Prolonged exposure has been reported to be effective for improving post-traumatic stress symptoms in 60%–65% of trauma victims suffering from PTSD (Grunert et al. 2007). However, a simple habituation model (on which prolonged exposure is based) is observed to be insufficient to address non-fear emotions (eg, guilt, shame, anger) in PTSD. In contrast, by adding an imagery-based, cognitive restructuring component (imagery rescripting and reprocessing therapy) to the treatment of individuals of PTSD who have failed to improve with prolonged exposure alone, 78.3% of clients showed full recovery from their PTSD symptoms and no longer met criteria for PTSD after 1–3 sessions of imagery rescripting and reprocessing therapy (Grunert et al. 2007). It suggests that individualised trauma assessments should be conducted for each patient to identify the predominant trauma-related emotions and cognitions which will help to find the best CBT “treatment fit” for the specific trauma characteristics of each patient (Grunert et al. 2007).
The traumas of war have long been associated with PTSD. In addition, soldiers exposed to combat remain at high risk for developing the disorder (Miyahira et al. 2010). Multicomponent CBT showed promise in a group of male combat veterans with severe and chronic PTSD for improving social functioning beyond that provided by exposure therapy alone, particularly by increasing social engagement and interpersonal functioning (Miyahira et al. 2010). CBT with brief virtual reality exposure has been found to be beneficial in treating PTSD in war veterans (Miyahira et al. 2010). A 12-session integrated treatment using components of cognitive processing therapy for PTSD, and CBT for chronic pain management in veterans with comorbid chronic pain and PTSD, suggested not only the feasibility of this treatment approach but also clinical benefit (Miyahira et al. 2010).
CBT vs EMDR
Various forms of therapies have been compared with CBT in the treatment of PTSD, namely supportive psychotherapy, problem-solving therapy, present-centred therapy, psycho-dynamic therapy, hypnotherapy, acupuncture, and structured writing therapy (Cottraux et al. 2008). However, more consistent comparison has been with EMDR. A systematic review of 23 clinical trials on the efficacy of CBT in comparison with other psychotherapies suggested that CBT had better remission rates than EMDR or supportive therapies. CBT was comparable with exposure therapy and cognitive therapy in terms of efficacy and compliance. These findings suggested that specific therapies, such as CBT, exposure therapy, and cognitive therapy are equally effective, and more effective than supportive techniques in the treatment of PTSD (Mendes et al. 2008).
Another systematic review of 33 randomized controlled trials compared all psychological treatments for adults suffering from traumatic stress symptoms for three months or more. Types of interventions studied were trauma-focused CBT/exposure therapy, stress management, other therapies (supportive therapy, nondirective counselling, psychodynamic therapy, and hypnotherapy), group CBT, and EMDR. With regard to reduction of clinician-assessed PTSD symptoms measured immediately after treatment, trauma-focused CBT did significantly better than other therapies and wait-list/usual care. There is no significant difference between trauma-focused CBT and stress management, trauma-focused CBT, and EMDR. Group trauma-focused CBT was significantly better than wait-list/usual care. It was concluded that individual and group trauma-focused CBT, EMDR, and stress management are effective in the treatment of PTSD. There was some evidence that individual trauma-focused CBT and EMDR are superior to stress management in the treatment of PTSD at 2–5 months following treatment (Bison & Cochran 2007)
In six studies comparing EMDR directly to trauma‐focused CBT, results were mixed. Three studies found an advantage for EMDR as compared to exposure alone and to exposure plus cognitive therapy. Three studies found exposure or its combination with cognitive restructuring and SIT was superior to EMDR (McFarlane et al. 2011).
The Australian Guidelines recommend trauma‐focused psychological therapy, delivered during 90‐ minute sessions, as the best evidence treatment for PTSD (ACPMH 2007). This type of treatment can be easily delivered in a community setting, given the availability of suitably trained therapists. Findings of more than 30 well controlled studies indicate that trauma‐focused Cognitive Behavioural Therapy (CBT), as well as Eye Movement Desensitization and Reprocessing therapy (EMDR) in addition to in vivo exposure, are the treatments of choice for PTSD (Pietrzak 2011). These treatments were found to be effective, not only in the treatment of PTSD symptoms, but also of co‐morbid anxiety and depression, as well as achieving improvements in broader quality of life (Pietrzak 2011).
