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Effectiveness of CBT on PTSD
Ezgi Yıldız, Ekin Çakır, Fulden Hazal Çalım, Necmi Uzun
Middle East Technical University
Post-traumatic stress disorder (PTSD) is characterized as the psychological and emotional outcomes
of experiencing a traumatic life event (Iribarren, Prolo, Neagos & Chiappelli, 2005). Potentially
traumatic life events such as childhood traumas, sexual assaults, and political violence are very
common and thus, post-traumatic stress disorder (PTSD) affects a large population. One of the most
effective therapy techniques to treat PTSD symptoms is Cognitive Behavioral Therapy (CBT). CBT
has different techniques for specific trauma types, and some examples for these techniques can be in
vivo and imaginary exposure, psychoeducation, homework, and relaxation trainings. In this review,
the effectiveness of CBT and its different methods on PTSD symptoms caused by different kinds of
traumatic events, as well as the effectiveness of CBT across different populations were assessed.
Overall, CBT is found to be a very effective technique for PTSD; however, it could be applied to a
larger population who has developed PTSD.
Keywords: PTSD, CBT, sexual abuse, childhood traumas, political violence.
Post-traumatic stress disorder (PTSD) can be
characterized as the psychological and emotional
outcomes of experiencing a traumatic life event
(Iribarren, Prolo, Neagos & Chiappelli, 2005).
Traumatic life events can range from rape, sexual
abuse, violence, accidents, natural disasters, death of
a loved one, and terrorist acts to war. According to
National Center for PTSD, post-traumatic stress
disorder affects 7-8% of the population during a
given year and women are affected two times more
than men; while women suffer more from sexual
assault, men suffer more from accidents and injury
(2007). Individuals with a PTSD diagnosis who
have been exposed to traumatic events might have
difficulty in overcoming the event and may
experience depression and anxiety. Moreover, the
event may recur as flashbacks, interfere with a
person’s daily life and may cause problems related
to sleeping, eating, socialization, memory, mood
stability and addiction (American Psychiatric
Association, 2013). In order to treat PTSD
symptoms, many treatment methods and therapy
techniques are introduced. A research which was
conducted by Kar (2011) shows that cognitive-
behavioral therapy (CBT) for PTSD yields both
long-term and short-term benefits and it is
considered as an effective treatment.
CBT has numerous techniques for different
disorders and for different symptomatology (as cited
in Dossa & Hatem, 2012). As it can be seen in the
following sections, there are different CBT
techniques that are preferred for specific trauma
types. In this review, it is aimed to examine the
effectiveness of CBT techniques on different kinds
of PTSD symptoms.
One of the most effective CBT technique for
PTSD is the exposure therapy (Kar, 2011).
According to the Kar’s research, after war trauma,
soldiers suffering from PTSD symptoms regarding
social functioning showed significant improvement
by undergoing exposure therapy and cognitive
processing. The same study suggests that by
applying prolonged exposure as the cognitive
behavioral therapy technique, symptoms resulting
from sexual assault and sexual abuse can also be
reduced. In prolonged exposure, patients with PTSD
symptoms gradually encounter their traumatic
memories, negative feelings and trigger situations
that they avoid in daily life. Another sample that
CBT is effective for is children with PTSD. Similar
to the adults, exposure therapy is applied to children
in some cases such as sexual abuse, physical abuse,
disasters, accidents, fear and loss of a loved one.
Although there has been some question marks about
children’s adherence to the CBT structure, it was
supported that CBT is effective for children, too
(Scheeringa, Salloum, Arnberger, Weems, Amaya-
Jackson & Cohen, 2007). Cognitive Behavioral
35
Intervention for Trauma in Schools (CBITS) is also
reported to have significant effect on reducing PTSD
symptoms in children and decreasing psychosocial
problems in their parents (Dorsey, Briggs & Woods,
2011).
Literature Review
CBT for Children Diagnosed with PTSD
Traumatic events and violence target not
only adults, but also children. Unfortunately, the rate
of children and adolescents who are exposed to
potentially traumatic events in the USA is 60.4%
(Finkelhor, Turner, Omrod & Hamby, 2009). A
considerable part of them develop PTSD and other
common trauma related disorders. Even non-clinical
PTSD symptoms make them vulnerable to other
psychological disorders (American Academy of
Child and Adolescent Psychiatry, 2010). Hence, it is
important to treat their PTSD symptoms (American
Academy of Child and Adolescent Psychiatry,
2010). In a meta-analytic review which was
conducted by Wetherington and his colleagues, it
has been seen that CBT is the most efficient
approach for treating child and adolescent PTSD
compared to play therapy, art therapy,
psychodynamic therapy and pharmacological
therapy (2008).
