have seen an example of this when PTSD is portrayed on TV – when we see the ex-military serviceman jump to the ground when he hears a car engine backfire.

Hypervigilance may result in the individual appearing irritable or impatient, and can result in changes to behaviour such as checking for danger or working hard to minimise any source of threat.

4.  Avoidance

Memories are activated by triggers, and this is also true for flashbacks, which are after all just extra-ordinarily vivid memories of a traumatic event.  In PTSD, we will often find that the individual will start to avoid certain places which activate the flashback memory or which they associate the sense of threat with.

What tends to happen however is that, whilst there is one initial trigger that an individual may avoid – say a particular street in which a trauma event occurred, this will gradually generalise to include more broadly associated triggers.  So instead of a single street being avoided, pretty soon a whole area is also avoided.

Avoidance contributes to the sense of threat being maintained in that the individual is not given the opportunity to test out whether the particular trigger is always threatening, rather than it being a one-time trauma event.  As such, avoidance in PTSD is part of what keeps the problem going.

It is not uncommon for people with severe PTSD to experience avoidance so troublesome that even leaving the home becomes extremely anxiety provoking and difficult.

5.  Emotional Numbing

Emotional numbness refers to the absence of, or reduction in, emotional experience in sufferers of PTSD.  Whereas the individual may avoid the emotion of fear by deliberately avoiding situational reminders of the traumatic event, emotional numbness is subtly different – Emotional numbness is an involuntary shutting down of all emotional experience, not just the fear response.

It has been suggested that Numbness occurs as part of the “Freeze” response to threat – “Freezing” is one generally much less often talked about part of the “Fight, Flight or Freeze” response.  When the individual has exhausted fight or flight reponses to the threat, numbing kicks in, detaching them from the emotional experience related to the trauma.

We may see the Emotional numbness symptoms of PTSD displayed in the individual as a lack of positive emotion, a feeling of disconnection from other people and activities or a lack of hope for the future

PTSD Self help resources

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What keeps PTSD going?

In the simplest of terms, PTSD is maintained by the intense, almost phobic, fear of a memory. When the memory of an event carries with it so much emotional content that it overwhelms us with fear, we may invest a huge amount of effort in trying not to remember it. This avoidance of thinking about the event, what we call thought suppression or cognitive avoidance, means that our brains struggle to deal with the memory properly, leading to the memory remaining “raw” and unprocessed.  This means that whenever our the memory gets activated (i.e., when we remember it), we get the full, emotionally intense version of the memory, as though the event was happening again in the here and now.

Take a look at the following example to understand this process further…

Imagine that your brain is like a factory. The main task of this factory is to take all of your sensory experiences (the raw materials) and run these along a conveyor belt, where they are processed and packaged into nice little units which can be stored in our long term memory store for remembering later.

The process involves the brain-factory putting a sort of “date-stamp” on the memory, to let us know that this is an event that happened and it is now part of our story – part of our past. When we want to, we can then go into the long term memory store-room and take out a memory, remember it and forget about it again, knowing that we can remember it again if we ever need to again in future.

Your brain is doing this all of the time and we don’t really ever think about it.

Illustration showing factory metaphor in PTSD

A trauma event is a little different. Whereas our everyday experiences are generally small, ordinary and easy to process without any special effort, a trauma event comes with uncommonly intense (and frightening!) imagery, emotions, sensations and thoughts, all of which require additional processing from the factory to get it into the long term memory store.

That is, the factory needs to put on overtime to process this traumatic experience and get it into the into the long term memory store.

However, because this memory is so out of the ordinary, with all of its unique scary features, whenever the event gets placed on the conveyor belt, we can become overwhelmed by it and shut down the factory.  The processing stops before it is finished.

And so, instead of the memory being processed, date stamped, and packaged into the long term memory store-room, in PTSD we get a raw materials memory, with intense emotion, imagery and sensation at the same intensity as the initial event, as though the event was happening again, in the here and now.

Illustration showing factory metaphor for unprocessed memories in PTSD

Avoiding memories, maintaining symptoms

Graphic showing how sensory triggers can activate unprocessed traumatic memories in PTSD

Memories rely upon triggers to activate them. If we see a friend that we haven’t seen for a while, we’re reminded of the good times we’ve had with them. If we smell sun-tan lotion, we might have the memory of being on San Antonio beach in Ibiza or if we hear the opening synths of Rick Astley’s “Never gonna give you up” we’re reminded of that awkward late-1980’s school disco.

You get the idea.

When memories have been processed fully, triggered memories like this rarely cause us any difficulties.  I “know” that I’m remembering an event because my brain has had time to contextualise the event into part of my past – that is, it has put a “date-stamp” on the memory.

