The Matrix - Cognitive Behavioural Therapy with a Trauma Focus (CBT-T)

Intervention Summary

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) includes psychological therapies for the treatment of PTSD and related conditions, that apply the standard principles of CBT and trauma processing. CBT-T therapies can be delivered to children, adolescents and adults, by CBT therapists who have training in trauma focused methods.

CBT-T is delivered in weekly sessions that focus on psychoeducation, stress management, cognitive restructuring and exposure therapy. The relative input of each of these components differ with the form of CBT-T. Delivery of CBT-T therapies is associated with significant reductions in PTSD symptoms, depression symptoms, reversal of PTSD diagnosis, and improvement in overall functioning.

Individualised Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) is available in every Scottish health board. It is recommended in inter/national guidance with high levels of efficacy and high-quality evidence.

Usability - Rating: 5

Core Components

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) is an encompassing term that describes any psychological therapies, for the treatment of PTSD and related conditions, which incorporates the basic principles of CBT with elements of trauma processing.

Typically, CBT-T applies standard CBT techniques that focus on the interrelationship between thoughts, beliefs, and behaviours, and how alterations in one domain can positively impact other domains. CBT-T combines this standard CBT principle with components of exposure therapy, which helps people confront traumatic memories and reminders thereby reducing excessive distress associated with the trauma event. CBT-T therapies can be delivered to children, adolescents, and adults.

CBT-T is typically delivered weekly, over 8-15 sessions, with each session lasting between 60-90 minutes. In these sessions, components of CBT-T that are typically covered include:

1) Psychoeducation to provide education about common responses to trauma which help people conceptualise their symptoms as common responses to trauma experiences. Psychoeducation also helps to enhance understanding of the cognitive model.

2) Stress management to teach skills to minimise physiological arousal and promote relaxation.

3) Cognitive restructuring to identify and challenge cognitive distortions and unhelpful thought patterns. These are intended to help people readdress dysfunctional understanding of the trauma event and of themselves, and to achieve logical, healthy thought patterns

4) Exposure therapy involving controlled exposure to traumatic memory or reminder, in order to help individuals confront their fears, lessen distorted trauma associations, and reduce avoidance behaviours. Variations of exposure therapy include imaginal exposure and in-vivo exposure. The relative input of each of the CBT-T components (i.e. psychoeducation, stress management, cognitive restructuring and exposure therapy) differ with the form of CBT-T.

CBT-T therapies typically have homework components as these provide opportunities for challenge between sessions, and to generalise the skills learnt to their everyday lives.

Fidelity

NICE recommends that Cognitive Behavioural Therapy interventions with a Trauma Focus (CBT-T) should be delivered by trained practitioner(s) with ongoing supervision, typically over 8-12 sessions (or more if clinically indicated). It is necessary that these interventions are delivered as per validated manual, and that stipulated content and structure are adhered to, to ensure consistency in delivery.

The Cognitive Therapy Rating Scale- Revised (CTS-R, Blackburn et al. 2001) can be used to assess fidelity. Raters should be trained in CBT with a trauma focus and should take into account the relevance of the formulation and change methods to a PTSD diagnosis.

Modifiable Components

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) can be delivered face-to-face (e.g. community mental health centres, outpatient clinic settings, hospitals, and schools), virtually (via videoconference) or through online CBT programmes/ courses.

CBT -T can be offered individually or to groups, typically weekly, over 8-15 sessions (or more depending on individuals response). Intensive delivery (i.e. over 5-7 days, totalling 18 hours of therapist time) of one form of CBT-T was evaluated and found it to be a promising alternative form of delivery (https://pubmed.ncbi.nlm.nih.gov/20573292/). Brief CBT-T delivered weekly over 4 weeks has also been found it effective in the short-term (https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.2007.164.1.82).

There is evidence that CBT-T improves symptoms of comorbidities associated with PTSD, including depression, anxiety, dissociation, and substance use disorder (when offered along-side substance use treatments (https://www.tandfonline.com/doi/pdf/10.3402/ejpt.v3i0.18805?needAccess=true).

Supports - Rating: 5

Support for Organisation / Practice

Implementation Support

Implementation support is provided mainly by trained supervisors who support the application of CBT with TF within each therapist’s practice. Support for implementing CBT with TF is available through the NES Psychology Trauma and CAMHS workstreams, including webinars, supervisor training and the trauma training plan.

Start-up Costs

There are no start-up costs associated with training provided within university training programmes (if training through an NHS or by NES). Costs apply when training is provided by private organisations.

Building Staff Competency

Qualifications Required

Staff will usually hold an undergraduate degree in a relevant area (e.g., nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).

Training Requirements

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in CBT-T is available through the NES Psychology Trauma and CAMHS workstreams.

Supervision Requirements

Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist with additional experience in delivering CBT with TF and has completed the following pathway of supervision training:

NES Generic supervision competences training (GSC) (or equivalent)
NES Specialist Supervision Training: CBT (adult or child focus)
Additional CBT with TF supervisor training

Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available that specifically supports CBT supervision skills and CBT-T supervisory practice.

