Aggression and Violent Behavior, Vol. 5, No. 1, pp.

79–97, 2000
Copyright  1999 Elsevier Science Ltd
Printed in the USA. All rights reserved
1359-1789/00/$–see front matter
PII S1359-1789(98)00021-4

COGNITIVE BEHAVIORAL THERAPY OF
VIOLENCE-RELATED POSTTRAUMATIC
STRESS DISORDER

Richard A. Bryant
University of New South Wales

ABSTRACT. Posttraumatic stress disorder (PTSD) represents the most common psychiat-
ric condition following exposure to violence. Although an increasing number of cognitive
behavioral therapy (CBT) studies point to efficacy of this approach in ameliorating PTSD
following violence, the methodological rigor of many studies has not been optimal. Further,
a significant proportion of traumatized individuals does not benefit from CBT. This article
reviews CBT outcome studies, discusses the methodological limitations of CBT studies for
PTSD, and offers suggestions for future research. This review highlights the need for more
systematic studies of components of CBT with a range of trauma populations to delineate
the parameters of effective CBT for individuals with PTSD.  1999 Elsevier Science Ltd.
All rights reserved.
KEY WORDS. Posttraumatic stress disorder, cognitive behavior therapy, treatment

THE PSYCHOLOGICAL SEQUELAE of assault have been well documented in recent
years (Foa & Riggs, 1995). The most common psychiatric condition to develop following
sexual and nonsexual assault is posttraumatic stress disorder (PTSD). Although this
potentially debilitating condition is reportedly common following assault, controlled stud-
ies of treatment for this disorder have only recently been conducted. The purpose of this
review is to summarize the current knowledge of cognitive behavioral treatments of PTSD,
to highlight the limitations of previous research, and to discuss the directions of future
study of treating violence-related PTSD.

DEFINITION OF PTSD
PTSD was introduced into psychiatric nomenclature in the third edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association,
1980). The definition of PTSD has undergone a number of revisions, and is currently

Correspondence should be addressed to Richard A. Bryant, School of Psychology, University of New
South Wales, NSW, 2052, Australia; E-mail: r.bryant@unsw.edu.au

79

acute stress disorder. In addition to requiring the individual to suffer reexperiencing. INCIDENCE OF PTSD FOLLOWING ASSAULT Two well-controlled studies have been conducted on the incidence and course of PTSD following assault (Riggs. 1993). inability to recall some aspect of the trauma. and dissociative amnesia. & Spiegel. Dansky. feelings. Rothbaum. or was confronted with an event or events that involve actual or threatened death or serious injury. helplessness. the ASD criteria stipulates that the individual suffers at least three of five possible dissociative symptoms. fear. Finally. irritability. & Best. Justification for the emphasis on dissociative symptoms is that they are considered predictive of longer term psychopathol- ogy (Koopman. see Bryant & Harvey. A major rationale for inclusion of ASD was that it could provide a diagnosis to identify those individuals whom subsequently develop chronic PTSD (Koopman. and provide early treatment to facili- tate recovery. hypervigilence. Classen. These symptoms may occur either at the time of the trauma or during the subsequent month. The individ- ual must also respond to this trauma with “intense. DSM-IV divides PTSD symptoms into three clusters. at this time the diagnosis of PTSD should be considered. and arousal symptoms. or heightened startle response. Cardena. These symptoms must cause marked im- pairment to one’s functioning. Kilpatrick. A. In defining a trauma. & Foa. one must initially have been exposed to a traumatic event. difficulty concentrating. 1995. & Walsh. The disorder is considered “chronic” if the symptoms persist for more than three months post- trauma. Bryant defined by DSM-IV (American Psychiatric Association.80 R. one must suffer at least three of the following symptoms: persistent avoidance of thoughts. (ASD). and that epidemiological studies indicate that violent assault represents one of the most common precipitants of PTSD (Resnick.” It should be noted that DSM-IV includes assault and exposure to violence in its examples of precipitating traumatic events. avoidance. Riggs. 1994). Acute stress disorder (ASD) is conceptually similar to PTSD and shares many of the same symptoms (for a review. and persist for at least one month after the trauma. DSM-IV also introduced a new diagnosis. Each study prospectively assessed sexual and nonsexual assault victims . & Spiegel. and acknowledges that the personal reaction to a trauma plays a crucial role in determining the development of PTSD. or psychological or physiological distress when reminded of the trauma. depersonalization. or emotional numbing. To suffer ASD one must display these symptoms at least 2 days after the trauma but after a month the diagnosis is no longer applicable. withdrawal from others and normal activities. a sense of reliving the trauma. These include numbing. The major distinction between ASD and PTSD is the former’s emphasis on dissociative symptoms. to satisfy the arousal cluster one must experience at least two of the following symptoms: insomnia. and reminders of the trauma. DSM-IV stipulates that: “the person experienced. nightmares. Foa. to describe acute trauma reactions that occur in the initial month following a trauma. reduced awareness of their surroundings. derealization. one must suffer either intrusive memories. or a threat to the physical integrity of himself or herself or others. Rothbaum. Saunders. Murdock. To satisfy the avoidance cluster of symptoms. 1995). or horror. The potential utility of the ASD diagnosis is that it provides an opportunity to identify those individuals soon after their assault who are likely to develop ongoing PTSD. To satisfy criteria for PTSD.” This second component of the stressor definition places significant emphasis on the subjective response to an event. 1992). witnessed. To satisfy the reexperiencing cluster of symptoms. Classen. 1994). 1997).

