Increasing The Effectiveness Of Trauma-Focused Cognitive Behavior Therapy

In this article, we will discuss the effects of trauma and the benefits of trauma-focused cognitive behavior therapy.

The Trouble with Trauma

Experiencing traumatic events can be overwhelming and disrupt a person’s ability to function. Serious cases can produce Post Traumatic Stress Disorder (PTSD) symptoms, including:

• Haunting memories with accompanying emotional upheavals as if the traumatic event was being experienced again
• Overwhelming frustration in the form of feeling threatened, with a heightened sense of vigilance
• An urge to fight or run away from the traumatic memory
• Irrational thinking patterns and beliefs about yourself, others, and the world

The traumatic event can be the experience of surviving a serious car accident, a terrorist attack, domestic, physical, or sexual violence, or it could be the experience of life-threatening situations such as wars or natural disasters, or other horrendous events. Survivors may have feelings of shock, fear, false guilt, shame, anger, or vulnerability. The effects of these experiences can last for decades, especially in cases of traumatic events during childhood.

The Two Major Techniques of Trauma-Focused Cognitive Behavior Therapy

Cognitive Therapy (CT)

This technique uses methods to help identify and change thoughts that evoke emotional distress and to create the motivation to modify thought patterns.

Some of these therapeutic methods include:

• Closely examining the accuracy and appropriateness of thoughts and emotions and changing those that do match up with reality
• Questioning the evidence that you have used to support your conclusions or beliefs – a lack of evidence can prompt you to modify them
• Considering other ways of looking at the causes of traumatic events that were experienced
• Evaluating whether you are making mountains out of molehills or making extreme conclusions about situations or outcomes
• Listing the pros and cons of maintaining your thoughts or beliefs to gain a larger perspective of things
• Considering how a positive outcome can grow out of a negative experience
• Seeking connections between automatic negative thoughts (ANTs) and deeply held beliefs and thought patterns
• Exaggerating a thought or belief that you have to where a more reasonable view is brought into your awareness
• Commanding yourself to “STOP” in an emphatic tone when you engage in negative self -talk.

These examples give the flavor of how CT can be used.

Rational Emotive Behavior Therapy (REBT)

A variety of methods are used by REBT to help avoid emotional distress. These include:

• Strongly and vigorously disputing beliefs about people, places, and things that remind of the traumatic event and changing them to correspond to reality
• Tracking events that trigger irrational beliefs and practicing the technique of disputing them
• Changing your use of specific statements that contain the words “must,” “should,” and “ought,” to statements that merely reflect personal preference
• Attending psycho-educational sessions to learn how to challenge irrational beliefs
• Using vivid and intense mental imagery to visualize desired thinking and feeling
• Poking fun at irrational beliefs to expose their absurdities
• Learning to be less inhibited and more spontaneous by engaging in behaviors that would normally cause shame or humiliation.

Other Therapeutic Options Commonly Used in Conjunction with Trauma-Focused Cognitive Behavior Therapy

Eye Movement Desensitization and Reprocessing (EMDR)  

EMDR seeks to change how you react to traumatic memories by focusing on other stimuli (i.e., eye movement, hand taps, and certain sounds) while traumatic events are discussed. It is administered by a certified EMDR therapist.

Group Therapy and Family Therapy

By talking with others who have also experienced trauma in group therapy may be helpful in reducing the severity of overwhelming emotions elicited by painful memories. Involving the family may be helpful since family members may not understand the nature of the stress and emotions associated with traumatic memories. For example, they may have reacted by withdrawing, becoming angry, or by feeling responsible for the person’s stress.

Sorting this out in family therapy can be a way to increase communication and maintain good relationships. The support of others and the facilitation of positive relationships can be quite helpful in increasing one’s awareness of their thoughts, emotions, and beliefs, which translates to more effective management of PTSD symptoms and the promoting mental health.

Medication

To reduce anxiety and feelings of fearfulness, medication such as serotonin reuptake inhibitors (i.e., citalopram (Celexa), fluoretine (Prozac), paroxetine (Paxil), and sertraline (Zoloft)) may be prescribed.

The Basics & Benefits of Trauma-Focused Cognitive Behavior Therapy

Trauma-focused Cognitive Behavior Therapy is considered by many to be an effective counseling technique to relieve the suffering of painful memories.  Repeated exposure to traumatic memories (without bad things happening) promotes feelings of being safe when bad memories become associated with corrective information.

It consists of replacing painful thoughts and memories with empowering thoughts and is touted as being able to help change thoughts about past trauma and to reduce the fear surrounding its memory. It seeks to identify fear-based thoughts and to exchange them for thoughts that are less distressing. TF-CBT is psycho-educational in that it teaches strategies to cope with and reduce negative feelings evoked by the thoughts, feelings, and situations that remind you of the traumatic event.

Broadly speaking, TF-CBT seeks to help people live life without being dominated by anxiety, fear, and other negative emotions arising from painful memories to overcome the tendency to avoid events that are likely to cause you to feel anxiety and fear, and to feel comfortable and confident in your interactions with others (and in situations) that remind you of painful events.