Seidler & Wagner (2006) suggest that in the treatment of PTSD, CBT and EMDR tend to be equally efficacious. Seidler & Wagner (2006) stated that future research should not restrict its focus to the efficacy, effectiveness and efficiency of these therapy methods but should also attempt to establish which trauma patients are more likely to benefit from one method or the other.
Considering the available literature it is clear that there is evidence for the efficacy of both CBT and EMDR in treating PTSD in the civilian and military population. What is less clear is which therapy is suitable to individuals who present with a specific set of variables and circumstances. The argument that EMDR is able to deliver results in a timely manner which can suit the “let’s get things done now” attitude of ADF members would appear invalid as the recommended session length of 8-12 is comparable with CBT. As both forms of therapy have proven effect and therefore are the current gold standard’s and recommended treatments for PTSD by the DoD and DVA, studies should now focus on dropout rates and assessment. Grunert et al. (2007) discussed the importance of individualised trauma assessments to assist the therapist in discerning a treatment fit for the trauma characteristics being presented. This is especially important for ADF members who are more likely to be exposed to complex multiple traumas. Further dismantling studies as to the effectiveness of CBT and EMDR components would also be useful in identifying presenting characteristics and effectiveness of specific interventions. This could lead to a multi-faceted treatment which is tailored to the specific needs of the ADF member promoting remission and completion of therapy.
Table 2. CBT techniques used in treating PTSD
Education offered to individuals with a mental health condition and their families to help empower them and deal with their condition in an optimal way. For PTSD this includes education on trauma and psychological and physiological reactions to trauma.
Relaxation training involves instructing the individuals in various relaxation exercises, which are used at times of anxiety or distress. Relaxation its effects by reducing hyperarousal symptoms. Once hyperarousal is reduced, the patient may be less distressed by trauma-related stimuli and, therefore, less avoidant (Taylor et al, 2001)
Cognitive Restructuring with PTSD involves challenging maladaptive cognitions of helplessness, hopelessness and worthlessness to reduce fear. This is achieved through questions such as “What is it about this situation that makes you weak?’’, ‘‘How is it that you are to blame?’’, and ‘‘What would you say to a friend in this situation? (Ehlers & Clark, 2000)
In Imaginal Reliving individuals are asked to relive the traumatic experience in the presence of the therapist, starting from the beginning and continuing to the point when they were safe again, while putting the experience into words (Foa & Rothbaum, 1998)
In Imaginal Exposure individuals are asked to recall the details of the traumatic event while focusing their attention on any occurring sensory feelings, thoughts, and emotions. Exposure to such memories results in reduction of fear and avoidance. The presumed underlying mechanism is the loosening of the association between unconditioned and conditioned stimuli (Foa et al., 1999)
In vivo Exposure
In vivo exposure involves planned confrontations with situations or objects associated with the trauma and that are therefore anxiety-evoking (Richards et al. 1991)
Post-Traumatic Growth is the subjective experience of positive psychological change reported by an individual as a result of the struggle with trauma. Some theorize it is a coping style, while others think of Post-Traumatic Growth as an outcome of coping with traumatic stress (Sheik 2008)
Stress Inoculation Training
Stress Inoculation Training involves teaching coping skills to manage stress and anxiety. This may include training in deep muscle relaxation, cognitive restructuring, breathing exercises, assertiveness skills, thought stopping, role playing, and guided self-dialogue. Stress Inoculation Training is often used in conjunction with other therapy techniques, such as CBT (Meichenbaum, D & Deffenbacher 1996)
Therapists assist the client to construct an exposure fear hierarchy, in which feared objects, activities, or situations are ranked according to difficulty. They begin with mildly or moderately difficult exposures, then progress to harder ones (Opdyke, Williford & North 1995)
in Imagery Rescripting expression of inhibited responses is facilitated as well as new information provided during evocation of the traumatic memory (Arntz & Weertman 1999)
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