Effectiveness of cognitive behavior therapy (CBT) in treating posttraumatic stress disorder (PTSD) diagnosed in adults

Final Project

The Final Project in this course will be a literature review aimed at determining the evidence to support a counseling theory, technique, or intervention of your choice. In this project, you will explore quantitative, qualitative, and mixed methods research articles published within the last 10 years in counseling journals related to your selected topic. In addition to examining specific research methodology, you will also include a review of articles focused on program evaluation efforts related to your topic of interest.

LITERATURE REVIEW

The Final Project for this course will involve the construction of a literature review that can be used to inform counseling practice. For this assignment, you will have to do the following:

a) Select a theory, technique, or intervention strategy that can be applied in your counseling specialty that you would like to explore in the professional literature

b) Visit the Walden University Library to determine if there is sufficient professional literature available related to your topic of interest

c) Submit your topic to your Course Instructor for approval

d) Select:

1. At least five quantitative research articles

2. At least five qualitative research articles

3. At least one mixed methods research article

4. At least one program evaluation article for review

Your review should include between 12 and 15 peer-reviewed articles. Note that mixed methods research articles may not be published on every topic of interest. In these cases, additional program evaluation articles may be substituted.

Constructing a Literature Review

Writing a quality literature review involves a thorough knowledge of research methods and exemplary writing skills. A well-written literature review conveys the story of the research that has been conducted to date on a certain topic. Contained in the story is a critical analysis of the research efforts (e.g., design, procedure, sample, data analysis, and interpretation) and an evaluation of how the research can inform practice. By conducting a review of the literature, it is possible to determine if gaps exist that require further research. Throughout this course, you will develop a thorough understanding of the literature review process and the components of a quality literature review.

Effectiveness of cognitive behavior therapy (CBT) in treating posttraumatic stress disorder (PTSD) diagnosed in adults

Abstract

 Cognitive behavioral therapy is the most relied upon psychotherapy approach used to treat PTSD.  This literature review’s aim is to analyze the effectiveness of cognitive behavior therapy in treatment of PTSD diagnosed in adults. To achieve this, various studies views about its effectiveness are incorporated.  The review incorporates different research articles in arriving at its conclusion on effectiveness of the therapy and its recommendation to those people with posttraumatic stress disorder.

            Keywords: Cognitive behavior therapy, posttraumatic stress disorder (PTSD), diagnosis

Effectiveness of cognitive behavior therapy (CBT) in treating posttraumatic stress disorder (PTSD) diagnosed in adults

Introduction  

Post-traumatic stress disorder (PTSD) is a disorder which normally develops after exposure to a terrifying event or something that possess physical harm or threat (Deise, 2008).  It is not necessary that a person who is harmed develops this trauma. It also affects other people such as loved ones and witnesses that experienced a harm event happen to their beloved ones. PTSD was first brought to the public limelight in the relations to the war veterans.  These veterans experienced horrifying situations in the battlefield and these impacted their life after retiring. Other traumatic situations that cause post traumatic stress disorder includes rape, mugging, being kidnapped, torture, child abuse,  being held captive , car accidents, bombings, train wrecks, natural disasters such as earthquakes and floods among others (Kindt et al (2007).

 Discussion

 According to Deise (2008), PTSD is an anxiety disorder caused by exposure to traumatic events.  After exposure to such events, a patient relives the traumatic event by always avoiding situations associated with trauma and hypersarousal.  It is estimated that PTSD affects 5% of men and 10% of women in United Sates with a lifetime prevalence of 7.8% (Deise, 2008). Most of the people faced with trauma and commonly associated with PTSD are military combats and females abused by sexual abuse. Cognitive behavioral therapy (CBT) is the major psychotherapy approach used to manage PTSD (Deise, 2008).  This approaches are subdivided into various groups which includes; cognitive techniques such as cognitive restructuring, behavioral approaches or techniques used include prolonged exposure therapy. Others include those based on Lang’s emotional processing and systematic desensitization.  Other modalities include psychodynamic psychotherapy, group CBTT, eye movement desentization, reprocessing and social skills training, and relaxation techniques (Brown-Bowers et al., 2012). In cognitive restructuring, techniques, it involves identifying and modifying distorted interpretations and beliefs in relation to a traumatic events exposed and the reduction of future traumatic symptoms. On the other hand, exposure techniques evoke traumatic memories by real exposures or imagery by triggering fear to reduce symptoms through habituation processing and emotional affective information (Brown-Bowers et al., 2012).

