CBT for PTSD: Basics and Rationale

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.

Highlights

  • CBT for PTSD involves helping the patient confront the reminders of the trauma in a therapeutic manner so that distress decreases.
  • Exposure therapy has more evidence of efficacy for PTSD than other interventions.
  • Prolonged Exposure (PE) has been found effective across trauma populations and in different cultures.

 

Transcript

Hello. This is Dr. Barbara Rothbaum. I’m a professor in psychiatry and a clinical psychologist. I’m at Emory University School of Medicine in Atlanta, Georgia. I have been treating and studying treatments for posttraumatic stress disorder since 1986. So I’ve been doing this a long time. And I’m very happy to talk to you about prolonged exposure therapy and cognitive-behavioral treatments for PTSD. So thank you for attending.

We’ll start the first video, which is on cognitive-behavioral treatments for PTSD. What are they? In general, CBT, cognitive-behavioral therapy, for PTSD, what we’re doing is helping people confront what they’re scared of but in a therapeutic manner. So we’re helping to promote these safe confrontations via exposure. And exposure is to the memories; It’s to real-life triggers. It’s also to discussions about the trauma. And we are aiming to modify dysfunctional thoughts that are underlying PTSD. We’re also aiming to modify the distress associated with these thoughts and reminders.

In general, cognitive-behavioral treatment—especially for PTSD, but in general—can be divided into three large categories. The first are exposure procedures. So those are the ones that we’re helping people to confront what they’re scared of in a therapeutic manner. The second category is anxiety management procedures and those are ones that we’re teaching patients coping skills and coping strategies to help manage their anxiety, such as cognitive restructuring or relaxation. The third category is cognitive therapy. And in cognitive therapy, that’s where we’re looking at these dysfunctional thoughts.

In general, a number of CBT techniques have been used to treat chronic PTSD. And these include exposure therapy and particularly prolonged exposure therapy, PE, which we’re going to be talking about a lot in this series; cognitive processing therapy, or CPT; stress inoculation training, or SIT; cognitive therapy. And I just want to mention systematic desensitization because it was one of the earlier techniques used for PTSD, actually before PTSD was officially PTSD. And nobody really uses it anymore, but sometimes people ask me about it so I wanted to mention it and mainly mention to say we don’t really need it anymore.

Let’s talk first about SIT, stress inoculation training. The theory behind SIT is that fear and anxiety are a normal response to trauma. The idea is that certain cues and the fear and anxiety are conditioned at the time of the trauma even to nonthreatening cues. Originally, a long time ago when I learned SIT, the idea was that it could be unlearned. These fears and anxiety could be unlearned to nonthreatening cues. Now, we don’t think that there’s unlearning. We think that there’s new learning on top of it, so learning that they don’t have to be scared to these nonthreatening cues.

References

Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. Guilford Press.

SIT assumes—and just like CBT—in general, that we experience fear and anxiety in 3 channels of responding: cognitive, or how we’re thinking; physiological, what we’re feeling in our bodies; and behavioral, what we’re doing, our actions.

References

Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. Guilford Press.

SIT’s approach to treatment includes anxiety management techniques for all 3 channels.
And we teach patients the stage response of anxiety. So what I mean by that is that usually unless it’s the time of the trauma, you’re not totally relaxed one minute and panicking the next or at the top of your fear and anxiety. Usually, and this is for chronic PTSD, it goes in stages. And if a patient can learn to recognize those stages, it’s easier to do something about it because it’s easier to intervene at an earlier stage than when anxiety is maxing out. And this next one is important. The goal is to manage anxiety, not to eliminate it. So many of our patients come in with anxiety and they want us to get rid of it. They hate anxiety. And I always try to explain: one, we couldn’t if we wanted to. We’re animals and we’re hardwired for anxiety. And we don’t want to. Anxiety helps us survive. Unfortunately, we live in a dangerous world and that anxiety is going to motivate us to do something that will probably help our survival if we find ourselves in a situation.

The SIT skills can be applied trans-situationally, across situations. And that’s wonderful because PTSD patients have problems across situations. They have problems at home. They have problems sleeping. They have problems at work. They have problems in their car driving to work. They have problems at the grocery store. So these SIT skills can be applied in all of those situations.
Another thing that we try to teach people with SIT, and probably in cognitive-behavioral therapy in general, is that anxiety becomes a cue to use these skills. So for example, for most of us, if we have not had a history of starvation, if we’re hungry, it doesn’t trigger anxiety. If we’re hungry, it triggers us to eat, to get food. Same with anxiety. Very often, when people come in to see us, their anxiety is a cue to get more anxious. They feel their heart pounding. Oh my gosh, here it happens again. And then they get more anxious. And what we want to teach them in SIT and in CBT is you feel your heart pounding, okay, good, you noticed that. Use your breathing. If you use your breathing, it should slow your heart rate down. If you noticed that you’re clenching your jaw, use one of the relaxation skills to decrease that. So the anxiety becomes a cue to use these skills rather than for more anxiety.

Now, I’m going to switch to prolonged imaginal exposure. And again, we’re going through an overview now. We’re going to go through PE in a lot more detail in the modules to come. In general, the theory behind prolonged imaginal exposure, we think in terms of an information or emotional processing theory. I make a lot of analogies to the grief process with this theory. And the idea is that when something important happens to us there’s no way to the other side of the pain except through it. And the way through it is we need to emotionally process it. I’ll give you an example not related to this. Say you’re driving to work and you have a near miss. Somebody almost hits you. The first person you see at work, you may talk about it. Then you see the secretary and you say, “Man, this Jeep Cherokee came out of nowhere, almost got me.” By the end of the day, you’re not talking about it anymore. You don’t need it. You’ve processed it.
So again, with PE, we think that fear and anxiety are a normal response to trauma. Someone holds a knife to your throat and says, “Don’t scream or I’ll cut you,” you’re going to be scared. That’s normal.