Evidence - Rating: 5

Theories of Change

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) is based on several theories that are specific to trauma and include:

Emotional processing theory of PTSD poises that PTSD emerges from the development of a fear network in memory of the traumatic event, which in turn elicits avoidance and escape behaviours on exposure to reminders of the trauma. It proposes that enabling people to repetitively face their traumatic memory would result in desensitisation of their fear, and alteration of their fear structure.
Social cognitive theory of PTSD goes beyond the elicitation of fear networks. It also addresses the development of other related primary emotions (sadness, anger) that are a direct response to the trauma, and secondary emotions (e.g., shame, guilt) that develop from misconstrued thoughts and interpretations of the trauma. Social cognitive theory of PTSD therefore focuses on cognitive content, cognitive interpretation, and the effects of cognitive misinterpretation on emotions and behaviours.
Ehlers and Clark (2000) cognitive model of PTSD which suggests that PTSD persists when individual’s processing of trauma produces a sense of serious, current threat. This sense of threat is believed to be a consequence of 1) exaggerated negative distortions of the trauma event, and 2) nature of the trauma memory. The sense of threat is subsequently maintained by 3) behavioural and cognitive coping strategies that are intended to mitigate it. This cognitive model therefore targets these three maintaining factors for PTSD in order to reduce the symptoms.

Practitioner’s understanding of these theories will facilitate more effective application of CBT-T treatment strategies.

Children and Young People - Rating: 5

Research Design & Number of Studies – Children and Young People

Eleven RCTs evaluated trauma-focused CBT interventions against wait-list control for the prevention of PTSD in children and young people with ongoing exposure to trauma. Three RCTs evaluated trauma-focused CBT interventions against treatment-as-usual for the delayed treatment (>3 months) of non-significant PTSD symptoms.
Nineteen RCTs evaluated trauma-focused CBT interventions against wait-list control, no treatment, or treatment as usual. These nineteen studies assessed the effectiveness of trauma-focused CBT interventions for the treatment of PTSD in children and young people when the interventions were delivered as delayed treatment (>3months).

Evidence of effectiveness of all interventions classed as CBT with trauma focus were combined and evaluated in meta-analyses, as they apply the same approach and their efficacies are expected to be equivalent. The observed outcomes have been summarised below. Complete information on studies included in the meta-analyses, and detailed results from the meta-analyses can be found within the NICE guideline evidence reviews 2018.

Outcomes Achieved – Children and Young People

Compared to wait-list control, no treatment, or treatment as usual, the following outcomes were observed;

Significant reduction in PTSD symptoms following delayed treatment (>3months) for single incident trauma and multiple incident trauma, and trauma with unclear multiplicity. Effects were observed at endpoint, and sustained at 1-3 months follow-up, and up to 12-months follow-up (3)
Significant reversal of PTSD diagnosis following delayed treatment, for single and multiple incident traumas, at end point and at 1-3 months follow-up (3)
Significant increase in number of people much/very much improved at endpoint, after delayed treatment, for single incident trauma and multiple incident trauma (3)
Significant reduction in anxiety symptoms following delayed treatment, for single and multiple incident traumas, at end point and up to 1-year follow-up (3)
Significant reduction in depression symptoms following delayed treatment (>3 months), for single and multiple incident traumas at end point. Overall effect, inclusive of all multiplicities of index trauma, sustained for up to 1-year follow-up (3)
Significant reduction in emotional and behavioural problems (for multiple index traumas) following delayed treatment. Effects were observed at endpoint for internalising problems, and at 3-months follow-up, 6-months follow-up, and 2-years follow-up for externalising problems (3)
Significant improvement in overall effect on quality of life following delayed treatment (3)
Significant reduction in functional impairment following delayed treatment for single incident trauma and multiple incident trauma. Effects were observed at endpoint, and sustained at 3-months and 12-months follow-up (3)
Significant improvement in global functioning following delayed treatment for single incident trauma and multiple incident trauma. Effects were observed at endpoint for single and multiple incident trauma, and sustained at 3-months follow-up for multiple incident trauma (3)
Significant reductions in PTSD symptoms, in PTSD diagnosis, in functional impairment, and in symptoms of comorbidities associated with PTSD (including depression and anxiety) in children and young people with ongoing exposure to trauma (4)
Significant reductions in PTSD symptoms and depression symptoms in children and young people with non-significant PTSD symptoms (4)

Adults - Rating: 5

Research Design & Number of Studies - Adult

Eight RCTs (Randomised Controlled Trials which are considered the gold standard for evidence of effectiveness) evaluated trauma-focused CBT interventions (alone or in addition to treatment-as-usual or psychoeducation) against treatment-as-usual, attention placebo, psychoeducation, waitlist, or no treatment, for the early prevention (initiated after1 month) of PTSD in adults.
Six RCTs evaluated trauma-focused CBT interventions against wait-list, attention-placebo or psychoeducation for the delayed treatment (>3 months) of non-significant PTSD symptoms in adults.
Thirty RCTs evaluated trauma-focused CBT interventions against wait-list control or no treatment control.

