What if Cognitive Therapy is Not Working For PTSD?


Trauma Shattered Mind

Some people do report that cognitive therapy or CBT can be ineffective, or at least very slow, in treating trauma or PTSD? Why is this the case and what alternatives might be available to overcome trauma in people’s lives?

The main reason cognitive therapy can sometimes be ineffective in treating trauma is that it tends to address things on a surface level and only attack symptom rather than cause. By this we mean it is focused on challenging beliefs in order to change behaviors. The problem here is that trauma can be a powerful driver of beliefs and behaviors and create patterns which can be very resistant to change unless the trauma itself is properly accessed and resolved.

Thankfully there are other therapeutic techniques which aim to do this should more surface layer treatments like CBT prove ineffective or slow. EMDR for example is a superbly effective, proven form of therapy which attacks trauma at the root, pulling it out psychosomatically before later installing healthier beliefs on top for the person to live a better life.

This kind of depth approach, tackling trauma on it’s own terms rather than addressing the symptoms of trauma in terms of the common problems associated with PTSD, has proven to be very effective at allowing people to move past their trauma and live more fulfilling lives. It is also a very efficient and fast acting form of therapy, delivering results in a much shorter space of time than other forms of therapy. Let’s look at the issue in more detail below.

The Problem With Trauma

The horrible thing for survivors of deep and prolonged trauma is the negative long term effects it can leave on a person’s life. Most commonly PTSD sufferers report a pervading sense of numbness or flatness, unable to gain any enjoyment out of life anymore.

They no longer take pleasure in the things they used to. The struggle to get up for things or look forward to the future. They feel stuck in the past and they sometimes report they “miss their old selves”. It is as though the trauma destroyed their old identity but they are left with nothing in it’s place.

There can also be more easily identifiable conditions resulting from trauma. such as depression, anxiety, insomnia, flashbacks, anger issues, loss of appetite, restlessness, and so on. These can all go alongside the pervasive numbness we mentioned and seriously affects the person’s quality of life. It is as though the trauma remains stuck in the person and they are unable to move on from it. They remain “frozen” psychologically.

The effects of this on a person’s life are very real. One crucial step to recovering properly is getting the right kind of therapy to deal with the trauma. There is a growing awareness among the psychology community that not all therapies are created equal, and some are more effective at treating certain conditions than others, though certain core overlap benefits remain.

This is perhaps even more true with trauma than with other psychological disorders. Anyone who has tried multiple different therapies to treat trauma will know for themselves the difference in effectiveness between more “surface” treatments like CBT and more “depth” therapies like EMDR. We will compare these two in more detail below.

The Problem With Using Cognitive Therapy To Treat Trauma

In short, cognitive behavioural therapy or CBT is not the most effective therapy for treating trauma or PTSD because it is only addressing symptoms and not cause. By focusing on challenging beliefs in the hope of changing them and therefore changing the patient’s behavior, the hope is to bring the person to living in a more functional and healthy way and ending self destructive thinking and behavior patterns.

What this approach misses is that the when dealing with PTSD, the dysfunctional beliefs and behaviors are arising not on their own but as an offshoot to the trauma that was suffered. They are the symptom of the person’s real problem and not the cause. The cause itself is the unprocessed, unresolved trauma which is still sitting inside the person physiologically and drives the dysfunctional thoughts and behaviors that the cognitive therapy is trying to treat.

These thoughts are often negative views about oneself that were formed because of the trauma, such as “I’m worthless”, “I’m powerless” “I don’t deserve anything”, “I’m not good enough” and so on. It is a strange quirk of humanity that when we experience a deep trauma we often insert into our memory of that experience a negative view of ourselves which continues to sit inside us and affect our self image and self esteem. We act in line with that internalized negative belief and not a healthier, more self serving, realistic belief.

This for example explains some (maybe not all) cases of seemingly talented, bright, capable people living deliberately self limiting lives, selling themselves well short of their potential in terms of jobs, relationships, social status and so on.

In many cases this is because the person is still acting on these deeply held negative internal beliefs about themselves that were formed formed due to some traumatic life experience. They don’t live happy, fulfilled lives because on some level they don’t believe they deserve to be happy or fulfilled.

This is a horrible situation and the sense of lost time and human potential that results from this is difficult to contemplate. One can try all they like to “push back” against these negative self beliefs and behaviors, but the reality is that the subconscious is very powerful and highly resistant to change. If the trauma remains sat inside them psychosomatically, then any attempts to treat the symptoms of this trauma in the form of dysfunctional self beliefs and behaviors will be either ineffective or painfully slow.

It is as though the trauma itself pushes back against any efforts to change beliefs and says “Until I am listened to and heard, nothing is changing“. This is why when dealing with trauma, it is far better to use therapeutic techniques which deal with the trauma on it’s own terms and not the offshoots or symptoms of this trauma. One such method is EMDR, to which we will now turn.

 

Using EMDR to Treat Trauma

A far more effective, proven approach to dealing with trauma is that of Eye Movement Desensitization and Reprocessing or EMDR. This is a non mainstream but very highly regarded therapeutic technique amongst practitioners and patients, which aims at firstly accessing and processing the trauma itself, before then placing healthier, more adaptive beliefs on top.

This is a crucial difference between EMDR and CBT, in that in the case of trauma, EMDR is actually targeting the root cause of the trauma itself and not any symptoms resulting from this trauma. In this sense it can seen to be a more fundamental, “depth” approach, resolving the problems at the deepest level first before addressing any surface issues.