94% met criteria for PTSD approximately 1 week following the assault. however. In a prospective study of ASD following motor vehicle accidents (MVA). (1992) compared the initial responses of rape victims who either did or did not develop chronic PTSD. Specifi- cally. intrusive thoughts of the trauma. and meanings. There is significant interest in early identification of victims of assault who will develop chronic PTSD. If those individuals who are at risk of chronic PTSD individuals could be identified at an initial stage. it is proposed that symptom reduction can be achieved by satisfying two conditions. and 47% met criteria 3 months after the rape (Rothbaum et al. 65% met criteria 1 month after the assault. trauma can result in the formation of threat-oriented schema that serve to maintain a range of PTSD symptoms. 1995). Importantly. A similar pattern was observed for the victims of nonsexual assault. 1995). these studies also indicate that a significant proportion of sexual and nonsexual assault victims continues to experience chronic PTSD. 1989). Harvey and Bryant (1998) reported that 78% of MVA survivors who met criteria for ASD still suffered PTSD 6 months posttrauma. For example. In this context. 1992). one promising means to identify trauma victims who are at risk of developing longer term PTSD is the diagnosis of ASD. As noted above. Foa and Kozak (1986) adapted Lang’s (1977) theory that fear is represented in cognitive networks of mental representations of fear- related stimuli. On the basis of this theory. it is interesting to note that Rothbaum et al. perhaps early intervention could prevent the subsequent development of PTSD. The finding that many victims remit without therapy suggests that it is not appropriate to provide formal intervention to all victims of assault who display initial PTSD symptoms. in that 76% met criteria for PTSD approximately 2 weeks posttrauma. This pattern was interpreted as evidence for the need for therapy for individuals who continue to experience PTSD after the initial 6 weeks posttrauma (Foa & Riggs. the fear network must be activated and the associated erroneous beliefs need to be corrected.. Posttraumatic Stress Disorder 81 during the initial 3 months following the assault. In terms of rape victims. Considering the evidence that at least half of people who suffer PTSD symptoms shortly after a trauma remit within 3 months.. 42% met criteria one month posttrauma. this diagnosis points to exciting opportunities to treat traumatized assault victims before PTSD becomes entrenched. and distorted beliefs about trauma-related issues (Litz & Keane. It is proposed that the constant activation of fear networks in PTSD can account for hypervigilence to danger. According to Foa and Kozak (1986). These findings converge on the conclusion that at least half of assault victims who initially develop PTSD symptoms will remit within the initial three months. To date there are no studies of the incidence and course of ASD following assault. THEORETICAL ISSUES Most cognitive behavioral treatments of PTSD are related to variants of information- processing theories of trauma response. Although the ASD diagnosis has yet to be thoroughly validated with assault victims. and 22% met criteria 3 months after the assault (Riggs et al. Those victims who did suffer long-term PTSD differed from the others in their greater symptomatology soon after the trauma and their failure to make clinical gains after the initial month following the rape. responses. this diagnosis appears to be a potentially better means to identify victims of assault shortly after the trauma who will develop longer term PTSD. There is increasing evidence that persistent PTSD is associated with inadequate activation and accessibility of the fear network. one recent study demon- strated that inability to access specific memories of one’s trauma several weeks after the .

imaginal exposure has the individual imagine feared events or memories of the trauma. This procedure. (c) there is habituation because anxiety subsides over time whilst remaining in proximity to the feared stimuli. 1984). it has been proposed that exposure to feared stimuli or memories leads to symptom reduction because: (a) reminders of the trauma objectively do not harm the individual. & Dang. OUTCOME STUDIES Systematic Desensitization Some of the earliest studies to apply behavioral principles to trauma victims focused on systematic desensitization. 1998). however. and second there is learning that the exposure does not lead to renewed threat. In the context of PTSD. by which time it is assumed that habituation may have occurred. A primary rationale for exposure therapies is that maintaining the heightened state of anxiety that is experienced during proximity to the fearful stimulus will result in habitua- tion. This development has occurred because a primary target symptom in the treatment of PTSD is intrusive memories.. and typically requires the individual to master feared scenes in a hierarchically graded regime. These studies concluded that treatment led to reduced fear and improved social adjustment. because there were no control groups. and (d) the experience of anxiety does not result in the feared loss of control (Jaycox & Foa. the street on which individual was assaulted). This form of prolonged exposure typically requires the individual to maintain this focus for at least 45 minutes. The conclusions that can be drawn from these studies are limited. First. and in 75% of cases the participants voluntarily initiated in vivo exposure exer- cises. Exposure Therapies Exposure therapies may take the form of either imaginal or in vivo exposure. the focus in recent years has been on imaginal exposure. In this sense it is argued that exposure leads to improvement because of two associated. Although there are numerous case studies that have supported the use of exposure (e. PTSD measures were not employed. Whereas in vivo exposure requires the individual to remain in close proximity to actual stimuli (e. Frank and colleagues investigated the efficacy of systematic desensitization in a series of studies with female rape victims (Frank & Stewart. the rationale of exposure to traumatic memories has been extended to incorporate the modification of beliefs. there is habituation of anxiety. Bryant. 1996). but distinct. Keane & .. A.g. developed by Wolpe (1958). In these studies systematic desensitization involved imagi- nation of the traumatic scenarios combined with positive scenes. (b) recalling the trauma does not involve reliving the threat. Caution about the utility of systematic desensitiza- tion is also indicated by a report by Becker and Abel (1981) that indicated only very modest symptom reduction for rape-related anxiety.82 R. Bryant trauma predicted severity of posttraumatic stress disorder 6 months posttrauma (Harvey. couples imagina- tion of the feared stimulus with relaxation. A common treatment of traumatic memories is to direct the individual to focus attention on their memories in a way that encourages them to engage fully with the distress associated with these recollections. Participants received 14 sessions. and because a proportion of participants were treated in the acute trauma phase some improvement may be attributed to natural adjustment. Specifically. Although many treatment programs utilize these two forms of exposure interchangeably. processes.g. 1983.