These thirty studies assessed the effectiveness of trauma-focused CBT interventions for the treatment of PTSD in adults when the interventions were delivered as early treatment (1-3 months) or delayed treatment (>3months). Evidence of effectiveness of all interventions classed as trauma-focused CBT interventions were combined and evaluated in meta-analyses, as they apply the same approach and their efficacies are expected to be equivalent. The observed outcomes have been summarised below.

Outcomes Achieved - Adult

Significant reduction in PTSD symptoms following early treatment (1-3 months) and delayed treatment (after 3 months), for single and multiple incident traumas, at end point and up to 1-year follow-up (1)
Significant reversal of PTSD diagnosis following early and delayed treatment, for single and multiple incident traumas, at end point and up to 8-months follow-up
Significant reduction in depression symptoms following early and delayed treatment (after3 months), for single and multiple incident traumas, at end point and up to 1-year follow-up (1)
Significant reduction in anxiety symptoms following delayed treatment, for single and multiple incident traumas, at end point and up to 1-year follow-up (1)
Significant reduction in dissociative symptoms and functional impairment following delayed treatment. Effects on both outcomes were observed at endpoint, while sustained effect on functional impairment was observed at 6-months follow-up (1)
Significant reduction in relationship difficulty and significant improvement in global functioning following delayed treatment (1)
Significant improvement in quality of life following delayed treatment. Sustained effect was observed at 3-months follow-up (1)
Significant reduction in PTSD symptoms, PTSD diagnosis, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following early initiation of intervention (i.e. <1 month) (2)
Significant reductions in PTSD symptoms, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following delayed initiation of intervention (i.e. > 3months) in adults with below threshold PTSD symptoms (2)

Complete information on studies included in the meta-analyses, and detailed results from the meta-analyses can be found within the NICE guideline evidence reviews 2018

Fit

Values

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) is an encompassing term that describes any psychological treatment, for the treatment of PTSD and related conditions, that incorporates the basic principles of CBT with elements of trauma processing. CBT-T therapies are based on several theories that are specific to trauma, including information/ emotional processing theory of PTSD, social cognitive theory, and Ehlers and Clark (2000) cognitive model of PTSD.

Do the target patients, underpinning theories, and the underlying mental health condition addressed by the intervention align with the requirements of your organisation?

Existing Initiatives

Does your service currently deliver interventions to treat PTSD and related conditions?
Are existing initiatives practicable and effective?
Do existing initiatives fit current and anticipated requirements?

Capacity

Workforce

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) can be delivered by professionals (e.g. psychologists, psychiatrists, or mental health nurses) who have undergone training to support its delivery. CBT-T is delivered weekly (to people using services), over 8-15 sessions.

Does your service have practitioners who are available and interested in learning and delivering CBT-T?
Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?

Technology Support

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) can be delivered can be delivered without access to technology but access to video platforms for remote delivery can be useful, as is access to methods of recording sessions for supervision.

W Will CBT-T be delivered remotely?
Does your service have the technology to support CBT-T remote delivery?
Can your practitioners access technology to record sessions for supervision?

Administrative Support

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) is typically delivered weekly, over 8-15 sessions. Face-to-face therapy sessions can be held in several settings including community mental health centres, outpatient clinic settings, hospitals, and schools.

Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.

In what setting will CBT-T be delivered?
Does your service have a venue to deliver PE sessions?
Can administrative supports needed to deliver CBT-T be provided?

Financial Support

Scottish Government/NES Psychology routinely funds training programmes in CBT, supervisor training and additional CPD on CBT with TF. Training is available from other organisations at a cost.

Can your service access the training programmes provided by NES?
Can your service financially support practitioner training costs if accessed outside NES?

Need

Comparable Population

Cognitive Behavioural Therapy with a Trauma Focus (CBT-T) can be delivered to children, adolescents, and adults for the treatment of PTSD and related conditions.

Effectiveness of interventions within the trauma-focused CBT class have been demonstrated in the early prevention (initiated ≤ 1 month) of PTSD in adults; in the delayed treatment (>3 months) of non-significant PTSD symptoms in adults; as well as in the early and delayed treatment of PTSD in adults.

Effectiveness has also been shown in the prevention of PTSD in children and young people with ongoing exposure to trauma; in the delayed treatment (>3 months) of non-significant PTSD symptoms in children and young people; as well as in the delayed treatment (>3months) of PTSD in children and young people.

Is this comparable to the population your service would like to serve?

Desired Outcome

Cognitive Behavioural Therapy with trauma focus (CBT-T) therapies have been shown to effectively reduce acute stress disorder diagnosis, PTSD diagnosis, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following early initiation of intervention (≤1 month). They have also been shown to reduce PTSD symptoms, reduce symptoms of comorbidities associated with PTSD (including depression and anxiety), and reverse PTSD diagnosis following early (1-3 months) or delayed treatment (≤ 3months). Effects have been sustained at follow-up.

Is delivering trauma-focus psychological therapy for PTSD and related conditions a priority for your organisation?
Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?