- Trauma affects our thoughts, behaviors, physiology, and emotions.
- Cognitive behavioral therapy (CBT) has been shown in many studies to be highly effective for treating post-traumatic stress disorder (PTSD).
- CBT includes trauma education, calming breath work, facing avoided situations and memories, and shifting our thought patterns.
This post includes descriptions of assault-related trauma. Names and identifying details have been changed.
I nearly cried in my first session with Barbara years ago when she described her most recent trauma. It wasn’t the first time her ex-boyfriend had assaulted Barbara in an alcohol-fueled fit of jealousy, but it was the only time he had stabbed her. The knife missed her heart but lodged in her chest and had to be removed at the hospital.
Not surprisingly, Barbara’s symptoms of post-traumatic stress disorder (PTSD) were as high as anyone’s I had treated. As much as she tried not to think about what had happened, the memory haunted her—especially as she tried to fall asleep. When sleep finally came, she often had horrifying nightmares. She was afraid to leave her apartment and felt a strong surge of fear every time she saw someone who looked like her ex (even though she knew he was in prison). Barbara felt cut off from life, hopeless about her future, and fundamentally damaged by what had happened to her.
Over the next few months, I led Barbara through exposure-based cognitive behavioral therapy (CBT) for PTSD. Multiple studies confirm what I found among the men and women I treated: This approach is highly effective at helping individuals to process and heal from trauma (Cusack et al., 2016).
By the end of her treatment, Barbara told me she felt like she was getting her life back. I could feel how her nervous system was no longer on constant high alert and how much easier it was for her to laugh (I still smile thinking of Barbara’s laugh).
Here’s what we worked on together (adapted from The CBT Flip Chart).
1. Understanding trauma reactions
Before treatment, Barbara felt like she was falling apart in so many ways. “I’m not sleeping, it’s hard to even get a shower, I’m isolating, and I’m pissed off all the time,” she told me. It was helpful for her to understand that all of these things were common reactions to trauma. I could see the relief on her face as she realized that everything she was struggling with was a common and expected trauma response. She also found hope in knowing that many of those symptoms were likely to improve as she moved through treatment.
There are many ways to educate ourselves about trauma: reading articles and fact sheets online, joining trauma support groups, and reading memoirs by trauma survivors. Seeing ourselves in others’ experiences helps us to feel less alone and can counter false assumptions, such as: “There’s something wrong with me for having these symptoms.”
2. Slow, relaxed breathing
Next, we worked on “breathing retraining,” which Barbara loved and said was very helpful in her recovery. Her fight/flight/freeze system had been working in high gear for a long time, and she felt constantly on edge as if the next attack could come at any time. Without realizing it, she was always taking short, shallow breaths, and breathing only into her chest, which amplified her stress and reinforced a sense of danger.
We can retrain the breath so it turns down our stress reaction and activates the relaxation response. Breathing retraining is very simple:
- Inhale through the nose for a count of four as the belly expands.
- Exhale out the mouth for a count of six as the belly falls.
- Continue for 3-5 minutes.
- Repeat 2-3 times a day, and notice how the practice affects your nervous system.
3. Facing safe trauma reminders
It’s understandable that we want to avoid people and places who remind us of our trauma when the whole world can feel frightening. But while avoiding these things can make us feel safer temporarily, in the long term, it makes our fear grow. The antidote to avoidance is to gradually face the things we’re afraid of, provided that they don’t pose a significant risk.
Barbara wanted to return to seeing her friends in the neighborhood, so she started by sitting on her front porch during the day. Over time, she progressed to walking around the block, meeting up with a friend while it was light out, and then going out with friends at night. With each step, she felt her confidence grow and her fear diminish, and situations that had been overwhelming were now available to her. These activities had the lovely side effect of boosting her mood and lifting her depression.
4. Revisiting the trauma memory
Trying to avoid the memory of our trauma has a similar effect to avoiding real-world reminders: The more we push away the memory, the more it will intrude, and we’ll feel less able to cope with it. By deliberately facing the memory, it becomes less terrifying and less likely to pop into our awareness uninvited.
Revisiting a trauma memory is called imaginal exposure in CBT and involves telling the story of what happened out loud or in writing. I sat with Barbara as she told me multiple times the story of when her ex tried to kill her. With each retelling, she allowed herself to experience the emotions it brought up and to feel how her body was reacting. It was really challenging for her to face that awful memory, especially at first when the images and emotions were still so raw. After many retellings, Barbara found that the memory no longer had a grip on her, and she felt like it was hers again—a part of her story, and not something that was constantly intruding on her mind.
5. Examining trauma-related beliefs
Like so many trauma survivors (myself included), Barbara’s beliefs about herself, others, and the world had shifted after her trauma. She held common trauma-related beliefs like:
- I’m weak.
- Nobody can be trusted.
- The world is always dangerous.
The first four steps of the treatment began to shift Barbara’s beliefs as she developed a greater understanding of her trauma reactions, quieted the alarm bells of her nervous system, and faced the situations and memories she’d been avoiding. She learned through experience that she was strong enough to face what she was afraid of and that much of the time, the world was a relatively safe place.
Barbara took a good look at some of the things she’d been telling herself, like that she should have done something different to avoid her ex-partner’s attack, and that she “should be over it by now.” Exploring her trauma memory helped her to see that the blame for what happened belonged only to her ex and that she had managed to save her own life by deflecting the blow of the knife so it missed her heart. Rather than blaming herself for what had happened, Barbara came to have compassion for herself and realized she deserved respect, not reproach.
Countless trauma survivors have gotten their lives back through CBT for PTSD. The treatment is available from many CBT clinicians. To find a therapist near you, check out Psychology Today’s Therapist Directory.
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., ... & Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141.
Gillihan, S. J. (2021). The CBT flip chart. Eau Claire, WI: PESI Publishing.