However, when a current trigger activates an unprocessed trauma memory, we get a memory which hasn’t had the opportunity to be date-stamped and contextualised as being part of my past experience.  We get an overwhelmingly intense re-experiencing of the event as though the event was happening again in the here and now. We call these experiences “Flashbacks“.

Because the Flashback can feel so frightening, people often avoid the things which they believe triggered the memory.

So for instance, if I had a flashback to a traumatic Road Traffic Accident the last time I drove past the road on which it took place, then I might deliberately start to drive via a different route, even if it adds 20 minutes to my journey to work.

As a consequence, my fear of the memory then starts to impact upon my day to day functioning (I avoid more and more and I can do less and less) and the memory remains unprocessed, meaning that a flashback can still be triggered by another related trigger; an ambulance siren, for instance.  Take a look at the graphic on the left to see the PTSD maintenance cycle in action.

So – we’ve now seen what causes PTSD and discussed the mechanisms which serve to keep the problem going.

But how can we recover from PTSD and Trauma?  Luckily, CBT has been shown to be an effective treatment for PTSD and the next sections shows us two of the most effective CBT approaches to dealing with PTSD.

Two CBT approaches to healing PTSD

Whilst there are other Trauma focused CBT ways of working I am going to introduce the two most widely used “models”.  The first is what we call “Prolonged Exposure Treatment” and it was developed by Psychologists Edna Foa and Barbara Rothbaum .

The second model was developed by Anke Ehlers and David Clark and is largely what we would call a “Cognitive Model of PTSD”.

Prolonged exposure therapy for PTSD

I have covered earlier how PTSD symptoms are kept going by the individual trying to avoid thinking about the birth trauma event and also avoiding things that remind them of it.

This avoidance results in the trauma memory remaining raw and unprocessed by the brain.  This means that when a memory is “triggered” it can feel emotionally overwhelming and can have the qualities of if it was happening all over again in the here and now, rather than in the past – we call this a flashback.

Basically, avoidance (both mental and physical) maintains PTSD symptoms.

Foa and Rothbaum’s prolonged exposure Treatment model works by teaching you how to directly overcome this avoidance.

Step 1 – Stress innoculation training

Because traumatic memories can by their very nature be distressing and emotionally overwhelming, it is vital the you are able to develop the skills with which to cope.  To support this, Prolonged Exposure Treatment is typically accompanied by “Stress inoculation training”.

Stress inoculation has two main aims:

  1. To enable you to cope with symptoms between therapy sessions
  2. To enable you to cope with your distress during prolonged exposure in session

Stress inoculation can take the form of diaphragmatic breathing, breathing retraining or progressive muscle relaxation.  Ideally we are aiming to give you the skills to regulate your distress to stay within what we call the “window of tolerance” during prolonged exposure.  Take a look at our Audio resources section to try out some of these stress inoculation techniques.

The window of tolerance

The window of tolerance is an area of emotional intensity in which the client is able to feel the emotion associated with the memory of the trauma.

If the client becomes too emotionally aroused, that is, if it becomes too emotionally intense, then the fear response can feel overwhelming, leading the client to shut down the processing of the trauma memory.

Conversely, if the client is unable to generate any emotion in relation to the traumatic event, in that they may not be able to associate with it, then the processing can again not take place.

The client needs to be able to feel some degree of emotion, but be able to regulate themselves enough so that they do not become completely overwhelmed.

This middle bit – not too high, not too low, is our window of tolerance.

By using stress inoculation techniques, we are able to manage the levels of emotion during treatment and, as you become more used to using the techniques and as you engage more in the treatment plan, the window of tolerance actually becomes wider.

The more distress you can learn to tolerate, the more prepared you are to tolerate distress in future.

Diagram showing the window of tolerance in trauma and PTSD therapy

Step 2 – Prolonged Exposure to the Trauma Memory

After being trained in how to use the stress inoculation strategies, you will then be helped by your therapist to begin to be exposed to the avoided aspects of the trauma event.

This takes two forms:

    1. Exposure to the memory of the trauma event.
    2. Exposure to external triggers associated with trauma event.

As mentioned earlier, avoidance of thinking about the trauma memory can prevent the memory from being fully processed, leaving it “raw” and emotionally overwhelming whenever it is remembered in future.  So, at this point in prolonged exposure treatment, the therapist will teach you to how to be exposed to the trauma memory.  This involves using mental imagery to “relive” the traumatic event in your mind multiple times until you no longer feel excessively emotionally overwhelmed.

