Cooper Hodges, PhD

Disclaimer: This article is for informational purposes only. Please speak with a medical professional before seeking treatment.

What does cognitive behavioral therapy treat?

PTSD; depression and anxiety related to both PTSD and TBI

What is cognitive behavioral therapy?

Cognitive behavioral therapy (CBT) can help you to think differently about your experiences and your relationships, with the goal of making some positive changes in your life. CBT is based on the idea that how we think, how we feel, and how we act are all closely related.

CBT can help you identify and change negative or unhealthy types of thinking. For example, if you are dealing with PTSD, you might have overly negative thoughts about yourself based on guilt from the trauma that occurred. And triggers that remind you of your trauma might cause painful emotions, leading you to avoid triggering situations. Once you become aware that these thoughts are flawed -- that you did the best you could when the trauma occurred -- you can work with a therapist to change your thinking so that you can respond to challenging life situations in a healthier way.

CBT can also be used to help people who have had a traumatic brain injury. Many people with TBI struggle with depression or anxiety, often because of fear of further injury or further loss of functioning. In this situation, someone with a brain injury might be anxious about certain situations that present the possibility of another injury occurring. CBT would help identify this fear and teach healthier ways of thinking. People with brain injuries also sometimes have anger management problems or act more impulsively. This is due to changes in how your brain works after being injured. In these cases, CBT can teach someone ways to recognize when this is becoming a problem and strategies for how to solve it.

There are several different types of cognitive behavioral therapy, including prolonged exposure therapy, cognitive processing therapy, and EMDR.

What is cognitive behavioral therapy like?

CBT involves multiple individual sessions with a trained therapist. You’ll need to feel like you’re in a safe space in order to confront painful or difficult thoughts, feelings, and situations. In some cases, sessions can take place remotely.

There are a number of different elements and strategies used in CBT, including education (specifically, “psychoeducation”) to help identify unhealthy thoughts and coping skills training that might include deep breathing and muscle relaxation techniques.

To address negative thinking, CBT often includes a technique called reframing. Reframing is a way to think about a problem differently. For example, someone who struggles with road rage might usually assume the worst of another driver (“Why is that jerk trying to cut me off?”). CBT would suggest a different perspective, with more concern for the other person. Maybe that other driver was dealing with a medical emergency, or terrified about being late to work, or struggling with something in their personal life that has nothing to do with you. This approach can help build empathy for others, instead of anger.

CBT can also teach you how to use positive self talk to challenge automatic negative thoughts that contribute to negative feelings such as depression, fear, anxiety, and anger. Self-talk is the internal dialogue we often have with ourselves. This is a healthy part of life. However, sometimes after trauma, or when you’re feeling depressed or stressed, self-talk can become relentlessly negative, and you wind up blaming yourself for anything that goes wrong. CBT helps identify these instances of negative self-talk and teaches healthier patterns of thinking that can lead to more constructive ways of coping with problems.

CBT can be very hard work, and it can take a long time to learn and remember how to reframe your negative thinking patterns and to use relaxation techniques. CBT can also greatly improve your quality of life, providing you relief from depression, anxiety, anger, and other challenges.

What do patients say about CBT?

When I went back to work, for example, I had situations where I was usually handling it incorrectly, but being that I’m thinking on my thought patterns and I’m seeing what’s motivating my actions, I can stop them before they become negative.

— Shawn Davenport, Veteran, U.S. Army

 

It was really just retraining my brain in the way that I was thinking.

— Susan, Veteran, U.S. Navy

 

Then I actually got assigned a counselor for the CBT, and that was for depression. You get to do exercises and change the way that you think about a situation. And in that process, you also want to remove the self-talk mechanism that a majority of us folks have. It's a good way to talk things out and get to the base and root of the problem.

— Gene, Veteran, U.S. Army

What do experts say about CBT?

You focus sessions on addressing the patient's unhelpful takeaways from the trauma. Again, in a very structured, systematic way, like weighing the evidence for or against the beliefs that they’ve developed. We’re looking at any unhelpful thinking patterns that they’re falling into, like over-generalizing and thinking about it in all-or-nothing terms, or maybe discounting some of the positives and focusing on the negatives.