Interpre- ting these results in terms of network theory. (1991) reported that at follow-up 45% of patients treated with exposure still satisfied criteria for PTSD. Fairbank. the authors claimed that whereas SIT led to short-term symptom reduction. Woods. Boudewyns. Frank et al. depression. Boude- wyns and colleagues (Boudewyns & Hyer. this review will focus on controlled outcome studies of individuals who developed PTSD following assault or violence. previous studies have often included in vivo exposure as an optional adjunct to imaginal exposure (e. Foa et al. 1982). Roth- baum. blind assessments are essential if results are to be deemed reliable indicators of the effectiveness of any treatment procedure. Hyer. however. stress inoculation training (SIT). supportive counseling. This study reported marked improvements for the exposure treatment.. As Foa and Meadows (1997) note in their criteria of gold standard practices for PTSD outcome studies. there has been a tendency in treatment studies to regard in vivo and imaginal exposure similarly. Cooper and Clum (1989) provided veterans with PTSD with either a standard treatment program (psychological/pharmaco- logical) or the standard treatment combined with imaginal flooding. This study provided participants with 9 twice-weekly sessions.. Keane. or a wait-list control group. In Vivo Versus Imaginal Exposure As noted above. This tendency appears unfortunate because there is convergent evidence that cognitive expo- . Whereas SIT resulted in greater gains than SC or wait-list control at posttreat- ment. and 44% did not achieve clinically significant gains. and reexperiencing symptoms than the control group.g. More rigorous investigation of the efficacy of exposure was conducted by Foa. a significant proportion of individuals with PTSD will require alternative approaches. Riggs. 1997). Posttraumatic Stress Disorder 83 Kaloupek. In summary. Absence of independent posttreat- ment assessment raises significant concerns over the extent to which posttreatment mea- sures may reflect expectancy bias. Foa et al. rehearsal with benign imagery. and Murdock (1991). in a later study Foa and colleagues reported that at follow-up only 75% of patients who received PE and 50% of those who received PE and SIT achieved good end-state functioning (cited in Foa & Meadows. This study randomly assigned female victims of sexual or nonsexual assault to either prolonged exposure (PE). In one of the first studies. Caddell.. Similarly. 1991) or as a spontaneous addition to imaginal exposure initiated by participants (e. & McCrame. These findings indicate that whereas PE is beneficial for many individuals. It needs to be noted. Harrison.. including greater reductions in reported fear. 1990. it must be noted that each lacked blind posttreatment assessments of outcome.g. In both studies there was greater reported improvement on general psychological functioning (specific PTSD symptoms were not reported). and Zimering (1989) randomly allocated Vietnam veterans to either flooding (imaginal exposure) or to a wait-list control group. Further. PE resulted in longer term benefits because the fear networks were activated and modified. The veterans who received imaginal flooding reported greater reductions in nightmares and anxiety. 1990) reported two studies of inpatient veterans who in addition to the regular inpatient treatment program received either direct therapeutic exposure (either imaginal or in vivo exposure) or traditional individual counseling. Exposure treatment included relaxation training. Although each of these studies point to the potential efficacy of exposure relative to more traditional treatment procedures. and imaginal exposure of traumatic memories. For example. there is increasing evidence that imaginal exposure is effective in reducing PTSD symptoms. 1988). and included blind assessments at posttreatment and 3-months follow-up. that in well-controlled studies efficacy of PE has been limited. the PE condition led to greater reduction in PTSD symptoms at follow-up.

