Only a minority of individuals exposed to trauma will develop PTSD.  In attempting to determine the individual risk factors for PTSD, researchers have begun to observe natural recovery from trauma. One potential difference between those who recover naturally and those who continue to experience distressing symptoms might have to do with avoidance: cognitive, emotional and behavioral.

The cognitive model suggests that the belief that the world is excessively dangerous coupled with beliefs about personal incompetence is important in the development of PTSD (Foa & Rothbaum, 1998). Following a traumatic event, such beliefs might be reinforced and therefore lead to avoidance of everyday, previously normal tasks such as grocery shopping, socializing, and traveling by car. Additionally, beliefs about the importance of maintaining strict control over distressing emotions and thoughts might also be factors mediating the development of PTSD (Ehlers & Clark, 2000).  Following a traumatic event, these beliefs might lead to attempts to avoid thoughts and memories of the traumatic event and the associated upsetting emotions.

In contrast, natural recovery from trauma might be enhanced by a willingness to return, over time, to normal activities. This behavior may strengthen beliefs about personal ability to manage difficulty, that other people are not generally dangerous, and that even extremely uncomfortable emotions are manageable.

One CBT approach for PTSD systematically and strategically recreates this recovery process by targeting the tendency to avoid feared situations and distressing recollections and emotions.  By systematically approaching the avoided stimuli, the individual can learn the same lessons as the person who recovers without intervention.  With the assistance of a skilled cognitive behavior therapist, individuals can acquire more accurate and helpful beliefs about themselves, others, and the world following the experience of a traumatic event.


Ehlers, A., & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.

Foa, E.B., & Rothbaum, B.O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York: Guilford Press.

Both David Burns (bestselling author of “Feeling Good: The New Mood Therapy“ and Abraham Low (founder of Recovery, Inc.) teach techniques to analyze negative thoughts (or identify distorted thinking — what psychologists call “cognitive distortions”) so to be able to disarm and defeat them. This is one of the major precepts of cognitive behavioral therapy.

Since Low’s language is a bit out-dated, I list below Burns’ “Ten Forms of Twisted Thinking,” (adapted from his “Feeling Good” book, a classic read) categories of dangerous ruminations, that when identified and brought into your consciousness, lose their power over you. They have been helpful in my recovery from depression and anxiety. After I identify them, I consult his 15 Ways to Untwist Your Thinking.

Depression can be hard to treat. It’s estimated that one in every 10 American adults battle with it.

Now there’s new evidence that different forms of therapy may work as well as antidepressants. Researchers reviewed 198 studies involving over 15,000 patients.

A total of seven different types of therapy were compared, including:

  1. interpersonal psychotherapy
  2. behavioral activation
  3. cognitive behavioral therapy
  4. problem solving therapy
  5. psychodynamic therapy
  6. social skills training
  7. and supportive counseling.

The data showed that all seven therapies were better at reducing symptoms of depression than usual care. Plus there were no significant differences between the various types of therapy.

As I sit across from a new client in his early thirties, who survived an assault while at college, he begins to tell me about his previous treatments.  He describes a string of therapies addressing many of the problems that followed the traumatic event, such as chronic drug use, sleep problems, depression, rage, suicidal ideation, and risky behaviors. He tells me, “The therapists were so nice, supportive and knowledgeable.  I went week after week.  I felt better at each session, but I never got better. I just figured, “there must be something wrong with me that I can’t get better.”

Clients with PTSD often present with multiple complaints and problems, as comorbidity with other psychiatric disorders is highly prevalent (79%-88.3%; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).  The therapist needs a well-formulated, efficient strategy for change to help the individual recover from PTSD and associated difficulties. The strategy should be based on a research-informed understanding of PTSD and a tailored conceptualization of the individual’s problems.  Guided by conceptualization and strategy, the therapist is better able to respond to the individual’s unique challenges, which can include extensive avoidance, shame, guilt, anger, substance use, suicidality, interpersonal disturbances, and more.  The ability to communicate this strategy to the individual can provide hope for the future and a framework for understanding an experience that feels frightening and chaotic.

Considering that survivors present with multiple, trauma-associated problems and many evidence-based therapies are available, the therapist can become overwhelmed with decisions such as where to begin therapy, which interventions to select, and how to respond when obstacles arise.  These decisions are even more difficult when coupled with the unsubstantiated opinions existing in the mental health field about the treatment of trauma and PTSD.  The use of an individualized, theoretically grounded, cognitive-behavioral conceptualization and strategy provides a guide for the therapist when planning treatment and helps the therapist maintain focus on an efficient course of treatment.