 Even though these modalities are effective, CBT, exposure therapy and cognitive therapy are effective compared to supportive techniques when it comes to treatment of PTSD. Furthermore, when it comes to promoting diagnostic remission CBT is more effective compared to EMDR (Deise, 2008).

 One of the causes of trauma is the terrorists’ attacks. The bombing that happened in London on July 7, 2005 affected many of the victims (Naomi et al., 2012).   Trauma focused cognitive behavioral therapy was provided to the survivors that had developed posttraumatic stress disorder. This therapy is important to help the survivors to come to the senses of what happened. They have to approach the experience in a positive way and accept that life was not going to be the same again (Naomi et al., 2012). Therefore, this therapy was important in encouraging and changing their cognitive or thoughts about the perpetrators and how their lives had changed. Such incidences cause trauma and stress.  For instance, in this study screening and treatment was done on 18 patients that directly experienced the attack and they indicated that it impacted on their lives on the day following the bombing (Naomi et al., 2012). They experienced shock, horror, disorientation, reorientation and reconnecting with the outside world and suffered posttraumatic stress and depression. Consequently, this therapy helped to identify how the patients felt and provide ways to recover from PTSD. The participants felt isolated from those who were not affected by the bombing. This was therefore a burden they were carrying in their hearts.

According to Kindt et al (2007), the prognosis on trauma victims varies in intensity and type of trauma. Different people exposed to these traumas usually develop PTSD. Most of people report PTSD shortly after the experience of the trauma and few of the victims show persistent experience that develops to chronic. Nevertheless, people deal with these symptoms in a different way. Kindt et al. (2007) conquer that indeed cognitive behavioral treatment is highly effective psychotherapy in treating PTSD.  However, they hold the view that mechanisms of change have not fully been understood and this deters its effectiveness. Trauma before and after CBT for PTSD can be treated by imaginal exposure combined with re scripting. This approach requires inductiont of new perspectives on the related occurrences or happenings by experiencing new emotions and views. Therefore, in ensuring effectiveness of this psychotherapy treatment method, changes in or increase in process and conceptual processing helps to predict treatment outcome. In treatment of PTSD, imaginal reliving during CBT is not effective in reducing symptoms but helps in promoting conceptual processing which helps in the prediction of better treatment outcomes (Naomi et al., 2012).

Posttraumatic stress disorder is debilitating mental health condition that is associated with psychiatric co morbidity and diminished quality of life and afterwards a chronic and lifelong course (Britt et al 2009).  In a study carried out on patients through online, there was a significant reduction in PTSD among various patients involved in the study. These findings therefore indicate that indeed this is an effective and reliable method. According to Britt et al (2009), enough evidence is available to show that cognitive behaviour therapy is a safe and effective treatment for PTSD. The therapy has further been found to be efficacious across a wide range of trauma groups in treatment of PTSD.  CBT involves psycho education, cognitive and exposure therapy, anxiety management and elapse prevention. Treatment of these disorders ranges between 9 to 12 weeks, which takes around 60 to 90 minutes every week and is normally conducted face to face (Harvey et al., 2003).

 Most of the problems that are experienced in the treatment of these mental problems in rural and regional areas are lack of accessibility as there are no enough professionals to provide good care to such individuals (Britt et al., 2009). Another challenge is cost. Many of the victims may not be in a position to access to these services and therefore, they cannot be able to get assistance to recover from their conditions. The cost is usually higher if the services are to be provided face to face. Furthermore, a large number of people fail to seek for medical attention because of stigma associated with mental illness. This therefore, makes it hard to apply CBT to help them cope up or recover from their PTSD. Therefore, to ensure that such patients are able to access to these therapies without feeling stigmatized or due to accessibility and costs, using internet is the best alternative to ensure that they are able to be assisted to manage their health situations.

