Trauma-Focused CBT

What is trauma-focused CBT?

Trauma-focused cognitive behavioural therapy adapts CBT for post-traumatic stress disorder (PTSD). NICE says to offer it to an adult who comes forward more than a month after a traumatic event. The NHS names trauma therapy such as trauma-focused CBT among the treatments you may have.

The name covers a family of closely related therapies rather than one script. NICE names four: cognitive processing therapy, cognitive therapy for PTSD, narrative exposure therapy and prolonged exposure therapy.

They share one idea. The memory of the trauma is stored in a way that keeps it feeling current. That memory can be worked on directly.

Sources: NICE NG116, NHS: PTSD

How it works

After a traumatic event, the memory often stays fragmented and vivid. It comes back as if the danger were still here. Meanings such as blame, shame or a sense that nowhere is safe keep the alarm running.

Avoiding reminders feels protective, but it stops the memory from settling.

Trauma-focused CBT works on all three at once. You revisit the memory in a steady, planned way so it can be filed as past rather than present. You look at what the event has come to mean, and test whether those meanings still hold.

Sources: Ehlers & Clark 2000, NICE NG116

What sessions look like

NICE describes a standard course as eight to twelve sessions. It says more may be needed, for example after several traumas. Your therapist will explain the plan before you begin any of it.

A typical course covers:

• Understanding PTSD. Learning why the memory behaves the way it does
• Building safety and skills. Grounding techniques and a plan for difficult moments
• Working with the memory. Talking or writing through what happened, at your pace
• Changing the meaning. Examining beliefs about blame, danger and yourself
• Reducing avoidance. Returning to places and activities the trauma took away
• Planning ahead. Knowing your triggers and what to do when they arrive

You will not be rushed into the memory work. Most therapists spend the first sessions on preparation, and you decide together when you are ready.

Source: NICE NG116

Cognitive processing therapy

Cognitive processing therapy (CPT) works on what the trauma made you believe. Patricia Resick built it for survivors of rape and sexual assault. It joins education, exposure and work on thinking.

A course runs to twelve sessions of about fifty minutes. You look at ways of thinking that keep you stuck. The sessions work through five themes a trauma often disturbs: safety, trust, power and control, esteem and intimacy.

A 2019 review gathered 11 trials of CPT. It found CPT ahead of waiting lists and placebo therapies. CPT was also ahead of other active treatments at the end of therapy, though not at follow-up.

Sources: Resick & Schnicke 1992, CPT: about, Asmundson et al. 2019

Prolonged exposure

Prolonged exposure asks you to go towards what you have been avoiding. Edna Foa and her colleagues wrote the manual behind it. It has two halves: going back over the memory in the room, and returning to safe situations between sessions.

In a 2023 trial, a course ran from eight to fifteen sessions. Each lasted ninety minutes, with forty of them given to the memory.

A 2010 review pooled 13 trials of prolonged exposure. It found a large effect against waiting lists and placebo therapies. Against other active therapies, including CPT and EMDR, it found no significant difference.

Sources: Powers et al. 2010, Sloan et al. 2023

Written exposure therapy

Written exposure therapy is the short one. You write about the trauma in the session itself, for thirty minutes at a time. A course is five sessions, and there is nothing to do in between.

Two trials have compared it with the longer therapies. In 2018 it did no worse than cognitive processing therapy, and far fewer people dropped out. In 2023 it did no worse than prolonged exposure, again with fewer leaving.

Both trials were run in United States veterans' hospitals. NICE's PTSD guideline came out in 2018 and does not name this therapy. Ask a therapist whether they work this way.

Sources: Sloan et al. 2023, Sloan et al. 2018, NICE NG116

Who is it best suited to?

Trauma-focused CBT is designed for people with PTSD after one event or many. It can be a good fit if you:

• Have flashbacks, nightmares or intrusive memories of something that happened
• Avoid people, places or conversations that bring it back
• Carry strong guilt, shame or self-blame about the event
• Want a structured approach with a clear plan and a known length
• Prefer to talk through what happened rather than process it another way

NICE says to offer it to children and young people aged seven and over as well. It asks for the therapy to suit their age, and for parents or carers to be involved as needed.

Source: NICE NG116

How it differs from EMDR

NICE also says to offer EMDR after a non-combat trauma. That applies once three months have passed.

Both work on the memory. The difference is the route.

Trauma-focused CBT puts the memory into words, with work between sessions. EMDR holds the memory in mind during a side-to-side movement and asks for far less description. Many people choose between them on that basis, and some professionals are trained in both.

Some people have intrusive thoughts with rituals to keep themselves safe. For that pattern, exposure and response prevention is the CBT built for it. A trauma specialist will help you tell the two apart.

Source: NICE NG116

The evidence

A 2020 review pooled 114 randomised trials of therapies for PTSD. It found robust evidence that trauma-focused CBT has a clinically important effect. The forms with the strongest evidence were cognitive processing therapy, cognitive therapy and prolonged exposure.

It is not a promise. Where symptoms remain afterwards, NICE says to consider CBT aimed at those symptoms, such as sleep problems or anger. The right person to start with is one who will tell you that honestly.

Not sure whether this is the approach for you? Our trauma and PTSD page starts from what you are living with, not from the name of a therapy.

Sources: Lewis et al. 2020, NICE NG116