Take a look at the graph below for an example of how this works:

Here we can see what happens to the individual’s distress when they are exposed to the trauma event multiple times.

On the first exposure we can see that the highest level of distress is recorded at 90% – clearly very high!

But look what happens to the level of distress over the course of the prolonged exposure session…

We can see that the distress levels start to go down.

Graph showing reduction in anxiety in prolonged exposure to fears in exposure and response prevention

Now look at the levels on the 2nd, 3rd, 4th and 5th prolonged exposure sessions.  The anxiety starts at a lower level each time, reduces more quickly and reduces to a lower overall level.  This process of reducing distress by facing the feared memory head on for a prolonged period is called Habituation.  We habituate to the feared memory and over time realise that we can not only tolerate the distress that it triggers, but also that it is nothing at all to be feared.

How your therapist will do prolonged exposure to the trauma memory

  1. Ask you to close your eyes – if you feel really uncomfortable with this then you may keep them open (no one can force you to do anything that you don’t want to) but closing ones eyes can help you to really get in touch with the trauma memory.
  2. Starting at the start of the traumatic memory, before anything “scary” had happened, begin to describe what happened.  This should be done in the first person perspective, as though it was happening in the here and now.  Your therapist will encourage you to describe as much sensory detail as you can remember – again, this is done so that you can really get in touch with the memory.  Here’s an example:

So, I’m driving my car to work. It’s 7am and the sky is quite cloudy. I’m listening to the radio, coldplay is on, and I can smell the pot pourri air freshener that my wife insists on using. I stop at the junction by Edge Lane and wait for the red light to change to green. I’m the first car at the junction. The green light comes and I drive forward. Suddenly I see an object coming from my right. I hear a loud, smashing sound…

3.  Continue in this way until you reach the peak of the distress in the trauma memory – This is called the “Hotspot”.  At this point, your therapist will support you to really slow down and focus upon each aspect of the hotspot.  Sights, sounds, smells, thoughts, etc.  This is so that you remain focused upon the event, can avoid very little and so habituation can take place.

4.  Gradually you will continue to work your way through the trauma event, back to a point at which you feel safe again – “Start safe, end safe“.

5.  Throughout this process, your therapist will have been asking you for ratings of your distress at regular (usually 10 minute) intervals.  These ratings will be given as a percentage – high distress is a high percentage, low distress is a low percentage.  We call these ratings “SUDS” which stand for “Subjective Units of Distress”.  Your therapist will ask, “What are your SUDS now?” and then will record your response on a chart like the one above.

6.  When you have completed one reliving of the trauma memory, the therapist will ask you to do it again, again following the procedure detailed above.  Typically, a Prolonged exposure therapy session will last for up to 90 minutes and will consist of a number of relivings of the trauma memory.  This is so that you have plenty of time to habituate to the trauma memory.

7.  The session will ideally be recorded, on audio at the very least.  This is so that you can take the recording away with you and repeat the prolonged exposure task by yourself at home as a between session task (there are lots of between session tasks in CBT!).

8. The therapist will also ask you, quite early on in therapy, to write out a detailed script of the trauma event.  Again, the purpose of this is to get you used to the emotions associated with the memory and to help the brain process it.  Again, this may seem quite daunting at first but there are so many benefits to this approach.

Step 3 – In-vivo Exposure

An important objective of any trauma focused therapy is to support you to “get your life back”.

Often, because of the combined effects of the symptoms of PTSD – the flashback, avoidance, nightmares and fear of something bad happening – an individuals life can change significantly.  You may have taken a lot of time from work, stop spending time with friends or isolate yourself from family.  In-vivo exposure aims to support you to face head on the situational triggers that you currently avoid.

Using the same principles of habituation as detailed above in prolonged imaginal exposure, the therapist will support you to overcome your fears by exposing you to feared real-life situations.  Again, just like with the imaginal exposure, habituation to these situations results in you losing your fears over time.

How to do in-vivo exposure

    1. Write a list of all of the situations that you currently avoid or feel a high level of fear in, as a result of it’s relationship to the initial trauma event.
    2. Decide which of these creates the most anxiety for you and which creates the least.  Grade each of the other situations in terms of how much anxiety each creates for you.  This is called a “Graded Hierarchy”.
    3. Now, starting with the least anxiety producing situation, your therapist will guide to to undertake your first in vivo exposure.  Just like with imaginal exposure, you will face your fear for an extended period until your “SUDS” reduce by more that half of what they were initially.
    4. Repeat this procedure daily.  The more you practice, the faster your recovery will be.
    5. Once you can tolerate one item on the Graded Hierarchy, move up to the next one and repeat the above process.
    6. Remember the golden rules for prolonged in-vivo exposure:  Exposure must be repeated, prolonged, graded and anxiety producing.