The conceptualization-driven course of therapy incorporates any of the possible presenting problems, with the goal of recovery from PTSD and a return to a meaningful life.

Aaron Brinen, PsyD
Beck Institute Adjunct Faculty
According to the cognitive model of anxiety, individuals with a vulnerability to anxiety make biased and exaggerated appraisals of possible harm and underestimate potential resources. Their inaccurate appraisals trigger fearful thinking (anxious automatic thoughts and images) which leads to anxiety symptoms. To cope with the experience of anxiety, patients employ unhelpful strategies that provide temporary relief, but also perpetuate anxiety and lead to further problems in the long-term.

The chart below lists the core cognitive content and unhelpful coping strategies associated with a number of common anxiety disorders. 

Core Cognitive Contents of Anxiety




Generalized anxiety
disorder (GAD)
Excessive apprehension about danger in a wide array of situations; intolerance of uncertainty Hypervigilance; chronic worry; avoidance of distressing mental imagery
Panic disorder Catastrophic misinterpretation of bodily/mental experiences requiring immediate intervention Hypervigilance for symptoms; overt or subtle avoidance; help-seeking

Health anxiety

Excessive fear of having a catastrophic medical problem Hypervigilance for physical symptoms

Specific phobia

Anticipated harm or disgust reaction in specific situations or upon exposure to specific object Avoidance

Social anxiety disorder

Fear of negative evaluation or humiliation in social or evaluative situations Avoidance: hyperattention to internal processes
 Obsessive compulsive disorder  Repetitive, excessive worries about potential dangers and responsibility for preventing harm Thought suppressing and/or compulsive behaviors to reduce distress
Posttraumatic stress disorder and acute stress disorder Fear of re-experiencing horror of a trauma Avoidance

Traumatic experiences are quite common, and survivors must in some way emotionally process and integrate these unwanted and painful events. Successful processing yields a realistic perspective in which the traumatic experience is in the past, reducing the person’s sense of current threat. Many trauma survivors accomplish this over time via natural mechanisms of recovery and do not require treatment. When this process is impeded or the natural processing is insufficient, posttraumatic stress disorder (PTSD), depression, and other problems frequently result.

Studies continue to show that PTSD is a common condition, with prevalence in the general US population of about 8%. Prevalence of PTSD in the active military and veteran population is even higher: Among US active duty service men and women returning from current military deployments, PTSD is estimated as high as 14-16% and among US veterans of the wars in Iraq and Afghanistan, estimates range from 4% to 17% (see Hoge et al., 2004; Richardson et al., 2010).

Given the impact of PTSD on individuals and families affected by this condition, dissemination and implementation of effective treatments is a very high priority.

Psychological treatments are aimed at helping the PTSD sufferer to process and integrate traumatic experiences. Cognitive behavioral therapies have extensive and strong empirical support and often result in remission or a decrease in the severity of PTSD, and decreased severity of depression and anxiety. All effective CBT interventions, which commonly include exposure (imaginal and in vivo), cognitive therapy, or skills training (e.g., stress inoculation; affect regulation and interpersonal effectiveness training), help the survivor to become less afraid of or threatened by trauma memories and reminders and of PTSD symptoms themselves, and to feel more competent and better able to cope. Theorists of exposure and cognitive approaches agree that treatment must in some way access or activate trauma memories, thoughts, and feelings, while providing corrective information that serves to modify the person’s unrealistic expectations of harm and danger and to reduce excessive negative emotion.

Prolonged exposure (PE; Foa, Hembree, Rothbaum, 2007) for PTSD has amassed considerable empirical support and is one of the primary treatments being rolled out by the U.S. Department of Veteran’s Affairs and the Department of Defense. While PE is a highly effective treatment, clinicians are sometimes concerned about whether it is an appropriate treatment for individuals with PTSD resulting from certain types of trauma or for those clients whose trauma narratives and current experience are dominated by emotions other than or in addition to fear: guilt, shame, anger, grief, and sadness. This is understandable – exposure-based treatments were designed for amelioration of excessive and/or unrealistic fear, not excessive guilt or anger. Experienced trauma therapists know that fear is but one of the emotional responses to trauma that are important to address in treatment. And most likely all would agree that facing trauma memories and reminders, and dealing with the feelings that result, are of prime importance.

