Cognitive-behavioral treatments are built around a set of fundamental helping procedures that target different sets of problems encountered by trauma survivors. These are (1) coping skills training, that focuses on teaching clients to respond effectively to the many situation-specific challenges associated with PTSD and other trauma-related difficulties, and to replace existing maladaptive responses with more effective ones; (2) prolonged exposure, that works to reduce conditioned fear responses connected with trauma memories and the stimuli that elicit them; (3) cognitive therapy, that assists survivors in modifying ways of thinking that create distress and interfere with recovery; and (4) acceptance methods, which recognize that some of the problems of trauma survivors are caused or worsened by avoidance behaviors, therefore encouraging survivors to fully experience and accept their own trauma-related emotions, thoughts, and feelings without trying to avoid them.
A primary feature of most treatments for PTSD is to educate clients about the disorder and the rationales for treatment. Treatments focus on providing information and teaching new skills for living. Those who deliver cognitive-behavioral interventions explicitly conceptualize much of what they do as skills training, and as the field has developed, cognitive-behavioral methods have been designed to address a wide and growing array of skills that can be taught by clinicians to their clients. In this book, skills training approaches are outlined across chapters and form large parts of some of the interventions discussed, such as Dialectical Behavior Therapy (DBT) as summarized by Wagner and Linehan in Chapter Six, the Skills Training in Affect and Interpersonal Regulation (STAIR) treatment described by Cloitre and Rosenberg in Chapter Thirteen, and the Seeking Safety protocol presented by Najavits in Chapter Ten. The book as a whole includes extensive discussion of the client skills sets that are related to distress tolerance, emotion regulation, interpersonal effectiveness, personal safety, and mindfulness. The chapter authors show how cognitive-behavioral skills training technologies can be used to ensure that clients learn, practice, test, and transfer these skills into the real world of their daily lives.
Central to approaches that focus on reduction of posttraumatic fear reactions is exposure therapy. Prolonged Exposure (PE) treatment is the most well-validated psychosocial treatment for PTSD. As described by Riggs, Cahill, and Foa in Chapter Four, it focuses on reducing trauma-related anxiety by encouraging the client to confront situations, activities, thoughts, and memories that are feared and avoided but that are not inherently dangerous. Treatment incorporates four primary procedures: education about trauma and PTSD, breathing retraining, in vivo or "real-world" exposure to feared but safe trauma-related situations that the client normally avoids, and imaginal exposure in which the client repeatedly describes memories of the traumatic event.
Many cognitive-behavioral approaches also emphasize how important to the recovery process it is to deal with distressing trauma-related appraisals and beliefs. Such beliefs are at the core of the difficulty experienced by clients, and this is readily apparent to most treatment providers. Cognitive Processing Therapy (CPT) represents perhaps the best articulated application of cognitive therapy methods to the problem of PTSD, and is described at length in this book by Shipherd, Street, and Resick in Chapter Five. CPT is built on the testable hypothesis that "an approach that elicits memories of the traumatic event and then directly confronts maladaptive beliefs, faulty attributions, and inaccurate expectations may be more effective than exposure therapy alone." Cognitive therapies also resonate with therapist experience in that they readily expand the range of trauma-related emotions tackled in therapy to include anger, sadness, helplessness, and guilt. The latter emotion often complicates treatment for those with PTSD; in Chapter
Eleven of this volume, Kubany and Ralston provide both a cognitive-behavioral conceptualization of trauma-related guilt and a detailed account of cognitive therapy applied to trauma-related guilt and shame.
Acceptance-based interventions are increasingly being integrated into cognitive-behavioral treatments for trauma survivors. These approaches are represented in these pages, on DBT in Chapter Six by Wagner and Linehan and on Acceptance and Commitment Therapy (ACT) in Chapter Seven by Walser and Hayes. DBT stresses the tension between acceptance and change, between accepting clients as they are but also attempting to modify their behavior. Both change-oriented and acceptance-oriented goals are seen as important in this therapy. ACT (which also stand for Accept, Choose, and Take Action) embraces the same two goals as DBT. It emphasizes a conscious abandonment of the mental and emotional change agenda when these change efforts do not work. The client is encouraged to accept thoughts, feelings, memories, and sensations without trying to eliminate or control them; to engage in practical, safe, and valued behaviors that may include changing the situation; and to discriminate between unworkable solutions (e.g., avoiding emotions) and workable solutions (e.g., commitment to behavior change).
Those who have been exposed to traumatic events are at risk for developing many kinds of problems, and if cognitive-behavioral methods are to be widely adopted by a broad range of practitioners, they need to assist clinicians in comprehensively addressing the needs of their clients. This book illustrates the fact that those who are developing cognitive-behavioral treatment have been showing increased attention to significant problems trauma survivors face that are beyond the traditionally identified diagnosis of PTSD. In this text, this attention is reflected in the work of Najavits in extending cognitive-behavioral methods to the treatment of substance abuse concurrent with PTSD, Cloitre and Rosenberg in conceptualizing interventions to reduce risk of revictimization among sexual assault survivors, and by Shear and Frank in Chapter Twelve in their work on complicated grief. It is also shown in Chapter Nine, in Bryant's adaptation and extension of the procedures found effective in management of chronic PTSD to treat acute stress disorder. In the final chapter in this volume, Chapter Seventeen, Ruzek discusses the potential for cognitive-behavioral psychology to inform efforts to prevent development of PTSD and shows how the work of Bryant and others has led cognitive-behavioral practitioners to become increasingly active in developing and testing early interventions with survivors of recent traumas.
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