In one study that examines the feasibility and
effectiveness of CBT in traumatized preschool
children, three major points were investigated:
whether preschool children can adhere significantly
in structured, trauma-related exposure exercises,
whether they can apply relaxation techniques well
enough, and whether their parents who are also
traumatized and have high levels of anxiety
constrain the children’s progress (Scheeringa et al.,
2007). They found that even though young
children’s ability of self-expression is still
developing, they could successfully join in the
structured-therapy, collaborate with exposure
techniques and homework, and at the end of the 12
sessions, their PTSD symptoms declined
dramatically. Also, their parents’ anxiety levels did
not interfere with the development of the therapy.
An inspiring study was conducted by Feather
and Ronan (2009) where they presented the
application of CBT methods to maltreated children
who were diagnosed with PTSD following physical
abuse, sexual abuse, neglect, emotional abuse, and
witnessing domestic violence. The Trauma-focused
CBT (TF-CBT) was applied by the same researchers
in previous studies with the aim of clarifying various
hypotheses. For instance, in a study conducted in
New Zealand with maltreated children of European
descent, Feather and Ronan (2006) completed the
first phase of the TF-CBT and reported an overall
reduction in PTSD symptoms and an increase in
coping behaviors related to specific abuse and
trauma-related concerns (as cited in Feather &
Ronan, 2009). The same researchers together with
Murupaenga, Berking, and Crellin replicated the
study with Maori and Samoan children and received
positive results showing that the treatment was also
cross-culturally valid (as cited in Feather & Ronan,
2009). In the latest phase of the study, the fully
developed TF-CBT method was applied by different
therapists and also included their parents and/or
caregivers (Feather & Ronan, 2009).
According to the above-mentioned study, the
TF-CBT program includes several aspects of the
therapy methods used in CBT. Although CBT
methods have been applied for only a few decades,
CBT approaches which are applied to PTSD
highlight the importance of a collaborative
therapeutic relationship, as well as use of creative
applications of the model, particularly when
working with children is concerned (Kendall, 1993).
Based on the “Coping Cat” program which is a
comprehensive CBT based treatment program for
children with anxiety disorders and aims children to
recognize and cope with anxiety and master difficult
tasks (Kendall, Kane, Howard & Siqueland, 2017) ,
the TF-CBT program compromised various methods
including; a) using creative media to create a
coherent trauma narrative with the objective of
desensitizing trauma in a safe therapeutic
environment, b) sand-play therapy which has been
found clinically useful for children in treating abuse
and violence trauma in children, c) the STAR plan
for anxiety disordered children, which is a form of
CBT technique developed by Kendall et al. (1990)
36
for anxious children and aims to improve children’s
coping skills, d) a gradual exposure procedure for
processing and resolving trauma, derived from
behavioral, cognitive and expressive therapy models
adapted for children and finally e) a transition to life
beyond therapy program (as cited in Feather &
Ronan, 2009).
The study findings supported the positive
results of the previous studies which showed that the
levels of PTSD symptoms were reduced, and
children’s coping mechanisms strengthened across
baseline and treatment, and also showing that TF-
CBT was superior to other treatments in improving
PTSD and related symptoms (Feather & Ronan,
2009).
CBT for Sexually Assaulted Women Diagnosed
with PTSD
Although all crimes might have a
psychological impact on the victims, rape and sexual
assault are the most horrifying experiences for
women, and they often result in critical
psychological problems (Breslau, Davis, Andreski &
Peterson, 1991; Wirtz & Harrell, 1987). Averagely,
over 500.000 women reported rape and sexual
assaults per year, and this statistic may not even
reflect the truth since most women are hesitant to
report sexual assaults (Bachman & Salzman, 1995).
Due to the fact that women are more likely to
develop PTSD after a traumatic event (as cited in
Tolin & Foa, 2006), sexually victimized women are
particularly vulnerable to chronic symptoms of
PTSD (Jaycox, Zoellner & Foa, 2002). These kind
of PTSD symptoms therefore may be severe,
difficult to manage, and may last for years without
treatment (as cited in Billette, Guay & Marchand,
2008).
For the most cases of PTSD in rape
survivors, CBT has been used in the context of an
empathic and supportive therapeutic relationship in
which supportive counseling techniques have been
used (Foa & Meadows, 1997). In spite of the fact
that CBT is the most widely used psychotherapy for
PTSD and that there is considerable empirical
support for its effectiveness (Foa, 2000; Foa &
Meadows, 1997; Solomon, 1997), specific and
adapted Greene CBT techniques are needed
considering the success rate is only from 46 % to 54
% (Bradley, Russ, Dutra & Westen, 2005).
