CBT for Trauma

By David Tolin
Multi-award winning CBT expert and author of ‘Doing CBT’

9 MIN READ APPROX.

CBT Tips and Insights for Mental Health Practitioners

 What is Trauma and PTSD?
In recent years, the word ‘trauma’ has found its way into everyday
language and conversation. It is sometimes used to describe stressful
life events such as getting a divorce or changing schools. While
language naturally evolves and people’s perceptions of events can
vary, it’s important to differentiate between these casual uses of the
term and the types of experiences that are associated with profound
psychological distress in a mental health context.

In the context of PTSD, the word “trauma” is used to refer to DSM-5

criteria and occurs when a person either experiences or witnesses an

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 actual or threatened death, serious injury or sexual violence. This can
include situations such as military combat, physical or sexual assault,
a vehicle accident, a life-threatening illness/injury, being a victim of
torture, or childhood sexual abuse. In each of these cases, the trauma
increases the likelihood that the client will develop PTSD.

It’s important to keep this definition of trauma in mind. The

treatments being described here are specifically designed for
traumatic events that are followed by symptoms of PTSD, rather than
for general stressful life events that a person might experience. It’s also
necessary that clinicians recognize that the experience of a traumatic
event does not automatically result in PTSD.

While distressing symptoms often follow traumatic events, not

everyone will go on to develop PTSD. In fact, the majority of individuals
exposed to traumatic events naturally recover over time, especially if
they engage with their emotions, seek social support and address any
misconceptions or distorted beliefs about their role in the event.

Clinicians don’t need to swoop in and start intervening on every single

case of trauma, especially if the experience was recent. For many
recent trauma survivors, some support, ensuring basic needs are
being met, and encouragement to engage with a social network will
be sufficient.

For a subset of clients, however, symptoms persist and they go on

to develop PTSD. PTSD is essentially a disorder of non-recovery from
trauma. When symptoms do persist and intervention is required,
it is usually due to one (or both) of two maintaining factors. The
first maintaining factor is avoidance of external stimuli related to
the trauma (situations, people, activities, places) or internal stimuli

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 (trauma memories, feelings). The second is negative interpretations
or core beliefs about the trauma, self and others (such as “I’m
hopeless” or “The world is a dangerous place”).

Cognitive Behavioral Therapy (CBT) is an evidence-based treatment

for PTSD. It includes three key treatment elements that we’ll cover
in the following pages. These include psychoeducation, exposure
and cognitive restructuring. By collaborating with your clients and
working through these treatment elements, you can help them to
regain a sense of control over their lives, find much-needed relief, and
ultimately overcome their symptoms.

Psychoeducation in PTSD Treatment

PTSD can flood individuals with distressing thoughts, often leading
them to believe recovery is unattainable. They may feel isolated,
thinking that no one can truly understand their experience. This is
where psychoeducation plays a pivotal role. It helps clients recognize
that PTSD isn’t a personal failure but rather a condition that can
impact anyone. By understanding the nature of PTSD - its triggers,
its impact on thoughts and feelings, and the efficacy of treatment -
clients can cultivate a sense of hope that therapy will lead to change.

Psychoeducation isn’t a one-off event; it weaves throughout the

entire therapeutic process. It’s about providing clients with timely and
relevant information to help them understand the rationale behind
therapeutic activities and interventions.

The overarching goal of psychoeducation is to ensure client

engagement in the therapeutic process. By being well-informed,
clients are more likely to be active, involved participants throughout

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 therapy. One of the most powerful effects of psychoeducation is the
sense of validation it offers clients. Feeling understood at an emotional
level strengthens the therapeutic alliance, which will help both the
therapist and the client during the challenging phases of therapy,
such as exposure.

One of the most helpful things to share with your client is the CBT
model of PTSD and in particular how it relates to their personal
situation. The CBT model looks at the interplay between thoughts,
feelings and behaviors and how each can reciprocally influence the
others. Intervention in one area can lead to positive effects in the
others.

For example, if a client is persistently avoiding situations, a behavioral

intervention for PTSD such as exposure will help them do things that
make them feel better and change how they think about themselves
and the world.

CBT for Trauma course

Watch CBT and trauma experts discuss the importance of psychoeducation

in the treatment of PTSD.

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 Exposure
It’s natural to avoid situations or feelings that make us feel
distressed or uncomfortable. Avoidance brings short-term relief, but
unfortunately it also leads to long-term problems such as PTSD. It
does this by reinforcing the idea that something is a serious threat
and too difficult to face. Avoidance after trauma can lead to chronic
symptoms including flashbacks, intrusive thoughts and images,
nightmares, intense feelings of fear and distress, and physical
sensations such as sweating, pain or nausea.

While confronting their fears and revisiting a trauma might be the last
thing a client wants to do, it can be the very thing that will help them
heal. The more your client confronts their fears, the less scared they
become and the more confident they feel.

Helping a client recognize that exposure will help them can be

challenging. Many individuals hold misconceptions about exposure,
such as seeing it as too intense or potentially harmful. Building a
strong therapeutic rapport and educating clients about the rationale
and mechanics of exposure are essential in supporting a client to give
it a try. Introducing the exposure hierarchy (see below) in the early
stages of therapy can give the client a roadmap for therapy and assure
them that they will progress at a pace they are comfortable with.

