Cognitive Therapy (CT)

Cognitive therapy for PTSD is derived from cognitive behavioral therapy (CBT). The cognitive model suggests a person will develop PTSD if the person processes a traumatic event in a way that leads to a feeling of a present and severe threat.

This can happen either because of extremely negative evaluations of the trauma or its sequelae or because of a disturbance in one’s autobiographical memory of the trauma. The person then re-experiences aspects of the trauma in a seemingly uncontrolled fashion that leads to unhelpful behavioral and cognitive coping responses.

The guideline suggests CT for the treatment of PTSD.

Treatment entails modifying the pessimistic evaluations and memories of trauma in order to interrupt the behavioral and/or thought patterns that have been interfering in the person’s day to day life. Like CBT, it is typically delivered in weekly sessions over three months either individually or in groups.

The therapist works with the patient to identify the relevant evaluations, memories and triggers of the trauma that sustain the patient’s specific PTSD symptoms. While the comparative weight given to the various treatment strategies differs from patient to patient, several strategies are generally used in therapy. These strategies are common to standard CBT, but are emphasized and used differently in CT.

First, the therapist works to help the patient understand the meaning behind traumatic memories and how they are presently appraised and to recognize that excessively pessimistic evaluations of the trauma or its sequelae may exaggerate the current feeling of threat. The therapist uses a strategy of Socratic questioning along with other approaches to help the patient arrive at a different evaluation that he or she finds compelling.

This new and different evaluation is then integrated with the traumatic memory or cues. This can be accomplished by the patient writing and thinking about the new evaluation while at the same time considering the trauma memory, or by embedding the new evaluation into a subsequent imaginal reliving of the traumatic experience.

The patient is also guided by the therapist in establishing a meaningful narrative account, an account that begins before the trauma occurred and ends after the patient feels secure again. This can be accomplished, in part, by writing a comprehensive account of the traumatic event, through imaginal reliving of the traumatic event, or by revisiting the location where the traumatic event occurred. While this has an element of “exposure,” the intent is to identify idiosyncratic memory points that appear to elicit strong responses and utilize cognitive restructuring in the moment. This elaboration of autobiographical memory helps lessen re-experiencing and challenges the problematic thinking that has become associated with the trauma.

Finally, the therapist helps the patient stop behaviors and ways of thinking that may decrease the feeling of current threat but in the long-term actually sustain PTSD symptoms. The therapist and patient target such things as rumination, safety-seeking behaviors, and thought suppression. They talk about how these behavioral and cognitive strategies disrupt everyday behavior and potentially contribute to keeping the PTSD symptoms. The patient is encouraged to drop these unhelpful strategies or to try behavioral experiments to overcome or reverse their impact.