Clinicians are also sometimes concerned that repeated revisiting of some trauma memories, particularly those associated with guilt or shame or anger about what occurred or what one did or did not do during the trauma, will be ineffective or will result in increased negative emotion. Many years of using and studying PE have yielded a rich understanding of emotional processing of traumatic memories via imaginal and in vivo exposure. Imaginal exposure – repeatedly revisiting trauma memories in imagination – and discussing and processing this experience with the therapist is a potent and efficient means of helping the PTSD sufferer to 1) fully access all of the salient information – facts, emotions, thoughts, behaviors, environment – within the trauma memory, 2) contextualize and understand his or her reactions and experience of the trauma and its aftermath, and 3) achieve a realistic perspective on the traumatic event and one’s behavior during it, as well as the impact it has had and will have in the future.

These outcomes are clearly illustrated in the case of a veteran treated with PE whose traumatic experience involved a deadly engagement with the enemy in which several of the men under his command were killed, despite his considerable and courageous efforts to lead this mission successfully and to save lives. The veteran presented for treatment about 5 years after this event with severe PTSD and depression, and he was suffering from extreme guilt and self-blame for the death of his men. In imaginal exposure he revisited the memory of that painful day in which these men under his command were killed and he was shot at while trying to render them aid. He was given a recording of this first imaginal exposure to take home and asked to listen to it daily before the next session, which he did.

During the review of his homework in the following session, the veteran reported that he had listened to the recording of his imaginal exposure frequently, as requested, and that he had done much ‘soul-searching’. He realized that he had done his job as best he could, and that if he had not done his job well, even more people would have died. Moreover, the veteran reported that thinking this over and listening to the session repeatedly had led him to accept that there was probably nothing that he could have done differently, and that he was beginning to feel a lessening of the “guilt and shame and the blame” he held on to for years after the death of his men. The veteran seemed relieved as he told his therapist that even though he had done everything in his power to bring everybody home, it was just not possible, and not up to him. He ended by saying that he was realizing through this process that he needed to try to let this go and to forgive himself.

This case is a good reminder that our powers of recovery are strong, and that when these powers have stalled or been impeded, they can be unleashed or facilitated by good, trauma-focused psychotherapy so that healing can proceed. Prolonged exposure and cognitive therapy, often primed by imaginal revisiting of the trauma memory as suggested by Ehlers and Clark (2000), are powerful and effective procedures that activate these forces and promote a reorganization of the trauma-related information that is more accurate and whole, an acceptance of what has happened, and a reduction of anxiety, guilt, anger, sadness, and other emotions that have dominated the person’s current experience, and result in reduction of PTSD and other trauma-related disorders.


Ehlers, A., & Clark, D.M. (2000). A Cognitive Model of Persistent Posttraumatic Stress Disorder. Behaviour Research and Therapy, 38, 319-345.

Foa, E. B., Hembree, E. A. & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences. New York: Oxford University Press.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.

Richardson, L. K., Frueh, B. C., & Acierno, R. (2010). Prevalence estimates of combat-related post-traumatic stress disorder: Critical review. Australian and New Zealand Journal of Psychiatry, 44, 4-19.

Elizabeth A. Hembree, PhD
Department of Psychiatry, Perelman School of Medicine
University of Pennsylvania

The messages that people in crisis send themselves become very negative and twisted, in contrast to the reality of the situation. Dilemmas that are constant and grinding wear people out, pushing their internal state of perception more and more toward negative self-talk until their cognitive sets are so negative that no amount of preaching can convince them anything positive will ever come from the situation. Their behavior soon follows this negative self-talk and begets a self-fulfilling prophecy that the situation is hopeless. At this juncture, crisis intervention becomes a job of rewiring the individual’s thoughts to more positive feedback loops by practicing and rehearsing new self-statements about the situation until the old, negative, debilitating ones are expunged. Cognitive Behavioral Therapy (CBT) seems most appropriate after the client has been stabilized and returned to an approximate state of precrisis equilibrium. Basic components of this approach are found in the rational-emotive work of Ellis (1982), the cognitive-behavioral approach of Meichenbaum (1977), and the cognitive system of Beck (1976) (James 14-15).

Xiomara A.Sosa, Clinical Mental Health-Forensic Counselor Scholar Practioner
The whole idea of negative thoughts (actually negative interpretations or expectancies contained in automatic thoughts) derives from work with depressed patients in whom extreme negative thoughts are highly dysfunctional: “I flunked the exam and that means I am a failure. . . I’ll never make it in this world. . . I might as well commit suicide.”