Solomon. Brom. 1995. They . Keane et al. Bryant sure treatments may lack optimal efficacy in treating the avoidance symptoms of PTSD (Frueh. 1995). 1992a). This failure was attributed. they reported that mean symptom reduction on the SCL-90 was 40% compared to 1. and Marks (1994) found that in vivo exposure was more effective than imaginal exposure in reducing avoidance. 1989). Shalev. & Defares. Richards. and found significant decreases in avoidance behavior. there is a marked need for investigation of the role of in vivo exposure to supplement gains that may be initiated by imaginal exposure. In the context of PTSD. A. & Perry. Despite the importance of cognitive therapy in a range of anxiety and depressive disorders (Beck. Resick & Schicke.g. 1992). Hearst-Ikeda. Cognitive therapy aims to identify erroneous beliefs. and accord- ingly there is a lack of direction for the most appropriate means to reduce avoidance behavior in PTSD. 1995.84 R.5% for wait-list controls. vulnerability. Kleber. which exposed soldiers to feared stimuli. or worthlessness following a trauma (Foa & Riggs. but these designs have not allowed the differential influences of exposure and cognitive therapy to be evaluated. This project highlighted the need for exposure studies to strictly define and adhere to appropriate parameters of exposure regimes. however. (1991) included in vivo exposure as one homework activity in their PE treatment. and teaches individuals to modify their thoughts within a more realistic framework. it is proposed that people may develop exaggerated beliefs about threats. For example. One reason for this appears to be the de facto role that it often plays in imaginal exposure treatments. Turner. to inappropriate provision of in vivo exposure strategies (Bleich. This proposition has been validated by a recent study that demonstrated that individuals with ASD exagger- ated both the probability of future negative events and the negative consequences of these events more than traumatized controls (Warda & Bryant. Shoham. This study was hampered. Shaw. 1979). 1991. 1998). In an initial study of imaginal and in vivo exposure.. 1987). & Beidel. resulted in poorer outcomes than controls (Z. D. Solomon et al. & Muff. This finding is consistent with proposals that in vivo exposure is the optimal treatment for reducing avoidance behavior in anxiety states (Marks. studies that have provided in vivo desensitization to traumatized individuals have reported signifi- cant gains in terms of reduced avoidance symptomatology relative to control groups (e. Previous studies have not adequately compared the relative efficacies of imaginal and in vivo exposure treatments. & Emery.. Further. among other factors. & Kotler. 1992). The Koach project. 1992). Rush. S. Resick and Schicke (1992b) have specifically proposed cognitive processing therapy (CPT) as a structured combination of imaginal exposure and cognitive therapy that is based on five major cognitive themes that they suggest are central to rape victims’ cognitive schema. Conclusions from this study are limited. The Role of Cognitive Therapy Cognitive therapy for PTSD is based on Beck’s (1972) theory that distorted beliefs about one’s self and the world lead to heightened anxiety and depressive reactions. Accordingly. however.. Numerous studies have included cognitive therapy as an adjunct to PE (Foa. Gerrity. Lovell. Although in vivo exposure has been more extensively employed with combat-related PTSD. Foa et al. there has been relatively little systematic research on the efficacy of cognitive therapy in treating PTSD. 1993). by the lack of control groups. In an initial comparison of CPT and wait-list controls.. These authors increased this initial sample in a subsequently reported study that included 54 female rape victims (Resnick & Schicke. For example. the results have not been encouraging (Frueh et al. Solomon. by the lack of blind evaluations and specific PTSD measures. In contrast. Foa et al. 1992b). (1989) found that imaginal exposure resulted in decreased intrusive and arousal PTSD symptoms but did not reduce avoidance and numbing.

Although Wilson. they do delineate the relative contributions of exposure and cognitive therapy. & Lohr. There are both theoretical and applied issues that need to be clarified by differentiating the benefits of cognitive therapy and PE. Kleinknecht. and future work also need to identify the utility of cognitive therapy with particular types of PTSD presentation. As will be discussed below. (1988) studied 84 participants who were randomly provided with systematic desensitization or cognitive therapy. In their later study. Although this technique has been the focus of much debate (see Tolin. 1984). Tinker. and identification and chal- lenging of cognitive errors.. however. 88% of those who received CPT were not diagnosed following treatment. The latter comprised self-monitoring. there are indications that specific types of trauma survivors may be more responsive to cognitive therapy than exposure-based therapies. Montgomery. Frank et al. the groups did not differ in PTSD symptoms. systematic desensitization was investigated with cognitive therapy (Frank et al. which requires the patient to focus attention on a traumatic memory while simultaneously visually tracking the therapist’s finger as it is moved across their visual field (Shapiro. 1988. In the series of studies with female rape victims conducted by Frank and colleagues that was described earlier. 1983. & Barrett. this study was flawed by the reliance . This study concluded that there were no significant differences between participants who received either of the treatment programs. In a study that compared EMDR to a control condition. Kleinknecht. Although these two treatments were not directly compared. and Becker (1995) found that EMDR led to greater reductions in PTSD-related symptoms than a wait-list control. Frank & Stewart. 1996). Our understanding of the theoretical framework for trauma recovery could be enhanced by firmer understanding of the differential roles that habituation and cognitive restructuring play in this therapeutic process. There are currently several projects underway that are investigating the additive benefits of cognitive therapy in association with PE. Posttraumatic Stress Disorder 85 reported that whereas 96% of the sample initially met criteria for PTSD. It has been proposed by information processing theories that PE facilitates recovery because it both promotes habituation to the anxiety- laden stimuli that is not being avoided and permits cognitive restructuring as one learns that fear-based beliefs are not reality-based (Jaycox & Foa. the evidence for EMDR is mixed. 1995). 1996). Vaughan and Tarrier (1994) reported that EMDR was comparably effective in reducing PTSD symptoms to both anxiety management and repeated presentations of traumatic stimuli. From an applied perspective. Conclusions that can be drawn from this series of studies are limited. and is hindered somewhat by the presence of methodological problems in most studies conducted to date. graded task assignments that minimized avoidance behaviors. because there were no control groups and the cognitive therapy included behav- ioral components that extended beyond the domain of cognitive therapy. 1996). many case studies have attested to its success in reducing distress associated with traumatic memories (see Lohr. and that both led to clinical gains. Although these studies point to the efficacy of CPT. Jensen (1994) found that although the EMDR group reported lower SUDS (subjective units of distress) ratings than the control group. Tolin. a subsequent comparison of treatment gains indicated that the two treatments resulted in comparable benefits (Turner & Frank. In terms of controlled studies. 1981). Eye Movement Desensitization and Reprocessing One popular variant of imaginal exposure is eye movement desensitization and reprocess- ing (EMDR). there is a need to assess the extent to which traumatized individuals require active cognitive therapy to supplement PE in order to modify threat-based cognitive distortions.

