Cognitive Behavioural Therapy for PTSD

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.

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.



CBT has a well-developed body of evidence to support its effectiveness in treating PTSD.


What Keeps Post Traumatic Stress Going?

Therapy for PTSD: 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.

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.



Symptoms Of PTSD

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.

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.

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.

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.

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.


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 CBT?          What Is EMDR?


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