Above: Dr. Aaron Beck converses with
workshop trainees at Beck Institute.
The question about any given automatic thought is not entirely whether it is irrational (Albert Ellis’s term) or invalid but whether it is dysfunctional, maladaptive, counter-productive, or unhelpful (various adjectives that have been used). Depressed patients may have dozens or hundreds of negative thoughts throughout a day, some of which are true (“I don’t want to get out of bed”) and some of which, upon evaluating their validity, are found to be untrue, or largely untrue (“No one cares about me”). Most of their negative thoughts, regardless of their degree of validity, are unhelpful.   


In contrast, when people are not suffering from a psychiatric disorder and are functioning well, negative thoughts can be useful. I have found over the years that my negative self-critical thoughts have helped me to compensate for mistakes I have made, prompting me not to make the same mistakes again. Many of our negative predictions, if we do not have an anxiety disorder, can help keep us safe. Negative thoughts associated with mild anger can propel us into constructive action. So, the essence of any type of cognition, behavior, affect, or physiological response is whether it is constructive, destructive, or neutral. (Most negative thoughts are probably fleeting and not terribly relevant to an individual’s well-being.)  
Of course, there are repetitive thoughts, as in obsessions, ruminations, and some types of worry. It seems that these problems might be best addressed by some type of acceptance/meditation approach, whereas automatic thoughts might be evaluated through a more empirical/logical approach. In no event do we “challenge” negative thoughts, or any other thoughts for that matter.
Beck Institute for Cognitive Behavior Therapy 