86 R. and ensure independent and objective outcome measures are conducted. supportive counseling. that is. In combination. these studies are limited in their inferences about the utility of EMDR because they lack adequate methodological rigor. index expectancy factors.. Resick and colleagues compared six 2-hour sessions of either SIT. As described earlier. inadequate information concerning minimal severity for inclusion in the study. Accordingly. and that gains were maintained at 6-months follow-up on fear measures. Veronen and Kilpatrick (1982) provided 15 female rape victims who displayed persistent anxiety and avoidance symptoms 3 months posttrauma with 20 sessions of SIT. however. That is. Rothbaum (1995) has reported that in a study of rape victims EMDR obtained greater symptom reduction than a wait-list control at both posttreatment and 3-month follow-up. (1991) compared SIT with PE. It should be noted that this program modified the SIT to include in vivo exposure to avoided stimuli. breathing retaining and muscle relaxation. In a better controlled study. posttreatment results pointed to the efficacy of SIT in reducing rape-related anxiety and depression. 1988). avoidance. They found that all treatments were comparably effective at posttreatment. monitor treatment adherence. The procedural similarities between EMDR and other imaginal exposure therapies highlights the need for future studies of EMDR to compare EMDR with other exposure therapies. and these gains were largely maintained at 3-month follow-up. & Marhoefer-Dvorak. assertiveness training. and role-plays. In a subsequent study by the same authors. and none chose desensitization. its efficacy relative to more standard exposure therapies has yet to be demonstrated. More recently. A. Whereas SIT was the most effective treatment . These findings indicate that whilst EMDR has potential as a treatment for PTSD. participants were required to have been raped at least three months prior to the study and to suffer rape- related fear and anxiety. or systematic desensitization (Veronen & Kilpatrick. 3 chose peer counseling. and self-talk. Bryant on self-report data and ambiguity about pretreatment severity levels. which includes psycho- education. 1983). by the lack of control groups. In this study SIT comprised education. Jordan. Pitman and colleagues compared EMDR with EMDR minus the eye movement component with veterans suffering PTSD (Pitman et al. modeling. supportive counseling. 1996). They reported marked symptom reduction in fear. this approach addresses management of the anxiety response rather than cognitions that contribute to the anxiety. Hutter. The most common anxiety management program employed in PTSD is Meichenbaum’s (1975) stress inoculation training (SIT). thought stopping. rape victims were offered either 10 sessions of SIT. or a wait-list condition with rape victims (Resick. Inferences drawn from this study are restricted. of the 15 who accepted. 11 chose SIT. Although no comparative analyses were viable in this study. Most women declined therapy and. Efficacy of SIT with rape victims was suggested by several early studies. Foa et al. relaxation skills. and the omission of assessment of all PTSD symptoms. Anxiety Management Techniques Numerous studies have treated PTSD on the basis that it is primarily an anxiety disorder that is mediated by inadequate skills to manage the symptoms of anxiety. thought stopping. the relevance of these findings to PTSD symptoms is uncertain. and depression. and a wait-list condition with rape victims who had chronic PTSD. however. peer counseling. Girelli. The finding that both groups showed symptom reduction suggests that exposure or nonspecific therapy factors were more critical to therapy gains than eye movement itself. by the lack of strict inclusion criteria. Conclusions of this study were limited. cogni- tive restructuring.

although the CBT group was less depressed. education about psychological responses to trauma. & Basten. Bryant and colleagues have recently reported that CBT. do not utilize CBT in a structured manner. inclusion criteria and the time frame of this study may involve a possible confound in that it is difficult to exclude the role of natural recovery in participants’ responses (Kilpatrick & Calhoun. This result has been attributed to the shorter time allocated to PE and SIT in the combined treatment group relative to those who received only PE or SIT (Foa & Meadows. Specifically.. that the Foa et al. and questions concerning the degree of pathology experienced after the rape. or the active intervention. & Benjamin. these are not well-controlled studies. & Gershuny. Therapy involved imaginal reliving of the trauma. Foa and colleagues recently reported on a brief cognitive behavioral treatment program provided to sexual and nonsexual assault victims shortly after the assault (Foa. Whereas 10% of the CBT group met criteria for PTSD at 2 months. Dang. The intervention comprised a 4. PTSD severity at follow-up assessment (M 5 10 months) was reduced by 66% after PE. Each participant received four treatment sessions. Harvey. there were no differences between groups at five months. (1995). 70% of those who received supportive counseling had PTSD 6 months later. its efficacy relative to PE was diminished at 3-month follow-up. whereas CBT resulted in 10% of participants having PTSD at 6 months posttrauma. and a wait-list control condition (cited in Foa & Meadows. with matched participants who received repeated assessments. and anxiety management. This negative finding needs to be interpreted.to 6-hour treatment program aimed to prevent phobic reactions as well as other PTSD symptoms. Posttraumatic Stress Disorder 87 at posttreatment. and then received assess- ment by blind assessors at 2 months posttreatment and 5 months follow-up. however. anxiety management. was effective in treating ASD in survivors of motor vehicle and industrial accidents (Bryant. and 48% after the combined exposure and SIT program. Viney. Bunn. and have not adequately indexed PTSD symptoms. Fifteen victims were randomly assigned to repeated assessments. comprising the same components as employed by Foa et al. it is not surprising that there are few treatment studies relevant to ASD.g. This proposal needs . in press). 1985). the lack of rigorous application of exposure. and cognitive therapy. 1993. This study compared CBT. 52% after SIT. Although there are reports of crisis intervention in the initial month(s) after a trauma being beneficial (e. in vivo exposure. 1997). 1988). & Hofman. SIT. which included PE. TREATMENTS OF ACUTE STRESS DISORDER Considering that ASD was only introduced into DSM-IV in 1994. with recognition of the small sample sizes. Somewhat surprisingly. and accordingly it did not test the capacity of CBT to assist individuals who met the more stringent criteria for ASD. (1995) study did not include participants who satisfied criteria for ASD. the combina- tion of PE and SIT. It needs to recognized. Brom. 1995). Riggs. Clark. In this context. 1997). 70% of the control group met criteria. This study indicated that the brief intervention was not more effective than the repeated assessments. Kilpatrick and Veronen (1983) reported on a brief behavioral intervention that was provided to rape victims immediately after the assault. Further. These authors subsequently replicated this study in a design that compared PE. Although the study of treating ASD has only commenced. delayed assessment. cognitive restructuring. Kleber. the early indicators suggest that chronic PTSD may be prevented by providing early and brief CBT programs to those trauma survivors who are most at risk of developing chronic PTSD. however. Sackville.