According to Katherine et al. (2011), intimate partner violence (IPV) is one of the serious and most public health problems that face most of women in the United States. Women who develop symptoms of PTSD and depression are at higher risks of causing intimate partner violence victimization. This   problem can be effectively managed through cognitive behavioral therapy. According to Katherine et al. (2011), CBT is effective in reducing future IPV symptoms but there is limited researches that have been conducted in this area. In their findings, they established that it is appropriate to treat PTSD and depressive symptoms and interpersonal traumas survivors to reduce the risk of future intimate partner violence.

Pre-treatment intimate relationships are important in managing PTSD. Most veterans with PTSD can be treated using CBT to help them recover from their traumatic conditions. According to Candice, Rodgriguez & Warner (2011), interpersonal relationships are important in the development, maintenance and possibly amelioration of PTSD. In predicting the development of PTSD, social support has been very instrumental hence; enough prove of its effective in helping patients with PTSD. Most of the people that have been found to suffer from PTSD suffer from myriad of intimate relationships problems, are likely to engage in divorce, and experience diminished relationship and intimacy satisfaction, even though, there has been insufficient investigation of how they are associated with PTSD treatment outcomes (Candice, Rodgriguez & Warner, 2011). The only method or approach established as highly efficacious in treating PTSD is cognitive behavioral therapy. When compared to drug treatments and other   control conditions, CBT has been established to be the treatment choice.  The treatment interventions of Class of CBT are categorized into various interventions, that are trauma focused such as cognitive processing therapy and prolonged exposure.  Adoption of these techniques in treatment of various cases resulting to PTSD such has sexual and non sexual assault, civilians with mixed trauma and combat veterans has shown reduction in PTSD symptoms. Hence, this demonstrates effectiveness of the techniques. However, some studies that have compared CBT with other forms have found noticeable differences in the outcomes indicating that indeed some techniques are more effective than others are.

Some of the authors have expressed concerns about generalability of results from efficacy studies and therefore recommend implementation of cognitive behavioral therapies interventions with trauma survivors in real world practice (Candice, Rodgriguez & Warner, 2011). Some have therefore questioned the tolerability and safety of trauma focused CBT to some patients as some have possibility of resulting to negative outcomes such as symptom worsening, drop –outs and substance abuse, self-medication with alcohol and substance abuse and behaviour dysfunction among many others. Such findings should be taken with the seriousness it deserves and measures put in place to ensure further studies on CBT with PTSD cover a wider scope and focus on patient characteristics associated with treatment outcome. This will help in enhancing the level of effectiveness and efficiency when using cognitive behavioral therapies.

According to Khoo, Dent & Tian (2011), the cases of PTSD in Australia have been higher in relations to the military deployment in Iraq, Afghanistan, East Timor, Egypt, Solomon Islands, Middle East and Sudan. Furthermore, many of the people in Australia are still recovering from the trauma caused to them through devastating bush fires, cyclones, flooding, and earthquakes. These incidences affect the mental component of people causing them to suffer from PTSD.  In their study, Khoo, Dent & Tian (2011), established improvement in the PTSD among the participants. The study indicated that indeed CBT concepts established by efficient research could be used in clinical settings to help in the treatment of these disorders. Using CBT produced positive results as it enhanced the quality of life and caused improvement in the life of an individual. For instance, in this study, it was revealed that CBT impacted greatly on symptom as   positive changes occurred within the first 3 months of therapy. Furthermore, it was found out that 60% of the patients were able to respond positively in a clinically significant way.  Therefore this information is enough to illustrate and support the effectiveness of using Cognitive behavioral therapies in helping to treat PTSD.