Xiomara A. Sosa – Cognitive Behavior Therapy Developed by Dr. Aaron T. Beck, Cognitive Therapy (CT), or Cognitive Behavior Therapy (CBT), is a form of psychotherapy in which the therapist and the client work together as a team to identify and solve problems. Therapists help clients to overcome their difficulties by changing their thinking, behavior, and emotional… responses. A System of Psychotherapy Cognitive therapy is a comprehensive system of psychotherapy, and treatment is based on an elaborated and empirically supported theory of psychopathology and personality. It has been found to be effective in more than 400 outcome studies for a myriad of psychiatric disorders, including depression, anxiety disorders, eating disorders, and substance abuse, among others, and it is currently being tested for personality disorders. It has also been demonstrated to be effective as an adjunctive treatment to medication for serious mental disorders such as bipolar disorder and schizophrenia. Cognitive therapy has been extended to and studied for adolescents and children, couples, and families. Its efficacy has also been established in the treatment of certain medical disorders, such as irritable bowel syndrome, chronic fatigue syndrome, hypertension, fibromyalgia, post-myocardial infarction depression, noncardiac chest pain, cancer, diabetes, migraine, and other chronic pain disorders. In the mid-1960s, Dr. Aaron T. Beck developed cognitive therapy as a time-sensitive, structured therapy that uses an information-processing model to understand and treat psychopathological conditions. The theory is based, in part, on a phenomenological approach to psychology, as proposed by Epictetus and other Greek Stoic philosophers and more contemporary theorists such as Adler, Alexander, Horney, and Sullivan. The approach emphasizes the role of individuals’ views of themselves and their personal worlds as being central to their behavioral reactions, as espoused by Kelly, Arnold, and Lazarus. Cognitive therapy was also influenced by theorists such as Ellis, Bandura, Lewinsohn, Mahoney, and Meichenbaum. Learn more about cognitive therapy Learn about the history of CBT Get training in CBT Get updates on CBT in the Beck Institute Blog Register for a CBT wrokshop Read Dr. Judith Beck’s answers to questions about cognitive therapy for prospective patients and their families The Cognitive Model Cognitive therapy is based on a cognitive theory of psychopathology. The cognitive model describes how people’s perceptions of, or spontaneous thoughts about, situations influence their emotional, behavioral (and often physiological) reactions. Individuals’ perceptions are often distorted and dysfunctional when they are distressed. They can learn to identify and evaluate their “automatic thoughts” (spontaneously occurring verbal or imaginal cognitions), and to correct their thinking so that it more closely resembles reality. When they do so, their distress usually decreases, they are able to behave more functionally, and (especially in anxiety cases), their physiological arousal abates. Individuals also learn to identify and modify their distorted beliefs: their basic understanding of themselves, their worlds, and other people. These distorted beliefs influence their processing of information, and give rise to their distorted thoughts. Thus, the cognitive model explains individuals’ emotional, physiological, and behavioral responses as mediated by their perceptions of experience, which are influenced by their beliefs and by their characteristic ways of interacting with the world, as well as by the experiences themselves. Therapists use a gentle Socratic questioning process to help patients evaluate and respond to their automatic thoughts and beliefs—and they also teach them to engage in this evaluation process themselves. Therapists may also help patients design behavioral experiments to carry out between sessions to test cognitions that are in the form of predictions. When patients’ thoughts are valid, therapists do problem solving, evaluate patients’ conclusions, and work with them to accept their difficulties. The Goal of Cognitive Therapy The goals of cognitive therapy are to help individuals achieve a remission of their disorder and to prevent relapse. Much of the work in sessions involves aiding individuals in solving their real-life problems and teaching them to modify their distorted thinking, dysfunctional behavior, and distressing affect. Therapists plan treatment on the basis of a cognitive formulation of patients’ disorders and an ongoing individualized cognitive conceptualization of patients and their difficulties. A developmental framework is used to understand how life events and experiences led to the development of core beliefs, underlying assumptions, and coping strategies, particularly in patients with personality disorders. A strong therapeutic alliance is a key feature of cognitive therapy. Therapists are collaborative and function as a team with patients. They provide rationales and seek patients’ agreement when undertaking interventions. They make mutual decisions about how time will be spent in a session, which problems will be discussed, and which homework assignments patients believe will be helpful. They engage patients in a process of collaborative empiricism to investigate the validity of the patient’s thoughts and beliefs. Cognitive therapy is educative, and patients are taught cognitive, behavioral, and emotional-regulation skills so they can, in essence, become their own therapists. This allows cognitive therapy to be time-limited for many patients; those with straightforward cases of anxiety or unipolar depression often need only 6 to 12 sessions. Patients with personality disorders, comorbidity, or chronic or severe mental illness usually need longer courses of treatment (6 months to 1 year or more) with additional periodic booster sessions. Cognitive therapists elicit patients’ goals at the beginning of treatment. They explain their treatment plan and interventions to help patients understand how they will be able to reach their goals and feel better. At every session, they elicit and help patients solve problems that are of greatest distress. They do so through a structure that seeks to maximize efficiency, learning, and therapeutic change. Important parts of each session include a mood check, a bridge between sessions, prioritizing an agenda, discussing specific problems and teaching skills in the context of solving these problems, setting of self-help assignments, summary, and feedback. Cognitive Therapy Techniques Therapists use a wide variety of techniques to help patients change their cognitions, behavior, mood, and physiology. Techniques may be cognitive, behavioral, environmental, biological, supportive, interpersonal, or experiential. Therapists select techniques based on their ongoing conceptualization of the patient and his or her problems and their specific goals for the session. They continually ask themselves, “How can I help this patient feel better by the end of the session and how can I help the patient have a better week?” These questions also guide clinicians in planning strategy. There is no one typical client for this approach, as cognitive therapy has been demonstrated in numerous research studies to be effective for depression, anxiety disorders, substance abuse, eating disorders; for bipolar disorder and schizophrenia (as an adjunct to medication); and for a variety of medical problems with psychological components. Of course, treatment has to be varied for each disorder and therapists must not only understand the cognitive formulation of a specific disorder but also be able to conceptualize individual clients accurately and devise a treatment plan based on this formulation and conceptualization. Cognitive therapy interventions must also be adapted for older adults, children, and adolescents and for group, couples, and family treatment. Effectiveness of Cognitive Behavior Therapy In hundreds of clinical trials, CBT has been demonstrated to be an effective treatment for a wide variety of disorders. To name just a few, it has been found useful for: psychiatric disorders such as depression, the full range of anxiety disorders, eating disorders, substance abuse, personality disorders, and (along with medication) bipolar disorder and schizophrenia; medical disorders with a psychological component, including several conditions involving chronic or acute pain, chronic fatigue syndrome, pre-menstrual syndrome, colitis, sleep disorders, obesity, Gulf War syndrome, and somatoform disorders; and psychological problems such as anger, relationship difficulties, and compulsive gambling. CBT is also used to address stress, low self-esteem, grief and loss, work-related problems and problems associated with aging. » See more conditions that CBT has been used to treat Broad Application Studies have shown that CBT is effective for children and adolescents, adults, and older adults. It is used in individual, couples, family, and group formats and in a wide variety of settings, such as schools, correctional facilities, outpatient, inpatient, and partial hospitalization units.!/cognitivetherapy