Consistent with this proposal. Veronen. (b) it may contribute to excessive noncompliance with therapy because of its distressing nature. & Williams. 1975). Victims of assault frequently feel frustrated by the trauma they have suffered. Jaycox. Accordingly. Kilpatrick and colleagues (Kil- patrick. self-reported anger levels prior to treatment were conversely associated with improvement. 1984). exposure-based therapies assume that individuals will experience elevated anxiety during anxiety. Although each of these points has been countered by various authors (Foa & Meadows. however. Freshman. and facial expressions of fear. Riggs et al. may impede activation of the fear network because it reduces the level of anxiety that is experienced. & Prue. 1993). and there is currently little empirical or theoretical direction for optimal management of this presentation. These initial indications point to the need for close scrutiny of factors that predispose one to adverse reactions to PE. For example. (c) it may inappropriately reduce anxiety to nonconsensual sex. Anger Anger is a common response in PTSD (Goenjian. however. & Foa. Dissociation Activation of the fear network can also be impeded by dissociative mechanisms. Van Landingham. Bryant to be qualified. Kilpatrick. such as emotional numbing (Foa & Hearst-Ikeda. 1995). and this response will promote habituation. Similarly. 1985. Vaughan and Tarrier (1992) reported that one of their sample of seven partici- pants suffered a marked deterioration following exposure. and (d) it does not directly teach coping strategies. This is consistent with clinical experience from our current study on exposure with assault victims.. Rychtarick. 1995. rather than anger. Pitman and colleagues (Pitman et al. 1996). Egan.88 R. 1982) have criticized flooding for sexual assault survivors because: (a) in aiming to reduce anxiety it may focus on symptom change rather than modifying irrational thoughts. (1995) found that assault victims who had higher state anger levels within 2 weeks of the trauma were more likely to have higher PTSD scores one month later. & Resick. Veronen. Stafford. by recognizing the need for replication of early intervention studies with a range of trauma populations. The predominance of anger. where a small but significant number of participants experienced increased PTSD and depressive symptoms following exposure. As noted earlier. there is evidence that early intervention with bereaved individuals may not be effective (Polak. Silverman. during the initial exposure session in therapy were strongly correlated with therapeu- tic gain (Foa et al. there is some evidence that exposure-based therapies may not be appropriate for all PTSD sufferers. Further. future research needs to establish the parameters of benefi- cial early CBT following trauma. Perry. 1996.. Vandebergh. 1991) reported that they ceased a study that employed flooding because of the significant adverse effects it had upon their participants. These findings indicate that more research is required that evaluates the efficacies of components of CBT in treating PTSD patients who present with severe anger. LIMITATIONS OF COGNITIVE BEHAVIOR THERAPY Detrimental Effects of Exposure Therapies There is increasing evidence that exposure-based therapies may not only be nonbeneficial for some PTSD sufferers but may even be detrimental. A. as well as more effortful cognitive avoid- . & Best.

As discussed above. it is imperative that future studies delineate factors that contraindicate use of exposure (see Litz. Several writers have suggested that hypnosis may serve to minimize the dissociative barrier between the mental representations of the trauma and their associated affect (Spiegel & Classen. and anxiety disorders are among the common comorbid diagnoses in the PTSD population (Davidson & Fairbank. Several studies have indexed depressive symptoms. we are currently conducting a treatment study of assault victims who meet criteria for ASD in which participants receive either CBT or CBT with hypnosis. & Keane. 1993. It has been proposed that posttraumatic depression is frequently secondary to PTSD . Depression. Vaughan & Tarrier. Considering the maxim that a major goal of therapy is to do no harm.. & Metzler. there is evidence of elevated rates of personality disorders (Faustman & White.. 1998) and (b) in very severe or prolonged traumas in which dissociative reactions are more prevalent (Zatzick.. Gerardi. This proposition argues that because hypnosis involves dissociative mecha- nisms. in press. 1990). It is possible that simply activating traumatic memories in a way that heightens the individual’s sense of anxiety and helplessness may further compound the posttraumatic stress reaction. Blake. 1994). 1992) support this possibility. substance abuse. Weiss. Posttraumatic Stress Disorder 89 ance strategies (Ehlers & Steil. 1991. This problem may be more prevalent (a) in ASD than PTSD because of the stronger dissociative responses reported in this acute reaction (Harvey & Bryant. 1991). 1998). 1995). Southwick. It is proposed that exposure can retraumatize the individual because the experience is perceived as overwhelming. 1995). Foa et al. In this context it is important for better understanding of the role of cognitive therapy in exposure because successful response to exposure for individuals with maladaptive perceptions of the trauma may require cognitive therapy in conjunction with exposure. 1989. Further. Yehuda. Further research will be required to determine the utility of adapting hypnosis as an adjunct to exposure-based ther- apies.. Accordingly. 1993) among PTSD populations. there is evidence that exposure may not be successful if the individual’s memories of the trauma are characterized by mental defeat or lack of mastery over the situation (Ehlers et al. Extreme Anxiety Recent commentaries have also noted that exposure-based therapies can be impeded by a participant’s excessive anxiety (Jaycox et al.. it may represent a more effective technique than nonhypnotic strategies. Hughes. Keane & Wolfe. Davidson. and it can engage people’s attention in a very focused way. The aforementioned reports of participants who have apparently suffered increased symptoms following exposure (Pitman et al. Marmar. 1990). & Giller. the rationale for CBT of PTSD is essentially to habituate anxiety and modify threat-related cognitive schema. MEASUREMENT ISSUES Comorbidity There is strong evidence that many people who develop PTSD will also suffer comorbid disorders. relatively little attention has been directed to the influence of CBT on comorbid conditions. & Blazer. 1995). To answer this question. and found that exposure treatments have resulted in reduced depressive symptoms (Bryant et al. No treatment studies to date have investigated techniques to effectively manage this potential obstacle. Relat- edly. 1991. Most cognitive behavioral treatment studies have focused predominantly on reduction of PTSD symptoms.