According to Vanessa, Deborah & Sue (2011) reliving even though is an integral part  of trauma focused cognitive behavioral therapy and  recommended treatment for post traumatic stress disorder (PTSD) with evidence base supporting its use, most of the clinicians are reluctant to employ it in their therapy . There are various reason advanced that make many of them reluctant to use this kind of therapy such as instilling fear. In relieving, patients are required to relieve their thoughts in their minds including feelings, thoughts, and images as they describe their experiences in the present tense (Vanessa, Deborah & Sue, 2011). Relieving is aimed to serve three major purposes which include facilitating recovery for PTSD through elaboration and contextualizing of the trauma memory, identification and discussion of hotspots to access any appraisals made and to test beliefs of what might happen when thinking about trauma (Vanessa, Deborah & Sue, 2011).

Most of the participants even though experience ambivalence and fear in expressing or remembering their experiences, at the end they found it helpful. They express that it gives them hope and revive their lives and would therefore recommend other people to the same (Vanessa, Deborah & Sue, 2011).  They found it necessary and more appropriate in reducing their PTSD. This finding were consistent with the findings treatments trial for trauma focused CBT. To ensure that this become effective participating need to trust the therapists to ensure that the process becomes effective (Vanessa, Deborah & Sue, 2011). It is therefore important for the therapists to help patients to overcome their fear of relieving by demonstrating confidence in the communication process to show that clinicians own concerns about relieving could hinder the engagement.  Therefore, there is supposed to be openness, honesty, genuineness, in the therapeutic relationships.

Cognitive behaviour therapies are mostly used in the treatment of PTSD among veterans.  Cognitive behavioral therapies have also been found to have a cost benefits compared to other   methods of treating PTSD (Meyers et al., 2013).  In a study at Midwestern VA medical center it was established that utilization of services and costs data to review revealed that there was decreased individual and group psychotherapy.  The direct costs associated with provision of health care were found to have decreased by 39.4% (Meyers et al., 2013).  This therefore shows that this technique apart from its effectiveness is also affordable and can be adopted in various facilities to help promote positive living.

CBT has also been found effective is helping to treat patients with insomnia and PTSD. Insomnia is one of the commonest symptoms that PTSD patients exhibit. This condition is found in around 70% of individuals suffering for PTSD (Baddeley & Gros, 2013). After successful evidence based treatment of PTSD, insomnia still poses a challenge in around half of the cases. It is therefore poses a challenge if it is not well handled. When dealing with patients affected  by  Insomnia and at the same time PTSD cognitive behavioral therapy for insomnia is usually used as a first step treatment. It helps to provide insomnia symptom relief, as psycho education and self-monitoring of PTSD Symptoms allows the client to proceed to exposure therapy.  Studies have found out that CBT is effective and essential in reducing such symptoms such as insomnia and PTSD while at the same time facilitating entry to exposure therapy for PTSD.

 Counselors can play cognitive behavioral therapy to provide treatments to patients with PTSD (Makinson & Young, 2012).  CBT treatment strategies incorporate the use of higher order thought process as it directs the attention of a client in a deliberate manner. This technique aims to correct problematic thought patterns and behaviors of the clients. CBT techniques are effective in ameliorating neurological challenges in PTSD. This technique is effective in helping re-wire the brain and help individuals manage their PTSD (Makinson & Young, 2012).  The moment symptoms of PTSD become apparent, neurons in the amygdale forms strong interconnections function in such a way that facilitates evoking of memories that trigger stimuli (Makinson & Young, 2012). The moment the connections are made, they are permanent and have the capacity to last for life long. This therefore allows or promotes diminished expression of learned fear helping in the recovery of a client. However, for this technique to be effective, it is recommended that the counselor know when and how much to stimulate their clients during any treatment plans.  Stimulation is important because it build resilience about future life stressors and promotes recovery from various illness related to psychiatric.

