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Cognitive behavioral therapy

Thread starter #1
Cognitive Behavioral Therapy (CBT) is one of the most widely used therapies for the treatment of Posttraumatic Stress Disorder (PTSD). CBT is a talk therapy that aims to change the brains cognitive functioning, encompasses both imaginary exposure therapy as well as actual exposure therapy to stressors. Specific to PTSD, the actual type used is called, Trauma Based, or often referred to as TB-CBT; though we will simply refer to it as CBT for the purposes here. The majority of primary PTSD therapies are actually CBT.

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Origins

CBT originated from Sigmund Freud's pioneering therapeutic approach to individuals who had suffered childhood sexual abuse in 1895, which involved retelling the traumatic event in order to promote emotional catharsis and abreaction, ie. release of repressed emotions. This approach was the precursor to current CBT techniques, especially prolonged exposure therapy.

Success & Failure

CBT on average across clinical studies, demonstrates an overall effectiveness of above 80%. Saying this, you will read below that studies also have bias, so this number is not necessarily accurate. What is accurate is accounting for actual clinician success rates, which are on average above 85% for CBT use in conjunction with PTSD. The Australian National PTSD course has reported rates from 50% to 90%, depending on location, course structure and physicians involved. Locations based near military bases often have the highest success rates, than elsewhere, due to the experience obtained via such influx of PTSD patients. [Obtained from course physicians]

Structure

CBT is often performed from 10 - 12 sessions, though can go for years if the trauma is of a more complex nature. Beyond this, something is wrong; either the patient isn't working hard enough, or the therapist isn't delivering and pushing the patient to work hard enough. One or the other is at fault beyond this time frame.

CBT for PTSD typically comprises 8 modules, they may slightly differ depending on expertise of the physician. Standard, these are:
  1. Introduction to the treatment
  2. Crisis and relapse prevention plan
  3. Breathing retraining
  4. PTSD primary symptoms
  5. PTSD associated symptoms
  6. Cognitive restructuring, the first 3 steps
  7. Cognitive restructuring, 5 step program
  8. Generalisation training and termination
Termination of trauma therapy is an essential aspect that either patient or therapist can overlook, as it provides an essential period of time that the patient must take the tools learnt and then begin to apply themselves. Without this essential break, the patient learns nothing, and only builds a co-dependence to the therapist of looking for answers, instead of working them out themselves, with the theoretical tools and procedures covered.

The expert method in session form is listed upon the forum itself as Cognitive Behavioral Therapy (CBT) for PTSD. The trivial aspects are often covered in introductory sessions, with follow-up sessions periodically for review after termination at 6 or 12 weekly intervals.

Comparisons

There is only one comparison to really make in regards to CBT, and that is Eye Movement Desensitisation and Reprocessing (EMDR). Both are about equally as efficient in the designed methods to enable the processing of cognitive trauma; they simply go about it in different manners. What is different is that CBT has a proven experience for longevity of symptom reduction, compared to EMDR. However, many EMDR practitioners are now building in the missing cognitive processing and exposure therapy to obtain the longevity results, beyond the trauma processing aspects. It is becoming an either / or comparison, bringing the outcome down to the delivery and patient specifics.

The real pluses for CBT, that EMDR cannot match, is that a majority of the structure can be delivered in a group environment, hence limiting the one-on-one patient / therapist time and achieving greater throughput of patients, without disregard for end results. CBT can also be used effectively by changing the delivery to suit children of any age, without losing effective purpose or outcomes. CBT can be delivered online, through Internet Therapy(Interapy), using a mixture of online tasks and electronic interaction with the therapist. These clear advantages are making it far more popular as the tool of choice with trauma specialist in relation to PTSD.

Whilst there are many therapies available for choice, none are specifically tailored to treat trauma or effective to measure on a scale for comparison to either CBT or EMDR. Some are adaptations from both, with little to no effect, some are nothing more than placebo based treatments, such as Emotional Freedom Technique (EFT). Even placebo based measures have a purpose, and do work, though the statistics prove a significant minority for placebo treatment.

CBT vs. Person Centred Therapy (PCT)

The primary type of therapy used is called PCT. This therapy is based on promoting a non-judgemental, comfortable environment, being genuine, empathetic and positive towards the patient, allowing the patient to really solve most of their own problems.

