Core components

CBT interventions for specific symptoms are those that apply cognitive behavioural approaches that focus on specific symptoms associated with trauma. This group of  interventions target domains that include avoidance, insomnia, nightmares, maladaptive appraisals, hyperarousal, negative mood, and unhelpful coping strategies and, hence, can be useful for some in  the treatment of PTSD. This is particularly the case for people with PTSD who are reluctant to receive trauma focused interventions however, it is emphasised that the latter remain the interventions with the strongest evidence base. However, symptom focussed interventions can also be applied as the initial step, in a stepped care approach, prior to delivering trauma focused interventions or to target remaining symptoms after trauma focused CBT. Intervention examples (taken from those reviewed in NICE PTSD guidance) include:

• Stress Inoculation Therapy (SIT)
• CBT for Insomnia
• Seeking Safety (SS)

These are briefly discussed below.

Stress Inoculation Therapy (SIT): 

This individually tailored intervention focuses on teaching coping skills with the aim of reducing stress and anxiety associated with PTSD. As part of therapy, people are exposed to stressful situations on a graduated basis, with the expectation that application of the skills learnt will increase tolerance to stressful stimuli. SIT consists of three phases:

• Conceptualisation phase: In this phase, therapists aim to build a collaborative relationship with the person accessing services; educate on the nature of stress and the key factors (e.g., appraisals, cognitive distortions) that influence reactions to stress; and assess stressors and stress-induced reactions.
• Skills Acquisition and Consolidation: In this phase, people are taught coping skills that are tailored to their specific needs, strengths and vulnerabilities. Skills that can be taught include breathing retraining, relaxation techniques, cognitive restructuring, problem-solving skills, and positive self-statements.
• Application and Follow-through: In this phase, people are exposed to increasing levels of stressful stimuli (via imagery, role playing, videos, and real-life situations). People then practice applying learnt skills to regulate their emotions and control their stress responses.

SIT is delivered with the goal of augmenting individuals’ repository of coping skills and increasing confidence in their capacity to flexibly apply these skills as needed. This manualised intervention is delivered over 3 months, in 8-15 sessions. Sessions are delivered weekly or twice weekly, and last about 60-90 minutes. Booster and follow-up sessions can be delivered over 3-12 months. SIT can be delivered alone, or in combination with other therapies. Virtual reality (VR) can be used to enhance SIT delivery.

SIT was tested in an RCT by Foa et al., (1999) with SIT demonstrating superior outcomes to supportive counselling and a control group. Initial outcomes were equivalent to Prolonged exposure (PE) although PE was superior at follow up (up to 12months).

CBT for Insomnia and Nightmares:

Sleep disturbance and nightmares are commonly reported in PTSD and are associated with levels of severity and distress. A number of CBT interventions for addressing insomnia and chronic nightmares have demonstrated effectiveness in RCT trials.  These include CBT-I e.g. Talbot et al., 2014; Marjolies et al, 2013), Imagery rehearsal therapy (Krakow et al., 2001) and Exposure, Relaxation and Rehearsal Therapy (e.g Davis & Wright, 2007). These interventions have been tested in general adult PTSD populations as well as sexual assault survivors and veterans. Outcomes include significant reductions in PTSD, mood and sleep related measures compared to waiting list controls with some studies demonstrating these outcomes at 6mth follow up.

Seeking Safety (SS):

SS is a CBT based intervention that addresses co-occurring PTSD and/ or substance use disorders and provides integrated trauma and substance abuse treatment for individuals with both conditions. This present-focused intervention identifies safety (in relationships, thoughts, feelings, and behaviours) as its overarching goal. It offers up to 25 topics that fit within four content areas (i.e. cognitive, behavioural, inter-personal and combination topics), and address coping skills that are pertinent to trauma and substance abuse. These topics include, but are not limited to honesty, getting support, healthy relationships, healing from anger, PTSD: taking back power, self-care, self-nurturing, red and green flags, grounding, safety, life choices and case-management.

Delivery of all 25 topics is not a requirement as focus can be on topics that are thought to be most relevant to the individual’s situation. SS sessions can be flexibly delivered (e.g., weekly or twice weekly, over a period of 3 months); can vary in length (e.g. 50 -90 minutes); and can be delivered alone or in combination with other therapies. Individuals delivering SS do not require specific therapy qualifications, but all delivery of psychological intervention should be aligned with the requirement for supervision provided by a suitably trained (e.g. NES Generic Supervision Competences at a minimum) person who has expertise in the intervention.

Typically, CBT interventions for specific PTSD symptoms can be delivered on a one-to-one basis. They can also be delivered in group format, as the non-trauma focus of some of these interventions circumvents the risks of re-traumatisation that can arise from introduction to other people’s trauma experiences. These interventions can be delivered to adults and adolescents, in several settings (e.g., community, outpatient, inpatient, residential), for the treatment of different types of trauma. CBT interventions for specific PTSD symptoms typically have homework components which provides opportunities  to practice their skills in day-to-day situations.

Fidelity

Fidelity is enhanced by ensuring adherence to treatment manual and providing on-going supervision to therapists. Recorded therapy sessions can be rated to assess treatment adherence. Fidelity scales for Seeking Safety can be freely accessed online here.

Modifiable Components

Modifiable components for two CBT interventions for specific PTSD symptoms, i.e. Stress Inoculation Therapy (SIT) and Seeking Safety (SS) are discussed below.

For Stress Inoculation Therapy (SIT), the delivery of its three phases will vary with the nature of individuals stressors (e.g. acute  vs ongoing  stressors, ), and their strengths. The content of the phases, the skills taught, and the nature of the inoculation trials will be specifically tailored to the person receiving therapy. Flexibility in delivery method facilitates delivery in individual, family, and group formats, with the number of sessions delivered dependent on progress.

Seeking Safety (SS) has been translated into multiple languages including Arabic, Chinese, Dutch, French, German, Greek, Japanese, Korean, Polish and Spanish. An audio version for people with blindness or dyslexia is also available. There is flexibility in the SS model which supports delivery in individual or large group formats, and by peers or professionals across different backgrounds. Flexibility in the SS model also supports delivery in different settings; for different types of traumas; and different types of substance abuses. SS also allows the use of examples that are relevant to situations, ethnicities and gender identification (https://www.treatment-innovations.org/uploads/2/5/5/5/25555853/2009_implementation_guide_ss.pdf)