Why do some sexual assault survivors
recover and others develop severe psychological
disorders? The following study suggests an answer
for that question as well as a detailed therapy
program for those women. According to Foa and her
colleagues (as cited in Jaycox, Zoellner & Foa,
2002) the reason lies in the Emotional Process
Theory. This theory indicates that in order to recover
from a traumatic event, individuals need to process
the event with special effort, and those who fail to
do so may end up with chronic disturbances.
Accordingly, Jaycox, Zeollner and Foa (2002)
created a CBT program including four important
components: breathing retraining, education about
PTSD symptoms, imaginal exposure to the trauma
itself and confrontation of feared situations, and
cognitive restructuring. In the study, investigators
explained all components in detail; each step to
follow, and session by session structure of the
therapy, and they have demonstrated this program
with a single case report: Janice. At the end of the
therapy, they found that Janice’s PTSD symptoms
reduced dramatically as well as her depression and
anxiety scores according to her weekly self-report
questionnaires (Jaycox, Zoellner & Foa, 2002).
In another study which investigated the
impact of spousal involvement in CBT for sexual
assault survivors, therapy sessions for women who
have PTSD and their spouses were tailored (Billette,
Guay & Marchand, 2008). The treatment included
the psychoeducation about PTSD and sexual assault,
anxiety management techniques, cognitive
restructuring, emotional regulation, in vivo and
imaginal exposure, and relapse prevention.
Women’s spouses were included in the sessions and
they showed their support for their partners. Before
every session, women reported their PTSD
symptoms on self-report questionnaires. The results
demonstrated that all subjects responded positively
to the treatment, and their PTSD symptoms
decreased every week. In addition, they were all
satisfied with the support from their spouses and as
therapy continued, their satisfaction levels increased
as can be seen in their self-reports. This research
suggests that although CBT is effective in PTSD
37
cases, in the context of sexual assault, social support
of spouses can be very helpful for treatment of
symptoms, and important for couples’ relationship.
In sexual assault trauma cases, stigmatization
and the feeling of loneliness is a common problem,
and group therapies are a really good way
eliminating these problems since the survivors feel
like they are being understood by others who have
faced similar traumas, (Prendergast, 1994) also a
perfect environment for sharing traumatic
experiences in a safe place is provided (De Luca,
Boyers, Furer, Grayston & Hiebert-Murphy, 1991).
This self-expressive environment could also provide
the enrichment of interpersonal functioning and
facilitates change during the therapy (Avinger &
Jones, 2007; Hazzard, King & Webb, 1986; Johnson
& Young, 2007). Accordingly, Misurell, Springer
and Tryon (2017) conducted a study which
investigated the effects of game-based CBT group
program for sexually abused children. With the help
of the therapy they have aimed to improve
internalizing symptoms, externalizing behaviors,
sexually inappropriate behaviors, lack of social
skills, self-esteem problems and knowledge of
healthy sexuality and self-protection skills. After
GB-CBT group program, they have discovered that
the program was effective for most of the variables
except for social skills and self-perception. Even
though the results were not statistically significant
for social skills and self-esteem, they have found a
positive direction for those.
CBT for Political Violence Survivors Diagnosed
with PTSD
Political violence is a concept which
includes terrorism, coups or coup attempts, and both
civil and intrastate wars (Sandler, 2016). Although
intrastate wars were not common in recent years,
deaths related to battles have been increasing
dramatically since 2010 (Sandler, 2016). According
to the list published on Wikipedia (2018), the
numbers of individuals who have been killed in
terrorist attacks are increasing every year. The fact
that there is a civil war in Syria, and the number of
individuals who are killed by terrorist groups are
increasing, put an emphasis on the importance and
severity of political violence. CBT has been applied
to many kinds of political violence survivors such as
refugees, war veterans, individuals who are tortured,
bombing survivors, and sexually abused women due
to war-related violence (Dossa & Hatem, 2012). In
this section, war related PTSD symptoms will be
focused on and the efficacy of CBT techniques on
survivors with war related PTSD will be evaluated.
Research about war survivors diagnosed with
PTSD have shown that CBT has minor to large
curing effects on them. Wilson, d’Ardenne, Scott,
Fine and Priebe (2012) claim that the TF-CBT
method had large efficacy on the survivors of the
London bombings which occurred on 7 July 2005.
While before the start of the treatment traumatized
individuals were emphasizing four themes which
were shock and disorientation, reorientation and
reconnecting with the outside of the world, horror
and getting out; as the treatments progressed, they
started to mention recovery and resilience.
On the other hand, Morina, Rushiti, Salihu
and Ford (2010) found no change in PTSD
symptoms in their study conducted with 81 civilian
war survivors of the war in Kosovo. They also
discovered that CBT treatment has a limited effect
on their sense of overall well-being and significantly
improved symptoms of depression and symptoms of
general distress as well as their quality of life. In this
study, war survivors received a CBT treatment
almost nine years after the war. During the therapy,
prolonged exposure and cognitive techniques were
used to treat post-traumatic symptoms.
