Cognitive Behavior Therapy in the Treatment of Posttraumatic Stress Disorder

Terence M. Keane and Danny G. Kaloupek

Department of Veterans Affairs Medical Center, Boston, MA
Tufts University School of Medicine

Reprinted from:
Keane, T. M. & Kaloupek, D. G. (1996). Cognitive behavior therapy in the treatment of posttraumatic stress disorder. The Clinical Psychologist, 49(1), 7-8.


I. Description of Treatment

Exposure therapy is a class of interventions that includes: systematic desensitization (imaginal or in vivo), flooding (imaginal or in vivo), implosive therapy, self-control desensitization, participant modeling, and other related techniques. In the treatment of PTSD, any of these approaches can potentially be used to access emotions associated with the traumatic event and promote emotional processing. It is this emotional processing that is viewed by many experts as the essential ingredient for treating PTSD (see Foa and Kozak, 1986).

Descriptions of how these different exposure techniques are implemented can be found in many original sources going back to the 1960's. Applications specific to PTSD are found in the clinical literature spanning only the past fifteen years (e.g., Foa, 1992; Keane, Fairbank, Caddell, Zimering & Bender, 1985; Resick & Schnicke, 1993; Saigh, 1992; Veronen & Kilpatrick, 1983). In vivo and imaginal exposure therapies for PTSD typically involve some form of graduated exposure to trauma-relevant cues, a procedure which may or may not be accompanied by attempts to maintain a fear-antagonistic state such as relaxation. This exposure could include returning to the place where the traumatic event occurred and attempting to come into contact with some of the salient contextual cues (e.g., time of day), as well as contact with other stimuli that have affective associations to the event (e.g., sounds or odors). More often, imaginal material is presented alone or in combination with in vivo cues in order to help the individual access the full array of emotional structures associated with a particular traumatic event.

Other forms of Cognitive Behavior Therapy for PTSD incorporate components of stress management or stress inoculation therapy. Essentially, this form of intervention follows a skills training model wherein the individual first masters specific behavioral techniques known to modify the anxiety response and then is coached in how to employ these new skills in the management of PTSD-type symptoms. Relaxation training, interpersonal skills training, anger management training, guided self-dialogue, and thought stopping are examples of skills taught to individuals, usually in a package of interventions designed to address specific trauma symptomatology.


II. Summary of Studies Supporting Treatment Efficacy

Initial case studies of the behavioral treatment of PTSD appeared in the early 1980's shortly after the diagnosis of PTSD appeared in the diagnostic nomenclature (e.g., Black & Keane, 1982; Fairbank & Keane, 1982; Keane & Kaloupek, 1982). Prominent in all successful cases was an emphasis on systematic exposure to some depiction of the traumatizing event(s). These early case studies relied on single-subject designs or generic psychological assessments to demonstrate clinical outcome. These studies and subsequent replications from other clinical research laboratories provided the foundation for larger, controlled evaluations of treatment outcome for PTSD.

These more elaborate comparative outcome studies have used standardized and well validated measures of PTSD, as well as random assignment of subjects to treatment conditions in an effort to improve upon the methods of the initial case studies. Several studies with combat veterans have demonstrated improved outcome as a function of exposure-based interventions for chronic PTSD (e.g., Boudewyns & Hyer, 1990; Cooper & Clum, 1989; Keane, Fairbank, Caddell, & Zimering, 1989). Two methodologically strong clinical trials employing women who have experienced rape also support the efficacy of cognitive behavioral procedures in the treatment of PTSD (Foa, Rothbaum, Riggs, & Murdock, 1991; Resick, Jordan, Girelli, Hutter, Marhoefer-Dvorak, 1988).

Clinical variations in treatments for PTSD sometimes supplement the exposure therapy component with cognitive procedures intended to address issues of guilt, cognitive distortions, irrational beliefs, and dysfunctional values. Whether these additional procedures add to the overall effectiveness of the treatment is an empirical questions that needs to be addressed. The cognitive adjuncts have both theoretical and intuitive appeal, and the field awaits the outcome of several ongoing clinical trails in both the United States and the United Kingdom that are designed to test their utility in the care of PTSD patients.

