Why Cognitive Behavioral Therapy May Not Work to Treat Trauma

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CBT can be an effective treatment for trauma, but it is not a cure-all. There are a number of reasons why CBT may not work for everyone with trauma:

  1. Trauma can cause significant changes in the brain. When we experience a traumatic event, our brains go into survival mode. This can lead to changes in our thoughts, emotions, and behaviors. These changes can make it difficult to think rationally and to challenge negative thoughts.
  2. Trauma can be overwhelming and re-experiencing the trauma can be retraumatizing. CBT often involves confronting the trauma and challenging negative thoughts and beliefs about the trauma. This can be very difficult and triggering for people with trauma.
  3. CBT may not be enough to address all of the symptoms of trauma. Trauma can cause a wide range of symptoms, including physical health problems, emotional dysregulation, and relationship difficulties. CBT can be helpful for addressing some of these symptoms, but it may not be enough to address all of them.

Introduction

Traumatic events can have a negative impact on people of all ages. Though two people experiencing the same trauma can express very different symptoms, it’s fair to say, traumatic events leave no one unscathed. Though some will experience the effects of trauma chronically, others may experience the effects of trauma intermittently.

Some of the most promising trauma research to date has been documented in the wildly popular book, The Body Keeps the Score by Bessel Van Der Kolk, M.D. Here, Dr. Bessel, a psychiatrist, explores trauma and its impact on the brain and body, and our innate ability to heal. With over thirty years of clinical experience, Dr. Bessel is considered a leading expert in understanding and treating trauma.

Though cognitive behavioral therapy (CBT) is a well-researched and effective form of treatment for many mental health issues, trauma may be better treated using a different modality. If you have witnessed or experienced a traumatic event and are considering seeking support in therapy, read on to find out which treatments may be more effective than CBT.

The difference between trauma and Post Traumatic Stress Disorder

Trauma is a response to witnessing or being a part of a terrifying or horrible event. According to the Substance Abuse and Mental Health Service Administration (SAMHSA), a trauma response can include having “initial reactions such as exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect. Most responses are normal in that they affect most survivors and are socially acceptable, psychologically effective, and self-limited.”

A trauma response tends to be limited and is considered a “normal” reaction to an abnormal event. Symptoms tend to last for a few weeks or perhaps as long as a couple of months. As the person begins to make sense of the event, their symptoms decrease or cease altogether. Eventually, the person is able to resume “normal” everyday life.

Post Traumatic Stress Disorder (PTSD) shares a lot of the symptoms of trauma; however, the symptoms of PTSD tend to occur over a longer duration and the symptoms tend to be more severe. The traumatic event itself does not define whether or not someone has PTSD, it is the symptoms and duration which help qualify a client for a PTSD diagnosis.

Traumatic events can include but are not limited to:

  • Bullying
  • War
  • Rape and sexual assault
  • Domestic violence
  • Physical abuse
  • Sexual Abuse
  • Neglect
  • Car accidents
  • Plane crashes
  • Natural Disasters
  • Being robbed or mugged

Why CBT may not be the right therapy for trauma and PTSD

CBT is typically performed in fewer sessions than other treatment modalities, averaging between 8-12 sessions, and tends to focus on more of the here-and-now issues of the client rather than exploring the past. Since it is considered short-term therapy and is supported by numerous research studies, insurance companies prefer this form of treatment over other forms of treatment. Due to this bias, it is important to know there are other equally effective, if not more effective, forms of treatment available for those experiencing the impact of trauma.

CBT focuses on the client’s thoughts, emotions, and feelings as well as their subsequent behavior and seeks to formulate more adaptive beliefs, leading to healthier emotions and behaviors. While this is helpful for many, for those with complicated childhoods, the lack of focus on how the past affects the present, may contribute to poorer outcomes.

For instance, let’s take a client who was raised in a family where outward appearances were highly valued. This client was raised to dress well and appear happy and confident regardless of their internal state. This client just experienced the trauma of surviving a disastrous earthquake and is having several negative symptoms. 

The familial belief that one must always appear in control or happy, will certainly impact how they handle their current traumatic stress. If CBT fails to address their childhood origin of beliefs, feelings, emotions, and behaviors and how those relate to the trauma, then the lack of a foundational understanding might contribute to a poor treatment outcome. In this way, CBT might not serve all clients.

CBT has not done so well for traumatized individuals, particularly those with histories of child abuse. Only about one in three participants with PTSD who finish research studies show some improvement. Those who complete CBT treatment usually have fewer symptoms, but they rarely recover completely. Most continue to have substantial problems with their health, work, or mental well-being.” (Bessel Van Der Kolk, The Body Keeps the Score, 2014)

How CBT treatment works

Cognitive Behavioral Therapy seeks to help clients improve their thoughts, feelings, emotions, and behavior. Though this tends to be the goal of all therapies, CBT is based on the belief that maladaptive behavior, feelings, and emotions are a result of maladaptive thoughts. If those maladaptive thoughts can be addressed and positively altered, then the client will experience positive feelings, thoughts, and emotions, and subsequently, their behavior will improve.