Psychoeducation, imaginal and in vivo exposure to
reduce avoidance of memories of the traumatic
experiences and associated distress, and reappraisal
of trauma related cognitions were included in the
therapy. In clients with depressive symptoms or
other relevant symptoms, additional CBT techniques
such as behavioral activation, reappraisal of
depressive cognitions techniques were used (Morina
et. al., 2010). As mentioned above, the results of the
overall therapy had no to limited and significant
effects in post-traumatic symptoms. Cook, Schnurr,
and Foa state that CBT techniques are not sufficient
in meeting the needs of more severely distressed war
survivors and that additional approaches may be
needed for war survivors with more severe long-
term symptoms (as cited in Morina et al., 2010).
However, the study shows that CBT techniques are
38
able to enhance the quality of life for individuals
with less severe symptoms in terms of war related
PTSD (Morina et al., 2010). Usefulness of CBT for
war survivors suffering from PTSD is a slightly
controversial topic in the literature. Some
researchers propose to consider the quality of life as
a separate goal and an outcome for civilian war
survivors (Besser & Neria, 2009). On the other
hand, another group of researchers argue to
introduce either more intensive therapies to resolve
PTSD, or alternate methods to specifically enhance
social support or personal efficacy in order to
improve the quality of life (as cited in Morino et al.,
2010). In conclusion, several CBT techniques such
as both in vivo and imaginary exposure,
psychoeducation, homework, and relaxation
trainings are used to treat PTSD symptoms and it
was found that they are mostly effective.
The studies which are mentioned in this
review have some limitations. First of all, almost all
studies have small numbers of participants, which
may create a problem about generalizability.
Therefore, conducting studies with much larger
samples would be good in terms of representability
of results. The second limitation is that in the
literature, there are a lot of studies which
investigated the effectiveness of CBT on children
and adults separately; however, there are not enough
empirical studies which compare the differences in
techniques and effectiveness rates among children
and adults. In further studies, it would be favorable
to investigate these differences, to compare these
different samples and if necessary, to create new and
more effective techniques for children according to
the results.
Another limitation concerns sexual assault
survivors. It is a known fact that not every woman,
especially in countries with conservative cultures,
can share all details of their traumatic stories, and
probably all of the symptoms that they have, which
might create a bias in the results. Moreover, spouse-
involvement may be a good idea and supportive in
the US; however, it may create serious problems for
women in conservative cultures. Women may not
want to share their stories since they may be afraid
of their partners’ reactions. Thus, while adapting
CBT techniques and application styles to another
country or population, it is important to consider the
culture that the individuals live in. Another
limitation is that most of trauma literature about
political violence belong to Western countries such
as Canada and the US (Dossa & Hatem, 2012;
Sloan, Unger & Beck, 2016; Garcia, Kelley, Rentz
& Lee, 2011; Rauch et al., 2009). However, it is also
known that political violence is more common in
Eastern countries, especially in the Middle East.
That means, countries, in which political violence
are more common, do not have many researches
about PTSD, and therapy methods to treat PTSD.
This is probably because these countries do not have
sufficient sources to conduct research; and it may
create a gap between the trauma literature and its
reflections on reality. If suitable techniques for
specific type of traumas are investigated further in
these countries, it could be a valuable contribution
for the trauma literature.
By looking at these studies and their results,
several implications can be suggested. First of all, to
be able to reach individuals who need help but do
not seek help due to the fear of being exposed,
psychotherapists should provide a setting in which
individuals can be anonymous. Providing therapy
via internet and conducting therapy sessions in an
intermediary association which individuals can trust
may be alternatives to provide anonymity. Since
some individuals who have been traumatized cannot
afford the costs of therapies or cannot see a
psychotherapist because they have to work whole
day, more feasible CBT methods should be created.
Therapy by walking around can be an option for
feasibility since it is a recent and untraditional way
of conveying therapy. In this technique, small
groups of mental health workers go out of the
therapy room and directly go into work fields to see
potentially traumatized individuals. They can either
give psychoeducation or teach brief techniques
(Orman, et al., 2002). Informative brochures and
qualified mobile applications giving
psychoeducation can also be used. Finally, the
techniques whose effectiveness are highly supported
by empirical studies should be delivered to a larger
population diagnosed with PTSD. In order to do
this, CBT based group therapies may be used.
39
Moreover, some CBT based therapeutic programs
may be prepared to be applied in schools, work
places, or neighborhoods. Online sources may again
be a good idea to convey CBT techniques to
individuals who need it. As mentioned above, more
feasible and anonymous settings can be designed or
created. Adapting to technology, following e-health
trends and improving or slightly leaving the most
traditional ways of CBT can be useful in this era.
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