Evidence-Based Reviews

Counseling trauma victims: 4 brief therapies meet the test

Current Psychiatry. 2005 August;4(8):50-63

Focused cognitive-behavioral interventions can provide lasting benefits.

References

1. Rothbaum BO, Meadows EA, Resick PA, Foy DW. Cognitive-behavioral therapy. In: Foa E, Keane T, Friedman M (eds). Effective treatments for PTSD. New York: Guilford Press; 2000.

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3. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War generation: report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel; 1990.

4. Pfefferbaum B. Posttraumatic stress disorder in children: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1997;36(11):1503-11.

5. Deblinger E, McLeer SV, Henry D. Cognitive behavioral treatment for sexually abused children suffering post-traumatic stress. J Am Acad Child Adolesc Psychiatry 1990;5:747-52.

6. Najavits LM. Seeking Safety: a treatment manual for PTSD and substance abuse. New York: Guilford Press; 2002.

7. Resick PA, Nishith P, Weaver TL, et al. A comparison of cognitive processing therapy, prolonged exposure and a waiting condition for the treatment of posttraumatic stress disorder in female rape victims. J Consult Clin Psychol 2002;70:867-79.

8. Foa EB, Keane TM. Friedman MJ (eds). Effective treatments for PTSD. New York: Guilford Press; 2000.

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10. Foa EB, Rauch SA. Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder. J Consult Clin Psychol 2004;72(5):879-84.

11. Foa EB, Riggs DS, Massie ED, Yarczower M. The impact of fear activation and anger on the efficacy of exposure treatment for PTSD. Behav Ther 1995;26:487-99.

12. Foa EB, Rothbaum EO, Riggs D, Murdock T. Treatment of PTSD in rape victims: a comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol 1991;59:715-23.

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15. Chard K. An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. J Consult Clin Psychol. (in press).

16. Shapiro F. Eye movement desensitization and reprocessing: basic principles, protocols and procedures (2nd ed). New York: Guilford Press; 2001.

17. Chemtob CM, Tolin DF, van der Kolk BA, Pitman RK. Eye movement desensitization and reprocessing. In: Foa E, Keane T, Friedman M (eds). Effective treatments for PTSD. New York: Guilford Press; 2000.

18. Meichenbaum D. Cognitive-behavior modification: An integrative approach. New York: Plenum Press; 1977.

Therapists once believed trauma survivors required years of treatment, yet we now know that relatively brief cognitive-behavioral interventions can yield long-term gains in psychosocial and psychological function.¹ Many psychiatric patients meet diagnostic criteria for posttraumatic stress disorder (PTSD), including:

33% of women experiencing sexual assault²
30% of male war veterans³
30% of the 5 million U.S. children exposed to trauma each year⁴(Box).⁵

We offer recommendations on how to prepare traumatized adults and children for cognitive-behavioral therapy (CBT) and discuss four tested models—prolonged exposure (PE), cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and stress inoculation training (SIT)—that psychiatrists may find effective when treating PTSD.

Box

Adapting CBT trauma interventions for children and adolescents

Exposure therapy with children is usually more gradual than with adults, and the child is first taught relaxation techniques to use while recalling traumatic experiences. Although re-exposing children to traumatic events may seem harsh, exposure-based cognitive-behavioral therapy (CBT) appears to be most effective when trauma memories or reminders are most distressing to the child.

As with adults, CBT with children typically includes:

exposure
identifying and challenging unhealthy or distorted trauma-related thoughts
teaching anxiety management techniques such as relaxation or assertiveness training.

In initial studies, CBT has been found safe and effective for treating posttraumatic stress disorder (PTSD) in children and adolescents.¹⁷ Through therapy, they can learn not to be afraid of their memories and can develop healthier, more-appropriate thoughts about the trauma. Children with uncomplicated PTSD—without severe, long-term physical injury—typically receive 12 to 20 CBT sessions. More sessions are needed for complex cases, such as when the trauma perpetrator was an integral family member.

Comorbid conditions—such as conduct disorder, attention-deficit/hyperactivity disorder, or depression—may need to be treated before PTSD or concurrently, using medication or other interventions.

Preparing trauma patients for CBT

Before starting CBT, evaluate patients thoroughly to determine if they meet DSM-IV-TR full or subthreshold criteria (

Not all patients are ready to confront their traumas when they arrive for psychiatric evaluation. For example:

For a domestic violence victim, the therapist’s priority is to help begin safety planning and to address trauma after the patient is out of danger.
Patients with poor coping skills and little social support often find it difficult to begin trauma treatment. For them, focus on building skills to offset the distress that accompanies trauma therapy.
Patients with PTSD and substance abuse may benefit more from CBT if the therapist first addresses the substance dependence.

Seeking Safety⁶ is a recent cognitive therapy designed to treat PTSD and substance dependence concurrently. Initial applications appear promising, but its efficacy with various trauma groups needs further evaluation.

CBT core concepts

CBT therapists typically help patients identify and evaluate disruptive cognitions, which helps them challenge and modify emotions, thoughts, and behaviors related to traumatic experience(s). Other CBT components include:

educating patients about PTSD
exposing them to the traumatic material
challenging and modifying their disruptive thoughts.

Some CBT outcome studies⁷ suggest that linking exposure with direct cognitive challenging may not be necessary. Patients who are exposed to the traumatic experience through mental imagery but are not challenged on their cognitive distortions still report more-adaptive thought patterns after treatment.

International Society for Traumatic Stress Studies (ISTSS) practice guidelines for PTSD⁸ include assessment and treatment suggestions (see Related resources). Whatever the model, CBT appears help patients manage their distress, not only during treatment but up to 5 years after completing therapy.⁹

Which CBT? Comparison studies have shown all four CBT interventions to be effective in treating PTSD, although initial trend data suggest that patients with:

fear-based PTSD may do better with PE or EMDR
PTSD-related guilt, anger, or other cognitive distortions may benefit more from CPT.

Because CPT’s written worksheets could be difficult for illiterate patients, an exposure-based treatment may work better in those cases. SIT can reduce some PTSD symptoms but has not performed as well as other therapies in comparison studies. It is most useful to help patients build coping skills before starting other treatments.

If you refer a patient, make sure the therapist is trained in CBT interventions and in working with trauma patients. To be effective, the therapist must be skilled in handling trauma processing work, suicidal thoughts/intent, and comorbid personality disorders.

Prolonged exposure

PE (Table 1) is typically conducted in 9 to 12 sessions lasting 90 minutes each and has been used to treat PTSD after sexual assault, combat, sexual abuse, and natural disasters. Although frequently offered in individual sessions, group PE has also been found to be effective.¹⁰

After educating the patient about PTSD and the treatment rationale, the therapist repeatedly asks the patient to describe the traumatic event as if it were occurring. During 45 to 60 minutes of this exposure, the therapist frequently asks the patient to rate his or her distress. This identifies “hot spots” in the account that need to be repeated. The therapist does not necessarily challenge distorted cognitions about the event (such as “I am to blame for the rape” or “No one can be trusted”).