1993). PE had a superior effect at follow-up. & Marmar. Solomon. 1987). 1991). Considering that many PTSD patients present with substance abuse. 1988). Foa et al. Vaughan & Tarrier. Bryant symptoms and that resolution of PTSD may lead to reduced depression (Nishith.. there is evidence that the course of PTSD can be influenced by ongoing stresses (Bryant & Harvey. Most studies include follow-up assessments of 6 months (Bryant et al. This is a surprising omission from the literature considering the increasing evidence that posttrau- matic stress and grief interact in many instances (Goenjian et al. Considering that exposure based therapies typically heighten distress and activate fear networks that include unwanted intrusions. 1995a.. 1995). Pitman et al. 1990). in press. some commentators suggest that the reexperiencing and numbing symptoms of PTSD are best understood in the context of bereavement rather than anxiety disorders (Horowitz. and it is conceptualized as a form of avoidance behavior that assists management of distressing intrusive symptoms (Keane. there is a lack of research to guide appropriate management of substance abuse in victims of assault who suffer from PTSD. Further. Further.. This pattern underscores the possibility that therapeutic techniques may mediate outcome differentially in the short-term and long-term. but there are currently no outcome studies to inform us of the merit of CBT of PTSD on major depressive episodes. For exam- ple. Z. Hearst.and 3-year follow-ups. This proposal has been demonstrated in a controlled case study (Nishith et al. Z.90 R. Similarly. Weiss.. Mueser. Substance abuse is a common posttraumatic response (Keane & Wolfe.. A. There are currently no controlled outcome studies of PTSD and bereavement... (1991) found that whereas SIT was more effective at posttreatment. Attrition Rates There is increasing recognition that exposure-based therapies can result in significant drop-out rates during treatment. 1992). Further. Considering the evidence supporting the use of cognitive therapy for managing depression (Beck et al. Kulka et al. Recent conceptualizations of bereavement have suggested that both cognitive therapy and exposure techniques may be applicable to pathological grief reactions (Kavanagh. may increase our understanding of the role of these interventions in long-term adjustment to trauma. 1979). Long-Term Outcomes A major limitation of many treatment studies is the relatively short periods of time in which follow-up assessments are completed. 1988) and the use of specific coping strategies (Bryant & Harvey. Mikulincer. & Flum. & Foa. Bereavement is a common condition in the posttraumatic reaction (Horowitz. 1990).. it is possible that this form of therapy may aggravate substance abuse. 1998. studies that have given participants a treatment choice have reported that most participants decline the opportu- . 1995). Different therapeutic inter- ventions may influence these posttrauma factors in ways that contribute to improved functioning. including 2. There is evidence that therapeutic outcomes can differ from posttreatment assessments to follow-up assessments. There is a need for controlled studies to index the utility of CBT in cases of PTSD that involve bereavement issues. 1995c. Numerous studies have alluded to the difficulties that many PTSD participants have in managing the distress elicited by exposure (Ehlers et al. 1991. future treatment studies of PTSD need to evaluate the relative contributions of exposure and cognitive therapy on comorbid depression. 1995). there is a need for outcome studies to guide the optimal management of substance abuse during exposure-based treatments. Longer term follow-up assessments. Foa et al. & Wolfe. Solomon et al.. Lyons. 1990. Gerardi. 1988).