Cognitive Therapy for PTSD

The cognitive model of PTSD treats the trauma memory a little differently.  Building upon Foa and Rothbaum’s Prolonged Exposure Therapy model, the Cognitive model still involves an aspect of “reliving” the trauma in memory, but it does so with the aim of identifying unhelpful beliefs encoded within the memory and then updating them through further reliving.

I’ve presented what the model looks like on the right of this page.  Lots of arrows and boxes, but please don’t get too hung up on this.

What these boxes and arrows show us are the different maintaining elements of PTSD.  We have the nature of the traumatic memory itself, which may have some parts which are particularly overwhelming or it may have some gaps in the overall narrative.  Your therapist will support you to develop this memory, through reliving and writing out what happened in the trauma event.

Next we have the box, “Negative appraisal of the trauma and its symptoms”.  This is were we place the unhelpful beliefs that are encoded within the memory and also the changes in how we view the world after the trauma event.

When we are exposed to a “matching trigger”, something which reminds us of the traumatic event, we can see that it leads us to the next box labelled “sense of current threat”.  This means that the memory and the thoughts we have about it combine to make us feel a sense of threat in the here and now.

Diagram showing Ehlers and Clark Model of PTSD

At the bottom of the model, we can see the box labelled “Coping strategies”.  This contains all of the things that we do to either reduce the sense of current threat or reduce other aspects of the PTSD symptoms.  One example of a coping strategy is that, if the memory makes me feel a sense of current fear, then I will try to avoid thinking about it.  Another might be to avoid “matching triggers” associated with the memory.

Following the arrows back up to the top of the model, we can see that the use of the coping strategies prevents the updating of both the nature of the memory itself (it remains incomplete, overwhelming and intrusive) and our beliefs about the trauma and its symptoms (I still should have done more, the world remains a threatening place).

How you will do Cognitive Therapy for PTSD

Your therapist will provide you with information about the symptoms of PTSD and about how it can be treated using Trauma focused CBT.  They will then help you to understand the maintaining factors of your PTSD symptoms using the model presented above.  This aspect of treatment is called “formulation“.

Then, to assist you in feeling confident in being able to tackle both working with the memory and doing the behavioural work necessary to get your life back, your therapist will show you how to manage your emotions using some of the self-help strategies for PTSD.

After this, the therapist will then support you to “relive” the trauma event.  The CBT Therapist will again be looking for “Hotspots” in the memory and will be carefully looking for aspects of thinking which may be contributing to current levels of distress.  For example, a father who witnesses his partner being hurried away to emergency care whilst in labour, may have a peak of distress at this point of the memory (a Hotspot).  The CBT Therapist will seek to identify the negative thought at this point – e.g., “They’re going to die”.

After working with the client to develop cognitive restructuring skills, the therapist will ask the client to relive the memory again, but this time at the point of the hotspot where the client has the thought about his wife and child dying will ask, “What do you know now?”

The client will, whilst still vividly reliving the memory, be able to answer the therapist with new, updated information – e.g., “They’re both safe and well.”  Understandably, this creates a different emotional response to the distress experienced previously.

You will also be asked to listen back to an audio recording of the session and to write out a detailed script of the event, this time including the new updated information.

By engaging in this process of reliving and updating, the client is able to enhance processing of the memory, discriminate between past and present interpretations of the trauma event and habituate to the memory, thereby reducing levels of distress when the memory is triggered naturally.

Again, just like with the Foa and Rothbaum PTSD model, the Ehlers and Clark PTSD model also has an emphasis upon enabling the client to “get their life back”.

This time however, the approach is based upon helping you to engaging in “behavioural experiments” to test out the reality of your trauma related beliefs in the real world.  For instance the individual may have the thought, “If I don’t keep checking on my baby then something bad will happen”.

After using thought challenging techniques, which include the client identifying which of the unhelpful thinking styles that they are using (e.g., prediction, catastrophizing), along with developing alternative, more balanced thoughts, the therapist will help the client to develop an experiment to test out the thoughts.

The client would be invited to return to their predicted negative thought and see if it truly was a realistic thought in light of the evidence gained from the experiment.  Further experiments would continue to test out and modify these negative thoughts.

As the coping strategies are modified and reduced, the negative beliefs about the trauma and symptoms are able to be modified, leading to a reduction in distress overall.

Next steps…

So here we have an over view of just what to expect from a course of CBT treatment for Post-traumatic stress disorder. 

If this is something that you feel may be of use to you then you can contact George Maxwell at Access CBT on 07887 701 176 or email us on

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