Solomon, Gerrity, and Muff (1992) provided a comprehensive review of the treatment outcome literature on PTSD that covered the studies noted above, as well as the only international study published to date on PTSD treatment (Brom, Kleber, & Defares, 1989). This investigation found that systematic desensitization was an effective treatment for PTSD that stemmed from a wide variety of traumatic events. Solomon et al. (1992) concluded that the value of systematic exposure treatments has been documented, but they also advocated for increased resources devoted to treatment outcome studies in the area of PTSD given the limited number of clinical trials currently available.


III. Recommended Clinical References

Black, J.L. & Keane,T.M. (1982). Implosive therapy in the treatment of combat related fears in a World War II veteran. Journal of Behavior Therapy and Experimental Psychiatry, 13, 163-165.

Boudewyns, P.A. & Hyer, L. (1990). Physiological response to combat memories and preliminary treatment outcome in Vietnam veteran PTSD patients treated with direct therapeutic exposure. Behavior Therapy, 21, 63-87.

Brom, D., Kleber, R. J., & Defares, P.B. (1989) Brief psychotherapy for posttraumatic stress disorders. Journal of Consulting and Clinical Psychology, 57, 607-612.

Cooper, N. A. & Clum, G. A. (1989). Imaginal flooding as a supplementary treatment for PTSD in combat veterans-A controlled study. Behavior Therapy, 20, 3, 81-391.

Fairbank, J.A., & Keane, T.M. (1982). Flooding for combat-related stress disorders assessment of anxiety reduction across traumatic memories. Behavior Therapy, 13, 499-510.

Foa, E. B. & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35.

Foa, H. B., Rothman, B.O., Riggs, D.S., & Murdock, R.B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, 715-723.

Foa, D. W. (1992). Treating PTSD: Cognitive-behavioral strategies. New York: Guilford.

Keane, T.M., Fairbank, J.A., Caddell, J.M., & Zimering, R.T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260.

Keane, T. M., Fairbank, J. A., Caddell, J. M., Zimering, R. T., & Bender, M. E. (1995). A behavioral approach to assessing and treating post-traumatic stress disorder in Vietnam veterans. In C. R. Figley (Ed.), Trauma and its wake (pp. 257-294). New York: Brunner/Mazel.

Keane, T. M. & Kaloupek, D. G. (1982). Imaginal flooding in the treatment of a posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 50, 138-140.

Resick, P. A., Jordan, C. G., Girelli, S. A., Hutter, C. K., & Marhoefer-Dvorak, S. (1988). A comparative outcome study of behavioral group therapy for sexual assault victims. Behavior Therapy, 19, 385-401.

Resick, P. A. & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park, CA: Sage Publications, Inc.

Saigh, P. A. (1992). Posttraumatic stress disorder: A behavioral approach to assessment and treatment. New York: Macmillan Publishing Company.

Solomon, S. D., Gerrity, E. T. & Muff, A. M. (1992). Efficacy of treatments for posttraumatic stress disorder: An empirical review. Journal of the American Medical Association, 268, 633-638.

Veronen, L. J. & Kilpatrick, D. G. (1983). Stress management for rape victims. In D. Meichenbaum & M. E. Jaremko (Eds.), Stress reduction and prevention (pp. 341-374). New York: Plenum.


IV. Resources for Training

National Center for PTSD
Educational Division (323EI 12)
Palo Alto VA Medical Center
Palo Alto, CA 94304

Behavioral Science Division (I 16B-2)
Boston VA Medical Center
Boston, MA 02130

Women's Health Sciences Division (I 16B-3)
Boston VA Medical Center
Boston, MA 02130

National Crime Victims Research and Treatment Center
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
171 Ashley Avenue
Charleston, SC 29425


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