Whilst this is slightly valid with the use of CBT, unfortunately it is completely wrong for PTSD. CBT is about getting the patient past denial, getting the patient to discover suppressed emotion, and PCT will not achieve that due to the tremendous trauma the brain has endured in the first place. [10] A therapist must be strong, they must push the patient, they must get them agitated in order to provoke the raw emotion that PTSD locks away. A PCT environment does not achieve any of these things, and only draws the conclusion of lengthening the CBT treatment itself beyond what should be needed. CBT is an assertive therapy, and it must be delivered that way with PTSD.

This is a fundamental difference between a therapist, and a trauma therapist.

Seeking Safety CBT Model

Seeking Safety is a type of cognitive behavioral therapy, used specifically for those who have PTSD with substance abuse issues, ie. cocaine, alcohol dependence, etc. It's a modification of the CBT model to correct both problems simultaneously, as the substance abuse itself can otherwise erode and de-structure the entire CBT process. SS has only been found suitable under such circumstances, and has obtained an approximate 60% retention rate, and shown a significant reduction in substance abuse by patients. Though it cannot be ascertained clearly whether the substance reduction was due to the CBT or the outpatient program to treat the substance abuse.

The often preferred method for treatment is that all substance abuse first be brought under control before the implementation of CBT, as this demonstrates that the person is clearly focused on wanting to get better, rather than just speaking the words. Actions speak louder than words with therapy, and a person who first gains control of substance abuse immediately states they are willing to put in the effort; with trauma specialists in short demand, their time can be limited.

Biology

A study using neuro-imaging in anxiety disorders concluded that CBT physically affects the brain, specifically in the areas of empathy and forgiveness. Neuro-imaging also identified that CBT in combination with pharmacology, that the two integrated to work collectively together in order to help open specific pathways within the brain, to assist in psychotherapy treatment.

It was identified that CBT helped regulate the dysfunctional neural circuits involved with the regulation of negative emotions and fear extinction.

Studies & Trials

There is an inherit issue within studies, in that no study exists to measure what clinicians claim and know from experience, due to the time based requirements involved on follow-up assessment five, or ten years later. There are then so many factors within such a time frame that would be insufficient to prove one method over the other clinically, ie. re-exposure to stressors, lifestyle changes, etc. Unfortunately due to these life restrictions, studies are typically only demonstrated for short-term gain vs. clinical experience where patients are monitored over years via feedback.

The major let down to 99% of studies, is that they control the conditions of the study to exclude real PTSD patients, being those with co-morbid diagnosis, ie. CPTSD (personality disorders), major depression, etc; also those at the severe end of the symptom threshold. In essence, they could, and most likely do, conduct trials with a majority of misdiagnosed persons who would befit Acute Stress Disorder (ASD) better than PTSD, with a 50% failure to meet PTSD diagnostic criteria after a 3 month wait period with zero therapeutic intervention. Six month wait period has discovered higher percentages again, being they do not have PTSD, and are suffering normal posttraumatic stress, or ASD, officially. Most studies claim that after 3 or 6 months of CBT, that 50% - 60% no longer fit the criteria for PTSD. Anyone with actual PTSD would know that just isn't the case at all. There are studies showing that studies are tainted in this regard, and now studies are starting to be produced from clinical based cases, not well picked patients, excluding anyone of severe statue or risk to the study outcome. These open based studies are demonstrating far superior results in terms of failure, issues, concerns and real life aspects that occur in therapy with PTSD.
 
L
#2
This is awesome, to have all of this information compiled in one place. I learned some new stuff, and without having to read a bunch of separate articles and putting it together myself like I have been. Thank you.
 

void

MyPTSD Pro
#3
CBT can be very helpful with the cognitive distortions that affect our daily lives.

Many people have CBT for years and though they are helped by it, the constant fear, body tension, hypervigilance, dissociation REMAIN despite all of the CBT.

The body remains in a state of retained activation of the nervous system and unless the PHYSICAL is dealt with the person with PTSD will continue to suffer.
 
C

CBT enthusiast

#4
In CBT the most important aspect is re-living, which doesn't appear to be one of the steps. If you look at ehlers and clarks work they have it pretty spot on. In the NHS the only two allowed approaches are EMDR and CBT specifically - Foa and Roth baum & Resick & Ehlers. Found this on the web for one of them :
can't find much on the others.
 
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