Therapists and patients who undergo this form of treatment report it to be a very effective and fast acting therapy, delivering quick noticeable improvements in the person’s quality of life. This is in contrast to cognitive therapy which can be painfully slow in dealing with trauma, taking months or years for any real improvement to be seen.

The reason we suspect for this is the one we mentioned above. EMDR is actually pulling out trauma by the root, which then makes placing healthier beliefs on top far easier. CBT by contrast is attempting to remould beliefs and behaviors without first resolving the underlying trauma, making it far more difficult. The brilliant psychologist Alice Miller sums up the reason for this, in that all trauma remains stored psychosomatically in the body:

“If we do not work on all three levels — body, feeling, mind — the symptoms of our distress will keep returning, as the body goes on repeating the story stored in its cells until it is finally listened to and understood.”

Thus until the traumatic memories of events themselves, and the feelings and beliefs associated with them, are pulled out and resolved on a visceral, psychosomatic level, then the person is likely to continue suffering symptoms of this trauma in the form of other psychological disorders. The table below summarizes how different psychological therapies approach and treat the issue of mental disorders or pathology.

 

How Different Therapies Approach Psychological Disorders

Type of TherapyViews source of psychological disturbance as:Treats With:
Psychodynamic TherapyConflicts in the conscious/subsconscious mindTalking, verbally working through conflicts and contradictions
Cognitive Behavioural Therapy (CBT)Dysfunctional beliefs and behavioursDirectly challenge and modify these beliefs; set homework tasks
EMDRUnprocessed memories stored in the body/brainAccess and process these memories using eye movements and other stimulus

How EMDR Actually Works

The actual process of EMDR works in a now well defined 8 stage process, taking the patient through the steps of drawing up a life history, accessing and resolving past trauma, and placing healthier beliefs on top of the reworked trauma. See our article on the full 8 step process of EMDR. We will quickly summarize it here.

The process usually begins with the therapist and client drawing up a detailed life history, including any deeply traumatic experiences which still in some way affect the person. These experiences will be grouped into suitable classes of experience, such as rejection, humiliation, abandonment, ridicule, invalidation, witnessing something bad, suffering violence, and so on.

Once grouped into classes then the therapist will start working with the client on the key standout experiences in each class – the most traumatic experiences which feel the most troubling to the person. The therapist uses a variety of techniques to neurologically tap the person back into these traumatic experiences, rekindling as best as possible the same feelings, emotions and physical sensations that were felt at the initial time it happened.

This may seem like a dangerous thing to do but in reality this allows the trauma itself to be properly processed and digested by the mind/brain. To do this the therapist will use a combination of some form of bilateral stimulation, usally in the form of their hand moving backwards and forwards, and sometimes other methods, to stimulate the mind of the patient to process the trauma in a way it couldn’t at the time it happened.

Quite why this use of hand movements and other forms of stimulation works so well in allowing the mind to process unpleasant trauma is still open to debate, but it is now well acknowledged that it does. The use of bilateral stimulation in the context of a structured EMDR session has been shown to be very effective in allowing traumatic memories and feelings to be fully processed and “pulled out” from the mind/brain of the person.

Patients report a vastly increased sense of well being and satisfaction from the treatment, feeling unburdened from the traumatic memories which had been until them causing them great distress. Often any offshoot symptoms resulting from this trauma, such as depression, will clear up on their own as well, since the trauma itself was driving these symptoms. The “sting” has been taken out of the memory for the client. it is now just another memory and doesn’t bother them in the same way it used to.

EMDR also has several benefits over other forms of psychotherapy, particularly in treating trauma, which make it a very effective and preferable to other forms of treatment. We will emphasize two here.

Firstly, EMDR is a very efficient form of therapy, in that there is a ripple effect to processed memories onto other similar traumatic memories. In other words, with EMDR, processing to resolution one or a few standout experiences in each class of experience (eg humiliation, abuse) will have a flow on effect to all similar experiences in that class of experience.

In other words, you don’t have to work with every single traumatic experience; you just need to work with the key standout experiences in each category and this will also have a flow on effect to all similar experiences. This makes for very efficient therapy and very strong and thorough healing in the client.

Secondly, the installation of healthier, more adaptive beliefs does take place in EMDR, but only after the trauma has been processed to resolution. For this reason the newer beliefs tend to “stick” far more easily, since you have pulled out the trauma which was providing so much resistance to change in this regard.

This is in contrast to the sometimes painfully slow process of CBT, where changing beliefs can be very hard without first resolving the trauma that is driving the beliefs. These and other benefits are described in very thorough detail below by EMDR expert Dr James Alexander in the video below.

EMDR practitioner Dr James Alexander explains the process in detail

Other Therapies

We wanted to focus on EMDR specifically in this article, since it is probably the best known and most effective therapy in dealing with trauma. To that end it is actually a recommended treatment for trauma by the World Health Organization.

However there are other forms of psychotherapy, some of which take a broadly similar approach to EMDR in the sense of dealing with it on a raw, psychosomatic level. However, they may have different specific methodologies by which the trauma is accessed and handled.

Here are a couple of other therapies which also take a “depth” approach to treating trauma and have delivered excellent results for some patients:

For those more interested in EMDR, check out our resources page for more books and videos. See also our page on finding a therapist if you feel it is something you want to pursue further.

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