Exposure also targets ‘safety behaviors’ - actions clients take to feel

safer, but which inadvertently perpetuate their fears. For example, a
client involved in a car accident might start riding their bike or taking
the train to avoid getting back in a vehicle again. While this behavior
makes them feel safer, it only reinforces their fear of driving.

There are two main types of exposure for PTSD: in vivo and
imaginal exposure.

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 In Vivo Exposure
‘In vivo’ exposure involves helping clients face and engage with real-
life reminders of trauma that are objectively safe. Its primary goal is to
counteract avoidance. The experiential insights and evidence gained
in in vivo exposure can be pivotal in correcting unhelpful thoughts
and beliefs about oneself, others, and the world - beliefs that often
maintain PTSD symptoms.

In most cases, the clinician works with their client to construct an

“exposure hierarchy” that is tailored to the client’s specific fears. The
hierarchy details a progression of exposures, ranked from the least to
the most distressing. Clients are then guided to progressively confront
these situations, usually outside of therapy sessions.

This step-by-step approach allows them to gradually face their fears,

fostering a growth in confidence, a sense of accomplishment, and the
motivation to continue therapy.

For instance, a client traumatized by a car accident might start

exposure merely by sitting in a car. As they progress, they might
progress to actions like starting the engine, listening to the radio,
practicing simple maneuvers, and ultimately, returning
to driving.

Imaginal Exposure
Imaginal exposure involves helping your client to revisit and process
traumatic memories or feared situations in detail during therapy
sessions. Its primary role is to reduce the client’s instinctual avoidance
of distressing memories and emotions. In doing so, it aims to correct

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 unhelpful thoughts and beliefs about oneself, others, and the world
- commonly seen in individuals with PTSD. For instance, a client
with a history of child abuse may be guided to re-examine a specific
traumatic memory. Doing so can organize and integrate the memory
into a more structured and coherent narrative. Also, by directly
confronting memories they are avoiding, clients learn to manage or
accept emotions that arise.

The underlying premise is that by confronting these memories

directly, clients are able to better manage and accept the emotions
they trigger. This reduces distress and reshapes negative beliefs.
A pivotal realization during this process can be that experiencing
anxiety or distress does not equate to “going crazy” or losing control.
This therapeutic process not only challenges but also corrects
underlying negative beliefs about self-worth and efficacy.

Sessions of imaginal exposure typically last between 30 to 60 minutes.

Often they are recorded, allowing clients to revisit and reinforce the
therapeutic work at home.

Doing Exposure Well

The efficacy of exposure therapy, like many therapeutic interventions,
is improved by the client’s sense of being genuinely listened to and
understood. Therapists can enhance this rapport through various
skills such as reflective listening, normalization, validation, empathic
curiosity, and genuine engagement.

An essential aspect of exposure interventions is demonstrating to

the client that you, as a therapist, can withstand and process the
depth of their traumatic experiences. This not only establishes trust

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 but also ensures they fully delve into the necessary details without
holding back. Avoiding these details, even with the best intentions,
inadvertently aligns with the client’s avoidance patterns.

CBT for Trauma course

Watch Kelly Chrestman demonstrate psychoeducation about PTSD

and avoidance.

Cognitive Restructuring
Cognitive restructuring also reduces avoidance because by
encouraging clients to closely examine trauma-related thoughts, they
inadvertently engage with the traumatic event in depth. Cognitive
restructuring involves helping clients to explore their thinking with
the goal of helping them process the traumatic event. You can use
cognitive restructuring to help your client change the meaning of the
traumatic events they have experienced.

In the context of PTSD, it is not uncommon for individuals to

retrospectively view traumatic events with self-blame or wishful
thinking about alternative actions.

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 Such distorted perceptions can manifest in thoughts like:

• “It was my fault.”

• “I should have done_____ instead.”

• “I don’t have any control.”

• “I’m bad.”

• “I’m dirty.”

• “I’m not safe.”

• “I can’t trust anyone.”

• “The world is a dangerous place.”

Cognitive restructuring helps clients to identify and challenge

distressing or maladaptive thoughts. This approach emphasizes a
fundamental truth: thoughts are not facts. Using tools such as the
Thought Monitor, clients can develop a heightened awareness of their
thoughts and an understanding of the triggers and sequences that
lead to strong emotional reactions.

Merely reassuring someone with phrases like “it’s not your fault” or
“the world isn’t dangerous” rarely works. In order to have more helpful
and realistic thoughts that clients truly believe, they need to come up
with them on their own. Clients are more likely to believe and act on
things that come from their own realization. Thus, the therapist’s role
is to compassionately guide them to that place by asking the right
questions, validating their emotions, encouraging realistic thinking,
focusing on specific details, and maintaining a curious stance.

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 A therapist may ask:

• Do you believe this to be true?

• Were there other choices available to you?

• To what extent did you have control over the event?

• How did you arrive at this belief?

The technique of Socratic dialogue is helpful here. Based on the

notion that genuine learning arises through answering questions, this
dialogue involves strategically posed questions by the therapist and
facilitates deeper client introspection and self-awareness.

CBT for Trauma course

Watch Debra Kaysen explain the value of good Socratic dialogue in

cognitive therapy for PTSD.

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 A Final Word
Assisting a client through PTSD recovery is among the most
rewarding experiences a therapist can have. The three treatment
elements we’ve explored are a robust framework for guiding your
clients out of the shadows of trauma to a rich and meaningful life.

1 Psychoeducation

2 Exposure

3 Cognitive Restructuring

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