Researchers hypothesize that exposing a PTSD patient to traumatic memories engages his or her brain’s pathologic “fear network,” which triggers an excessive fear response to non-threatening stimuli. Continued exposure allows the patient to habituate to this network, with subsequent extinction of fear and anxiety reactions. Foa et al11 found that mentally re-experiencing a traumatic event helps patients organize memory cues about it, which encourages cognitive restructuring of the trauma.
PE has been shown to enhance the trauma survivor’s self-control and personal competence and to decrease generalization of fear to non-assault stimuli.12 For example, many combat veterans report fear of situations—such as going to the beach or into the woods—that bring back memories of traumatic events. Their fears may keep them from enjoying a walk in the park or family vacations.
Through in vivo exposure, these patients can face associations between environmental cues and their trauma. As they learn to modify the fears associated with these cues, their personal and social functioning improves.
PE can be successful for those who complete therapy, but it has a relatively high drop-out rate, reported as 8%13 to 41%.14 The pain of continually reliving a traumatic event probably causes many patients to quit. To reduce drop-out rates, many therapists combine PE with cognitive restructuring or other techniques that help build patients’ coping skills.
Table 1
Using prolonged exposure therapy to treat PTSD, session by session
| Session | Content |
|---|---|
| 1 | Education |
| Treatment rationale | |
| Review of PTSD symptom response | |
| Introduce breathing retraining | |
| 2 | Review handout, ‘Common reactions to trauma’ |
| Introduce Subjective Units of Distress | |
| Create fear hierarchy for in vivo exposures | |
| 3 | Provide rationale for imaginal exposure |
| Conduct imaginal exposure | |
| Assign in vivo exposure homework | |
| 4 to 8 | Conduct imaginal exposure |
| Discuss in vivo exposures | |
| 9 or 9 to 12 | Conduct imaginal exposure |
| Suggest continued in vivo exercises | |
| Termination | |
| Source: Foa EB, Rothbaum BO. Treating the trauma of rape: cognitive behavioral therapy for PTSD. New York: Guilford Press, 1998. | |
Cognitive processing therapy
CPT (Table 2) was created as a protocol to treat PTSD and related symptoms in rape survivors.7 Sessions can be group, individual, or combined, depending on the needs and resources of the patients and clinic.
Originally, CPT contained 12 weekly sessions, although versions up to 17 weeks have been developed for adult survivors of child sexual abuse, domestic violence survivors, and war veterans.15 Sessions can be added or adapted to address each population’s type of traumatic experience (such as developmental impairment of sexual abuse survivors).
CPT is based on information processing theory, which suggests that as people access a traumatic memory, they experience and extinguish emotions attached to the event. Guided by the therapist, the patient identifies and challenges distortions the trauma created in three cognition domains: the self, others, and the world. Patients learn to change or replace these cognitive distortions—which therapists often call “stuck points” or “rules”—with more-adaptive, healthier beliefs.
Common byproducts of trauma are feeling out of control or hopeless. Thus, CPT focuses on personal safety, trust, power/control, esteem, and intimacy within each of the three domains. Modules on assertiveness, communication, and social support can also be added.
Although CPT is being adapted for populations other than rape survivors, comparison studies are needed to determine if it is as effective as other CBT therapies for these groups.
Table 2
Using cognitive processing therapy to treat PTSD, session by session
| Session | Content |
|---|---|
| 1 | Education |
| Review of symptoms | |
| Introduce ‘stuck points’/rules | |
| Write impact of event statement (IES) | |
| 2 | Review IES |
| Identify stuck points | |
| Introduce A-B-C sheets | |
| 3 | Review A-B-C sheets |
| Assign writing of traumatic account | |
| 4 | Read traumatic account |
| Identify stuck points | |
| Rewrite the account | |
| 5 | Read rewritten account |
| Identify stuck points | |
| Introduce challenging questions sheet (CQS) | |
| Assign writing of next-most traumatic incident and CQS | |
| 6 | Review CQS |
| Assign review of faulty thinking patterns (FTP) | |
| 7 | Review FTP |
| Assign safety module and challenging beliefs worksheets (CBW) on safety | |
| 8 | Review CBWs on safety |
| Assign module on trust | |
| 9 | Review CBWs on trust |
| Assign module on power/control | |
| 10 | Review CBWs on power/control |
| Assign module on esteem | |
| 11 | Review CBWs on esteem |
| Assign module on intimacy | |
| Rewrite IES | |
| 12 | Review CBWs on intimacy |
| Read both impact statements | |
| Address remaining areas of concern | |
| Termination | |
| Source: Resick PA, Schnicke MK Cognitive processing therapy for rape victims: a treatment manual. Newbury Park, CA: Sage, 1993. | |
Eye movement desensitization and reprocessing
Like other PTSD treatments, EMDR is based on an “accelerated information-processing” model.16 Because it also incorporates dissociation and nonverbal representation of traumas (such as visual memories), EMDR is often classified as a cognitive treatment, although ISTSS practice guidelines8 present it as a separate category.
EMDR protocols call for the trauma patient to watch rapid, rhythmic movements of the therapist’s hand or a set of lights to distract attention from the stress he or she feels when visualizing the traumatic event. The original technique—developed by Francine Shapiro, PhD—is based on the observation that persons with PTSD often have disrupted rapid eye-movement sleep. In theory, inducing eye movements inhibits stress, allowing patients to more freely access their memory networks and process disturbances. Subsequently, Dr. Shapiro has suggested that using other auditory cues or hand taps may be as effective as eye movements.16