TF-CBT has a focus on reconstructing thinking patterns that minimize dysfunctional ideation and negative emotions. It seeks to promote the changing of how you think about trauma and its aftermath, modulate negative emotions, and change behavior associated with trauma.

Strengths and Weaknesses of Cognitive Behavior Therapy (CBT)

Strengths of CBT

CBT is an evidenced-based counseling treatment and categorized by managed care as a brief therapy appropriate for nearly anyone (irrespective of age, culture, disabilities, religion, etc.) and qualifies for insurance coverage. It is offered in many inter-disciplinary settings by mental health professionals and is capable of addressing not only PTSD, but a host of other mental health disorders.

Its use is widespread among mental health professionals and has the potential to become the most dominant form of therapy in the years to come. CBT respects the client by collaborating with them in setting treatment goals, and progress toward treatment goals is intrinsically monitored to assure clinical accountability. CBT also is credited for being concerned with present issues – current thoughts and environments that elicit PTSD symptoms.

Shortcomings of CBT

Although CBT values a therapeutic relationship with clients and typically follows a bio-psycho-social evaluation, its value is limited. First, as a technique, method, or intervention, it has little interest in looking at the client as a whole person (i.e. as body, soul, and spirit) and the totality of their past experience.

In a sense, it is a mechanistic technique comparable to how we would go about fixing a car. It is focused on the mental health problem that needs fixing. In the process, efforts to collect important historical and spiritual data may be neglected and sessions may be characterized as being psycho-educational rather than therapeutic in nature. The CBT therapist is likely to be viewed as a behavioral expert rather than a person genuinely interested in a client’s welfare.

Second, CBT neglects important existential and spiritual issues (i.e. the meaning of life, how to choose values, fears of death, etc.) which are important considerations from a Christian perspective.

Thirdly, CBT may unintentionally overlook other seemingly unrelated issues such as experiences of discrimination, oppression, or marginalization. Finally, and most importantly, it has not been proven that CBT helps clients deal with guilt or other complex emotions. Studies show that those who complete CBT treatment rarely recover completely. Most continue to have substantial problems with their health, work, or mental well-being. Dr. Van Der Kolk, an expert on treatment for trauma, reported that CBT works about as well as being in a supportive therapy relationship and only is useful if the patient is not overwhelmed by their traumatic memories.

Christian Cognitive Behavior Therapy (CCBT) Goes Beyond CBT for Maximal Benefit

Like CBT, CCBT posits that changing behavior and perception necessarily involves recognizing and correcting dysfunctional thinking, but CCBT does not cite “rationality” or “thinking errors” as the only criteria in differentiating between functional and dysfunctional thinking. CCBT asserts that thoughts, beliefs, assumptions, and behavior should be measured not so much against a set of logical beliefs, but against God’s Word. To CCBT, liberation from resistant misbeliefs is the essence of therapy.

Dealing with trauma and its aftermath is a unique experience that often prompts spiritual questions. It can be a turning point for a deeper dependence upon God and His grace. It is at such times that value-congruent and religiously-based CCBT can be particularly useful. In support of this idea, psychotherapy literature suggests that religious patients are more likely to terminate and benefit less from therapy if the therapist and client do not share religious convictions. With the experiential support for Christian presuppositions, CBT is enlarged to encourage a sense of spiritual well-being which is a powerful aid to recovery. This dynamic can also pave the way for spiritual growth and unite with others of like faith in the community.

There is an added benefit to CBT when delivered from a Christian orientation (CCBT). The warm, empathetic, genuine relationship that can be found in this kind of setting will maximize the therapeutic relationship. It seeks to bring the whole person of the client and the larger picture of their lives into view – not just PTSD symptoms.

CCBT also is not limited to naturalistic reasoning and self-effort. It will necessarily emphasize the role of experiential spirituality that corresponds to the Christian faith and biblical teaching and access to the power of the Holy Spirit who enables you to do what seems to be impossible. A Christian context also presents a platform to deal with spiritual oppression by forces of darkness that often come to lodge on the branches of one’s life. In a Christian context, the Holy Spirit is called upon to minister healing and to bring emotional, cognitive, and behavioral change into the realm of possibility.

Integrating Christian Counseling with Trauma-Focused Cognitive Behavior Therapy

A Christian orientation can be integrated together with TF-CBT. Religious or spiritual issues and the use of Christian resources (i.e. praying and discussing Scripture) can easily be incorporated into therapy sessions when clients agree to such practices. It can be diplomatically initiated depending upon the needs and problems of the client. It is a process where sensitivity to the leading of the Holy Spirit in a professionally competent, ethically responsible, and clinically sensitive way (with informed consent) increases the potency of clinical insights.

Within the context of counseling, a Christian orientation can be introduced that can take either an implicit or explicit direction. An implicit approach would be to only introduce prayer and Scriptural references in an indirect way. A Christian therapist would use this approach if the client did not authorize it and preferred not to talk about religious and spiritual things. The therapist would only use unspoken prayer and seek to hear the leading of the Holy Spirit while the client is talking.

An explicit approach would be the other option where the client wants to have prayer and Scripture as part of the counseling process. In this case, the counselor would engage freely with the client about religious and spiritual concerns.