References

Foa, Hembree, Rothbaum, & Rauch (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences, Therapist guide, 2nd edition. New York. Oxford University Press.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press.

Fear, anxiety, and what I call social conventions then lead to avoidance. So the fear and anxiety, if I think about it and it makes me feel bad, my natural inclination is going to be not to think about it. If I go outside after dark by myself and I get very scared, maybe I stop doing that. And what I mean by social conventions, our society is not very good about talking about negative events, and certainly not the kinds of events that lead to PTSD. And very often, trauma survivors receive the message implicitly and sometimes explicitly. Go on with your life. Forget about it. Put it behind you. In other words, don’t talk about it, I don’t want to hear about it. And then this avoidance is reinforced. If I’m not going outside by myself anymore, I’m not feeling as anxious. If I’m not talking about it as much—sometimes, I’m explicitly reinforced by others. We’re so glad we have our old Barbara back. We’re so glad you put that behind you.
But when we need to think about it and feel it to process it, this avoidance prohibits emotional processing. And that’s how we think that it festers and haunts people.

References

Foa, Hembree, Rothbaum, & Rauch (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences, Therapist guide, 2nd edition. New York. Oxford University Press.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press.

For adequate emotional processing, we think we need two important processes. One is activation of the trauma memory. Now, a lot of my PTSD patients tell me, “Doc, what are you talking about? I get triggered 100 times a day. How is this different?” So they get activated, but then they push it down immediately. When we activate it, we want the other component, corrective information. We want to activate the memory, but we want to put it back differently.

References

Foa, Hembree, Rothbaum, & Rauch (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences, Therapist guide, 2nd edition. New York. Oxford University Press.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press.

The approach to treatment in prolonged imaginal exposure is that we can activate this memory for most people pretty easily through exposure to the trauma memories and to nonthreatening cues, nonthreatening reminders.
They receive corrective information when they do these exposures via, one, safety. So they’re going outside by themselves and nothing bad is happening. Habituation. And some people use the term habituations; some, extinction. I’ll use both pretty interchangeably here. So what that means is when you’re doing it and you do it over and over again and nothing bad happens, the distress comes down. The fear comes down. And also, they receive corrective information through acceptance. When they are telling their therapist the most scary, shameful, embarrassing, terrible moments of their lives and the therapist isn’t responding with horror or “I can’t hear it” or disgusted looks on their face, when the therapist is responding with acceptance, then that’s important corrective information as well.

References

Foa, Hembree, Rothbaum, & Rauch (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences, Therapist guide, 2nd edition. New York. Oxford University Press.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press.

We’re going to talk in detail later on that habituation is important between sessions.
And just an important comment, the habituation is to the traumatic memory, not to harm. In 1986 we were doing prolonged exposure therapy with rape survivors with PTSD. And at first, we were criticized and someone said, women should be scared of getting raped. You shouldn’t desensitize that memory. And obviously, we agree. And the distinction we want to make is the desensitization or habituation or extinction is to the traumatic memory, not to harm.

References

Foa, Hembree, Rothbaum, & Rauch (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences, Therapist guide, 2nd edition. New York. Oxford University Press.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press.

Some of the exposure therapy principles are based on extinction training and that comes from the animal literature and it’s based on learning principles. So I wouldn’t do a whole primer on conditioning extinction. But briefly, for example, you can pair, say, a tone with a shock and the animal will learn to be scared of the tone. This is just like Pavlovian conditioning. And so you present the tone and that’s called fear conditioning. When you want to do extinction training, you present the tone by itself repeatedly and the animal learns that the tone no longer predicts shock. And so the fear to the tone decreases. And that’s called extinction training and extinction learning and it’s based on learning principles.

Not all exposures are therapeutic. I will give you an example unrelated to this. Say a child is bitten by a dog and develops a phobia or PTSD so severe that that child doesn’t want to leave the house for fear of encountering dogs. If you put that child in a room with a dog and the kid runs away screaming, this is an exposure, but it’s not a therapeutic exposure because nothing has changed. What you might want to do is start with a cute puppy, maybe work up to dogs that are bigger or resemble the dog that bit the child. And what you want to happen is for the child to stay with the animal long enough to learn in their bodies, in their brains that this animal poses no threat. So I’m always asking for therapeutic exposure, “What does your patient need to learn from this exposure?”

References
Foa, Hembree, Rothbaum, & Rauch (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences, Therapist guide, 2nd edition. New York. Oxford University Press.

Rothbaum, Foa, Hembree, & Rauch (2019). Reclaiming Your Life from a Traumatic Experience: Client workbook, 2nd edition. New York. Oxford University Press.

Switching to cognitive therapy, the focus is identifying dysfunctional erroneous thoughts and beliefs that usually we call cognitions. And we teach the patient how to challenge these cognitions and we want to replace these cognitions with more functional realistic cognitions.

Emotional processing in therapy, as we mentioned earlier, requires accessing the fear structure. You want to activate it and put it back differently.

So in general, there are several CBT programs that are very effective for PTSD. PE, or prolonged exposure, has received the most empirical evidence with a wide range of traumas of any intervention for PTSD, including two medications with an FDA-approved indication for PTSD.

So the key points for the first video are that cognitive-behavioral treatments, or CBT for PTSD involve helping the patient confront the reminders of the trauma in a therapeutic manner so that the stress decreases. Exposure therapy has more evidence for its efficacy for PTSD than any other intervention. And prolonged exposure therapy, PE, is a specific protocol for exposure therapy for PTSD that has been found effective across trauma populations and in different cultures.

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