B. Cognitive Therapy (CT)

BACKGROUND

Aaron Beck, at the University of Pennsylvania, developed Cognitive Therapy (CT) as a structured, short term, present-oriented psychotherapy for depression (Beck, 1964). It is an approach that focuses on improving mood by modifying dysfunctional thinking and behavior. Beck and others have successfully adapted CT to the treatment of a diverse set of psychiatric disorders, including PTSD (Freeman & Datillo, 1992; Freeman et al., 1989; Scott et al., 1989).

CT for PTSD typically begins with an introduction of how thoughts affect emotions and behavior. The cognitive model of change and expectations for participation in therapy is reviewed. Early in treatment, new skills to identify and clarify patterns of thinking are taught using techniques such as recording thoughts about significant events, identifying distressing trauma-related thoughts, and converting such dysfunctional thought patterns into more accurate thoughts. CT also emphasizes the identification and modification of distorted core beliefs about self, others, and the larger world. CT teaches that improved accuracy of thoughts and beliefs about self, others, and the world leads to improved mood and functioning.

DISCUSSION

Randomized controlled trials (RCTs) have shown that CT is an effective intervention for patients with PTSD (Lovell et al., 1998; Marks et al., 2001). It is useful for identifying and modifying the many negative beliefs related to a traumatic experience. CT can be used effectively to reduce distressing trauma-related thoughts (e.g., about survival guilt, self-blame for causing the trauma, feelings of personal inadequacy, or worries about the future). Modifying thoughts about these and other trauma-related issues can reduce PTSD symptoms and improve mood and functioning.

In RCTs, Lovell et al. (2001) and Marks et al. (1998) indicated that CT can produce a substantial treatment effect for civilian men and women with PTSD resulting from a variety of non-combat-related traumas. There are no RCTs that specifically evaluate the use of CT in military or veteran PTSD patients; however, the use of CT in this population is recommended based on expert consensus.

CT techniques are often delivered as part of treatment "packages" that can include exposure therapy, trauma-related education, and anxiety management. For example, Cognitive Processing Therapy, which has been manualized and validated for use with female sexual assault-related PTSD in women (Resick et al., 2002), combines aspects of CT and exposure therapy. CT can also be delivered in conjunction with a range of other psychological therapies (e.g., EMDR and psychodynamic therapy). CT techniques may be an especially helpful treatment component when co-morbid depressive and/or anxiety disorders are present.

Contraindications for CT have not been empirically established, but may include psychosis, severe brain damage, or severe intellectual impairment.