The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
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
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
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
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
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
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.
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.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
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.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
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.
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.
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.
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.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