For example, a client may come to therapy for support with obsessive compulsive disorder (OCD). As the client discusses his rituals and his compulsions, the therapist might challenge the client’s belief about ritualistic hand washing, using medical information as a psychoeducational adjunct. As the client begins to understand the science behind germs and handwashing, his beliefs might change and therefore his behavior might be positively impacted by ceasing to excessively wash his hands. 

Many of us, whether we are currently experiencing a mental health challenge or not, have maladaptive thoughts and beliefs which lead to unhealthy behavior, feelings, and emotions. CBT aims to challenge these negative thought patterns and replace them with more realistic and healthy beliefs. While this therapy has been successful and effective for many, it isn’t a panacea for all.

Alternative treatments which may be more effective than CBT

Dr. Bessel says it best, “there is no one treatment of choice for trauma, and any therapist who believes that his or her particular method is the only answer to your problems is suspect of being an ideologue rather than somebody interested in making sure (their patient) gets well.” (Bessel Van Der Kolk, 2014)

Trauma affects people both psychologically as well as physically. Trauma also affects people’s relationship with themselves as well as with others. As such, trauma should be treated in a multifaceted manner, tuning into the different ways in which people are negatively impacted.

There are many effective psychological therapeutic treatments for relieving the symptoms of trauma. The number one attribute of a qualified therapist is one who is specifically trained to treat trauma. The second most important attribute of a successful therapist is one who is warm, welcoming, nonjudgmental, and has healthy professional boundaries. Many therapists trained to treat trauma will use more than one method to treat symptoms, therefore appropriate training and likeability are of the utmost importance when seeking therapeutic support.

People who experienced trauma at the hands of caregivers, family, or friends are likely to have the greatest difficulty feeling safe with others, especially a therapist. Whereas those who experienced trauma from an accident, may not have as much difficulty creating a safe therapeutic space. For those who have difficulty feeling safe with others, animal therapy has proven to be a highly successful form of treatment.

Bodywork, such as massage, acupuncture, yoga, Reiki, or craniosacral therapy are effective adjuncts to talk therapy. The nature of safe touch and body movement helps people to calm down. When physical stress is relieved, mental stress can also be relieved. For those who have disassociated from their bodies due to a traumatic event, safe therapeutic touch and body movement can be very important in “getting back into one’s body.”

Certain medications may be helpful in combating trauma response symptoms for some people and are most effective when used in conjunction with regular “talk” therapy. It is also important to note, medication does not have to be life-long, in fact, medication can sometimes be most impactful in the short term and allow clients the biochemical support they need during other therapeutic treatments.

Talk therapy can be limiting for some individuals. Art therapy, music therapy, drama therapy, and play therapy can be effective alternative treatments to traditional talk therapies. Though these therapies may involve some talking, introspection, and communication, these therapies do not rely on verbal communication as the only form of expression.

EMDR (Eye Movement Desensitization and Reprocessing) has been well-researched and regarded as highly successful in treating trauma. This form of treatment does not require the client to talk and therefore serves a population of people who may be verbally limited. EMDR involves creating new neural pathways and integrating information in a way that is tolerable.

How to find therapists to treat trauma and PTSD

It is always recommended to do your own due diligence when seeking out a therapist for treatment. Whether you are seeing a therapist in-person or online, it is imperative to state your needs, goals, and preferences. It is always ok to ask a therapist about their training, credentials, and experience. You can search reviews here to seek online licensed therapists or look locally using Psychology Today’s local therapist search.

Advocate for what you are seeking and make sure not to settle for any therapist that does not feel like a good fit for you. You are the expert in your life and though therapists are educated and experts in their field, trust your instincts and choose accordingly.

How long does it take to treat trauma and PTSD

The length of treatment depends on numerous factors. The length of time you have experienced symptoms, the severity of your symptoms, the training of the therapist, and other factors all affect the length of treatment. While EMDR has been shown to be effective in fewer sessions than other modalities, treatment length is highly individual.

How to support someone who is experiencing trauma or PTSD

If you know someone who is living with trauma or PTSD, showing support by listening to them is essential. Listening to their thoughts, feelings, and experience without judgment can be very healing. As important as it is to show support, oftentimes, trauma requires trained individuals to relieve symptoms – especially those living with PTSD. 

If someone you care about is struggling, reach out to the national hotline for immediate help at 988 (call or text). “When people call, text, or chat 988, they will be connected to trained counselors that are part of the existing Lifeline network. These trained counselors will listen, understand how their problems are affecting them, provide support, and connect them to resources if necessary.” – Lifeline

Conclusion

If you are struggling with trauma, there are many effective therapeutic interventions known to be successful at resolving symptoms. Whether in person or online, there are licensed and trained therapists available to assist you. Though CBT may not be the optimal choice for treating trauma, there are many other treatment modalities a therapist can employ to help you meet your goals.

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