 According to Brown-Bowers et al (2012), cognitive behavioral can be used as conjoint therapy for posttraumatic stress disorder in improving PTSD symptom and in enhancing the intimate relationship adjustment. In order to ensure that the therapy functions and results to positive results, there are various stages or rather phases required to be followed. Phase 1 includes psycho education on the reciprocal influences of PTSD symptoms and relationship functioning, conflict management skills, and exercises to promote positive effect and behaviour.  In the second phase, these behavioral methods address avoidance and emotional numbing and in increasing relationship satisfaction.  Consequently, it allows people and even couples in this situation to approach various issues without fear. It is therefore, important in ensuring that this disorders or trauma is approached positively aiding in their resolution. The third phase focuses on specific trauma appraisals and on cognitions of PTSD and relationship problems.

Conclusion

In conclusion, cognitive behavioral therapy is one of the effective therapies that used to provide solutions to clients with PTSD. There are various approaches to these techniques, which help to reduce PTSD symptoms and studies have found out their level of effectiveness in reducing these symptoms. One of the reasons that demonstrate its effectiveness is that it have helped many persons especially veterans military personnel to recover from their PTSD and lead positive lives. The traumatic events these officer are exposed to affect them mentally and therefore, through these techniques, many of them have managed to deal with the disorders in a positive way. Its effectiveness has also been experienced in other traumatic cases such as rape, natural disasters victims among many others.

References

Baddeley, J., & Gros, D. (2013).  Cognitive Behavioral Therapy for Insomnia as a Preparatory     Treatment for Exposure Therapy for Posttraumatic Stress Disorder, American Journal of        Psychotherapy, 67(2): 203-214.

Britt, K et al. (2009). A Therapist-Assisted Internet-Based CBT Intervention for Posttraumatic     Stress Disorder: Preliminary Results, Cognitive Behaviour Therapy,  38,(2): 121–131.

Brown-Bowers, A. et al. (2012). Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress             Disorder: Application to a Couple’s Shared Traumatic Experience, Journal of Clinical      Psychology, 68(5): 536-547

Candice, M., Rodgriguez, B., & Warner, R. (2011). Cognitive-Behavioral Therapy for PTSD in   the Real World: Do Interpersonal Relationships Make a Real Difference?, Journal of          clinical psychology, 61(6): 751-761.

Deise, D et al. (2008). A systematic review on the effectiveness of cognitive behavioral therapy   for posttraumatic stress disorder, Baywood Publishing Co., Inc.

Harvey, A., Bryant, R., & Tarrier, N. (2003). CBT for PTSD. Clinical Psychology Review, 23,    501–522.

Makinson, R., & Young, J. (2012). Cognitive Behavioral Therapy and the Treatment of    Posttraumatic Stress Disorder: Where Counseling and Neuroscience Meet, Journal of     Counseling & Development, 9(9):131-140

Meyers, L. et al. (2013). Service Utilization Following Participation in Cognitive Processing        Therapy or Prolonged Exposure Therapy for Post-Traumatic Stress Disorder,  Military            Medicine, 178(1): 95-99

Katherine, M et al. (2011). Cognitive–Behavioral Therapy for PTSD and Depression Symptoms Reduces Risk for Future Intimate Partner Violence Among Interpersonal Trauma     Survivors Journal of Consulting and Clinical Psychology, 79(2): 193–202

Khoo,  A., Dent, M., & Tian, P. (2011). Group cognitive behaviour therapy for military service-   related post-traumatic stress disorder: effectiveness, sustainability and repeatability,      Australian and New Zealand Journal of Psychiatry, 45:663 –672

Kindt, M. et al.  (2007). Perceptual and conceptual processing as predictors of treatment outcome            in PTSD, J. Behav. Ther. & Exp. Psychiat. 38 (2007) 491–506

Naomi, W. et al.  (2012). Survivors of the London Bombings With PTSD: A Qualitative Study of            Their Accounts During CBT Treatment Traumatolgy, 18:1-11.

Vanessa, S., Deborah, L., & Sue, C. (011). How do clients experience reliving as part of trauma-  focused cognitive behavioural therapy for posttraumatic stress disorder?,Psychology and   Psychotherapy: Theory, Research and Practice, 84, 458–472.

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