Cognitive Behaviour Therapy (CBT) based Trauma Therapy

CBT based trauma therapy is a well-established, evidence-based therapy designed to address the painful thoughts, feelings, associations, and behaviours linked to traumatic events. It is designed to be time-limited and can be used for adverse life events, cPTSD and PTSD. Many trauma therapies, including Imagery Rescripting (ImRS), Cognitive Processing Therapy (CPT), and Exposure Therapy, are founded on CBT principles.

A key feature of CBT based trauma therapy is exploring the way adverse life events have shaped the client’s view of:

1. Themselves
2. Others
3. The world

Core beliefs about oneself, others, and the world, are then looked at in terms of how well they serve you now, with the aim of keeping helpful beliefs and letting go of beliefs that no longer serve you. 

For example, someone who grows up in a highly competitive or hostile environment may develop the world view “it’s a dog eat dog world” (i.e. I have to look out for myself and I can’t trust others). While this belief might be a useful coping strategy in the situation it started in, over time it may start to get in the way, or prove inaccurate, when applied to all situations in adulthood.

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Examples of common core beliefs about self following an adverse life event include:

I am unworthy

I am unsafe

I deserve bad things

I am a burden

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Examples of common core beliefs about others following an adverse life event include:

People can’t be trusted

People are manipulative

Others will try to hurt me if given the chance

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Examples of common core beliefs about the world following an adverse life event include:

The world is a cruel and horrible place

Nowhere is safe

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CBT Based Trauma Therapy Phases

As with almost all trauma therapies, there is an initial preparation phase of stabilisation and skill building. In this phase, the therapist works with the client to establish a good therapeutic relationship, develop safety plans, and support the client to develop coping skills such as relaxation techniques, emotion regulation strategies, safe place imagery etc. 

The active phase in CBT based trauma therapy involves exploring painful memories (either by using a timeline or by processing recent triggers) with an emphasis on cognitive restructuring.

Cognitive restructuring involves identifying unhelpful patterns in thinking, developing more helpful and well-balanced beliefs, and then changing behaviours accordingly. More helpful can mean: 

• Less triggering
• Less emotionally painful
• Seeing things more clearly or accurately
• Making a more skilled response possible

Cognitive restructuring aims to build on the client’s ability to recognise automatic thoughts and feelings as soon as they come up, and to evaluate their accuracy and helpfulness.

When people first learn about cognitive restructuring, it can easily be mistaken for focusing on the positive. This is an unfortunate oversimplification that can lead to people feeling misunderstood, patronised, and invalidated. It can also be harmful, for example by leading people to stay in an unhealthy or dangerous relationship in the unfounded hope that the other person will change.

Cognitive restructuring instead aims to develop a more sophisticated viewpoint that considers both positive and negative perspectives and is ultimately more:

• Realistic
• Healthy
• Balanced
• Flexible
• Helpful
• Effective

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For example, rather than replacing the belief: 

I can’t trust others

with

I can trust others 

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Cognitive restructuring will instead aim to work towards a more balanced perspective such as:

I can trust some people. Some people in my life have proved to be unhelpful for me, while others have been helpful

CBT may then involve exploring what makes someone trustworthy or untrustworthy, what can point to trustworthiness or untrustworthiness, how to protect oneself without shutting oneself off completely etc.

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CBT Based Trauma Therapy Exercises

Three common CBT based trauma therapy tools are:

• Using an Automatic Thought Record (ATR). This involves writing down intrusive trauma-related thoughts as they come up and using cognitive restructuring techniques, either in real time or after the fact
• Art therapy exercises can help people understand themselves, make sense of things, and gain a new perspective in a less cognitive and more creative way 
• The Cognitive Triangle (pictured below) demonstrates the way our thoughts, behaviours, and emotions are all interconnected. It demonstrates the importance of shifting thoughts and behaviours as a way to change emotions

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Other CBT Based Trauma Therapies

Exposure Therapy

Cognitive Processing Therapy (CPT) - This is a short-term (12 session) CBT based psychotherapy for trauma that focuses on how the event changed the person and their ways of thinking. Each thought is weighed against the evidence to see whether it is accurate and helpful now. 

Stress Inoculation Training (SIT) - This is a psychotherapy that can be used either alongside other therapy or on its own for PTSD. It involves identifying your triggers and developing a range of coping skills to reduce stress and anxiety. Examples of coping skills include deep breathing, helpful self-talk, progressive muscle relaxation (PMR), communication skills, role playing etc.

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Self-guided SIT skills can be downloaded for free at https://mindfulnesspractice.tumblr.com/

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Limitations of CBT Based Trauma Therapies 

While CBT is a leading therapy for adverse life events and PTSD, it does not work for everyone. Some people find the focus on thoughts and thought diaries doesn’t shift how they feel. In these cases, the person may benefit from a different form of trauma therapy (such as Imagery Rescripting or Compassion Focused Therapy) or a therapy that focuses on shifting painful emotions in other less cognitive ways, such as using the emotion regulation skills in Dialectical Behaviour Therapy or the somatic strategies in Sensorimotor Psychotherapy.

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