— Dr. Edward Chandler Wright, a board-certified clinical psychologist in the Home Base Program of Massachusetts General Hospital

Somebody with PTSD might say, "Well gee, I went to the marketplace in Iraq or Afghanistan; a bomb went off. It's dangerous to go out in public places. So, I'm just going to stay home in my room and I'm going to be safer." Well the problem is that staying home in their room, they're not getting that social interaction. They start to feel more down, withdrawn, and so forth. They end up just getting worse as a result of that. So, this behavior that they — at some level — figure may be protective is actually perpetuating the impairment of function. So, CBT looks at those behaviors, helps the patient look at them, and tries to adapt them.

— Col. Michael Roy, M.D. (Ret.)

How strong is the evidence for CBT?

According to the American Psychological Association’s Division for Clinical Psychology: “Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.” The American Psychological Association strongly recommends CBT as an effective treatment for adults with PTSD. This recommendation is based on the strength of scientific evidence, benefits versus harms/burdens, patient values and applicability. CBT is considered one of the most effective and lasting treatments for PTSD.

CBT isn’t just effective for PTSD. CBT has also been shown to have effectiveness in treating symptoms of depression and anxiety that develop following traumatic brain injury. One randomized controlled clinical trial of 100 adults with major depressive disorder that developed after brain injury found that people who completed multiple sessions of CBT reported better symptom improvement and greater satisfaction with depression care than people who did not complete CBT (Dis, 2019).

In addition to the APA's recommendation, the U.S. Department of Veterans Affairs includes trauma-focused psychotherapy as a practice guideline for veterans with PTSD, recommending cognitive processing therapy, EDMR and prolonged exposure, which are all types of CBT. Cognitive processing therapy and PET are both used by the United States Veterans Administration to treat military veterans with PTSD.

Please note that research on CBT is for individuals with PTSD alone. Individuals with combined TBI and PTSD may present special challenges. Therefore, treatment may need to be adapted based on the nature of specific TBI-associated cognitive and behavioral symptoms that may interfere with the therapy process.

Where can I find more information?

Where can I go to get this treatment?

“You can get a referral from a doctor, health insurance plan, friend or other trusted source. Many employers offer counseling services or referrals through employee assistance programs (EAPs).” (Cognitive Behavioral Therapy, 2019)

Video

Research, Articles, and Book

References

Cognitive behavioral therapy. (2019, March 16). Mayo Clinic.

Cohen, J., & Mannarino, A. P. (2008). Disseminating and Implementing Trauma-Focused CBT in Community Settings. Trauma, Violence, & Abuse, 9(4), 214–226.

Dis, E. M. A. M. (2019, November 23). Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Systematic Review and Meta-analysis. JAMA Network.

Fann, J. R., Bombardier, C. H., Vannoy, S., Dyer, J., Ludman, E., Dikmen, S., Marshall, K., Barber, J., & Temkin, N. (2015). Telephone and In-Person Cognitive Behavioral Therapy for Major Depression after Traumatic Brain Injury: A Randomized Controlled Trial. Journal of Neurotrauma, 32(1), 45–57.

Jensen, T. K., Holt, T., Ormhaug, S. M., Egeland, K., Granly, L., Hoaas, L. C., Hukkelberg, S. S., Indregard, T., Stormyren, S. D., & Wentzel-Larsen, T. (2013). A Randomized Effectiveness Study Comparing Trauma-Focused Cognitive Behavioral Therapy With Therapy as Usual for Youth. Journal of Clinical Child & Adolescent Psychology, 43(3), 356–369.

Mendes, D. D., Mello, M. F., Ventura, P., De Medeiros Passarela, C., & De Jesus Mari, J. (2008). A systematic review on the effectiveness of cognitive behavioral therapy for posttraumatic stress disorder. The International Journal of Psychiatry in Medicine, 38(3), 241–259.

Simon, N., McGillivray, L., Roberts, N. P., Barawi, K., Lewis, C. E., & Bisson, J. I. (2019). Acceptability of internet-based cognitive behavioural therapy (i-CBT) for post-traumatic stress disorder (PTSD): a systematic review. European Journal of Psychotraumatology, 10(1), 1646092.

Disclaimer: This article is for informational purposes only. Please speak with a medical professional before seeking treatment.

 

Reviewed by Amy Shapiro-Rosenbaum, PhD, Lyndsay Tkach, MA, CBIS, and Michelle Neary, March 2021.

The BrainLine Treatment Hub was created in consultation with TBI and PTSD experts.