g. Further. Studies of other anxiety disor- ders in which exposure techniques are commonly employed. 1990.. Posttraumatic Stress Disorder 91 nity to receive treatments that involve some form of exposure (Veronen & Kilpatrick. Acknowledgement of these rates. Chronic PTSD There is now strong agreement that many chronic PTSD populations are resistant to psychological treatments (for reviews. but distinct. reexperiencing symptoms) and “second generation” symp- toms (e. These reports indicate that whereas exposure may be useful for a significant propor- tion of participants who complete treatment. social dysfunction) because the long-term adjustment problems that develop . The aforementioned studies of PTSD following sexual and nonsexual assault (Riggs et al. the designs and measures used in these studies did not allow any comparison between exposure and other CBT strategies.. have noted the need for factors that minimize the efficacy of exposure to be monitored and removed. 1989). 1995.. will permit more accurate assessment of the utility of exposure in PTSD. Specifically. 1989.. 1983). Further. (1995) found different recovery rates for females and males following nonsexual assault. O’Leary. In Frueh et al. rather than restricting attention to compliant participants. it may not be sufficient for people who have developed long-term adjustment problems that have compounded their PTSD... (b) drop out of exposure treatment programs. 1996). Rothbaum et al. there is a need for treatment studies to report the proportion of participants who: (a) decline treatment because it involves exposure. 1990. 1993). this rate decreased to 21% for females and 0% for males 4 months posttrauma. 1995). Numerous studies have indicated the failure of CBT to effectively reduce PTSD in chronic veteran populations. and (c) do not comply with exposure exercises or homework. 1993) and generalized anxiety disorder (Brown.. such as obsessive compulsive disorder (Riggs & Foa. & Barlow. Cooper & Clum. Accordingly. recent approaches to treating more chronic PTSD populations have suggested that therapy separately addresses “first generation” symptoms (e.’s (1995) review of exposure-based treatment studies of combat- related PTSD (Boudewyns & Hyer. Boudewyns et al. see Frueh et al. SPECIFIC POPULATIONS In recent years there has been increasing awareness that PTSD needs to be studied in specific trauma populations. treatment studies need to take into account the specific clinical needs that are associated with different types of trauma. Pitman and colleagues have reported that exposure therapy resulted in modest reduction of PTSD (Pitman et al. Keane et al. whereas 70% of females and 50% of males satisfied PTSD criteria (excluding the duration criterion) an average of 19 days posttrauma. types of trauma. there is a need for future studies to index covert avoidance strategies that participants may use to minimize anxiety during exposure.. Riggs et al. Accordingly. There is increasing evidence that Vietnam veterans have complex comorbidity issues that may require more comprehen- sive treatment programs that extend beyond exposure to traumatic memories and specifi- cally address multifaceted adjustment issues. it was noted that whereas exposure was associated with reductions in intrusive symptoms and psychophysiological indicators.g. These authors suggested that whereas this form of therapy may be useful for individuals who have recently suffered a trauma. At this stage there appears to be justification for not generalizing findings from treatment studies of shorter term PTSD to more chronic populations. 1992) indicate that the recovery process is not identical following these related.

Children Despite the extensive literature on problems arising from childhood abuse.. There are also important developmental issues that prevent generalizing from one age group to another. it may not be appropriate to assume that exposure-based therapies will function in a similar way with childhood PTSD as it has been shown to with adults. & Lambert. In a recent review of treatment studies of abused children. There is a need to tailor and evaluate treatments for each developmental stage. There is also the need to distinguish between acute and longer term childhood traumas. there is a dearth of well-controlled treatment studies of this population (see Finkelhor & Berliner. Accordingly. Accordingly.. 1994). Finkelhor and Berliner (1995) concluded that “because enough appropriate studies have not been done. and assume that similar processes are occurring in response to the treatment. the effectiveness of sexual abuse treatment has not yet been proven” (p. and help-seeking behavior (Waterman. & Charney. In terms of PTSD. Feldman. there appears to be some critical differences in the presentation of PTSD in children and adults (McNally. For example. & Henry. For example. Cardarelli. A. one should not provide a treatment to 5-year-old and 12-year-old children who have been abused. 1987). The utility of cognitive behavior therapies are also not adequately tested in the context of childhood PTSD. Bryant in the years posttrauma require distinct therapeutic approaches (Johnson. Moreover. 1994). Horowitz. the prevalence of intrusive memories in adult PTSD may not occur as much in children (Hopkins & King. and the long-term outcomes of CBT. Williams. Sexton. 1990). & Finkelhor. this population represents a very heterogeneous group. Treatment of PTSD in traumatized children may also need to take into account the long-term effects of the trauma that may only be observed at subsequent developmental stages (Briere. 1995). 1987). & Sauzier. maternal distress (Deblinger. 1415). and apply strict experimental rigor to permit firm inferences about the components of CBT that may be effective. It would be erroneous. however. Treatment studies need to account for the role of familial influence on recovery. treatment studies of PTSD in children need to address the role of family and environment in a way that may not be as applicable with adults. Accordingly. There is evidence that the effects of childhood abuse can be strongly influenced by the family environment in which it occurred (Nash. Hulsey. Future research needs to systematically evaluate CBT in children following acute and longer term traumas. 1993) are strong predictors of recov- ery following abuse. the suitability of CBT at different developmental states. Relatedly. 1991).g. 1994). For example. to assume that a single trauma is comparable to long-term abuse suffered within the context of intrafamily abuse. A major obstacle to treatment studies in the past has been the difficulty in identifying target symptoms that are to be treated. 1993). South- wick. 1992). family cohesion (Conte & Schuerman.92 R. 1990). One study has reported that deterioration follow- ing abuse was most likely in children with fewest initial symptoms (Gomez-Schwartz. This possibility points to the need for long-term follow-up of treated children. initial evidence indicates that treatments that include parental involvement may result in different therapy outcomes than those that only treat the abused child (Deblinger. treatment studies also need to identify the timing of intervention because onset of symptoms may occur either in the acute stage or at later stages. Pynoos et al. . Recent work indicates that childhood abuse does not lead to a definitive constellation of symptoms but can result in a wide range of disorders (Kendall-Tackett. 1993). Harralson. McLeer. Much of the work that has documented PTSD in children has focused on acute traumas (e.

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