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What Is Cognitive Behavior Therapy?


Changes or goals might involve:




Everyone experiences stress in their lives, but when an event or series of events is exceptionally stressful, it is called a trauma or traumatic experience. Those who have been directly affected as survivors, as rescue workers, or as friends or relatives of victims, as well as those who have witnessed tragedy and devastation, either firsthand or on television, may be suffering from the effects of trauma. What makes an experience traumatic are a sense of horror, utter helplessness, serious injury, or the threat of physical injury or death. Bearing witness to others’ intense suffering can be traumatic as well. When exposed to these types of experiences, a profound emotional reaction, both immediately and afterwards, is to be expected. The lives of those affected by the trauma of September 11, 2001, will be disrupted for some time. It is hard for anyone to readily return to their normal routines.

People cope with trauma in various ways, although there are some common coping strategies that are typically associated with better posttraumatic adjustment. For example, it is helpful to obtain comfort from loved ones, talk with friends and loved ones about their experience, find respite from daily demands, and engage in forms of relaxation (e.g., naps, walks, quiet time, meditation). The other thing to keep in mind is that the old adage about “time healing all wounds” is mostly correct. Intense fear, anxiety, and the pain of remembering something awful will gradually decrease over time. Surprisingly, most people are able to return to their normal routines in about a month.

A small percentage of people suffer from intense emotional or physical distress, called acute stress disorder (ASD), which typically occurs in the first month following a catastrophic event. Individuals may be suffering from posttraumatic stress disorder (PTSD) if the problems remain or become worse and if the problems go beyond 3 months.

What Is PTSD?

PTSD is a set of significantly distressing symptoms or problems tied to exposure to trauma that persist for many weeks or months after the event. Below are some of the more common symptoms of PTSD. Whenever the difficulties appear, they can disrupt lives. But help is available.

Reexperiencing: "I can’t shake the memory." Having survived the attacks on the World Trade Towers and the Pentagon, having watched it from another building or on TV, people experience the tragedy as so horrible that it feels like they cannot let go of the memory. Even worse, vivid images, sounds, or other sensations reminiscent of the trauma can interrupt or dominate their thoughts. At times, they actually feel as if the attack were happening again. These experiences are referred to as flashbacks. Other times, the survivor can’t shake the memories. Trauma-related nightmares are also common. These experiences are often accompanied by fear, tension, or anxiety in the form of a racing heart, rapid breathing, feelings of panic, and excessive sweating.

Avoidance: "I can’t be around anything that reminds me of what happened," or "I feel numb."

People may feel afraid of being in, or even going near, tall buildings, feel afraid of going on airplanes, or being around lots of people. They may feel unable to take an elevator to a high floor. Sometimes the fear related to trauma leaves people totally house-bound. Moreover, while many people try to avoid situations that remind them of the trauma, some will also try to avoid thoughts and feelings about the trauma as well as the physical reminders. People may feel unable to watch any news for fear of being reminded of the horrors of this attack and the devastation that followed. When they encounter a reminder of the trauma, they may feel extremely tense or anxious. Some people will paradoxically seek out reminders in their environment. This type of behavior does not typically make the person feel better; often these experiences will increase the fear, sadness, isolation, or anger.

Trauma involves loss. This may be the loss of life — a spouse, child, coworker, or friend — or may be the loss of safety of your routine. Grief and sadness after loss can be so overwhelming and difficult to talk about that a person can only report feeling numb. This response is not unusual. One way of adapting to horrible events is to “shut down,” emotionally protect oneself for a period, and seemingly have no feelings. Trauma survivors often feel guilt for not feeling the way they believe they “should,” or not feeling sadness or compassion for other survivors or those who died in the same traumatic event they escaped. For some, the feeling of numbness causes isolation or withdrawal from social contact. Another way that people avoid the anxiety is called dissociation, where people disengage from their surroundings. It is literally feeling as if they are not present when they really are. Occasionally, this is a feeling of being cut off from their surroundings, including the people around them. It can also be similar to “zoning out,” where the person might lose their thought or stop listening to another. In effect, the survivor’s body is present, but the mind has gone elsewhere.

Hyperarousal: "I can’t calm down."

People who have been traumatized are usually quite anxious. Although it may not be obvious, the body systems of trauma survivors may be working overtime. Their heart rate, blood pressure, and sweat response may be higher. They often have an exaggerated startle response; a sharp noise may cause them to jump, or a horn may result in a pounding heart or involuntarily ducking down or scrunching the head between the shoulders. Such people may become irritable or have a quick temper. Anger outbursts may lead to other problems, such as violence and child abuse. Some people resort to drugs or alcohol to manage the anxiety.

These behaviors, alone or in combination, may or may not be ASD or PTSD. It is normal, after all, to be profoundly affected by tragedy, and, therefore, is not necessarily a sign of a larger problem. But, if a number of problems are experienced, consultation with a mental health professional is strongly recommended to formally diagnose its presence and, more importantly, to obtain help in relieving symptoms.

Can Psychotherapy Help?

Psychotherapy can help a person gain relief from many of the symptoms mentioned above. Most therapists agree that telling one’s story is central to feeling more in control. Also, the earlier the survivor obtains help, the more likely serious problems can be averted or prevented. Behavior therapists have a practical focus with two fundamental goals: to decrease the anxiety or hyperarousal and to increase the connection the survivor has with family, friends, or the job setting (i.e., decrease avoidance). This is usually done in a gradual fashion.

Survivors are caught in a vicious cycle in which the memories and thoughts surrounding the traumatic event keep coming back. Because the survivor reacts to these with anxiety and, sometimes, horror, he or she pulls away from the thoughts and memories. The survivor never really comes to understand or process the memory, because it is always cut off before the person can make sense of it. In behavior therapy, the individual is assisted in processing the memory in ways that make it tolerable. The memory will never be a happy one, but it will no longer cause intense physiological distress.

Behavior therapists try to make the symptoms understandable to the survivor. In the context of a caring and trusted relationship with the survivor, the therapist helps the survivor reduce the symptoms by using techniques like relaxation. Sometimes the therapist will explore the survivor’s thoughts about the traumatic incident and, where appropriate, help the survivor understand when his or her beliefs about the incident are contrary to reality. Behavior therapists often teach additional skills, such as how to grieve, how to manage anger and rage, and how to socialize again, depending upon client needs. The ultimate goal is to reintegrate the survivor into his or her social structure.

Behavior therapists sometimes use techniques such as deep relaxation or hypnosis to help clients manage the fear and anxiety. Medication can be an appropriate adjunct to therapy for survivors of trauma, especially those for whom depression or anxiety is severe.

Survivors of this horrible act, and those who experienced it from a distance, whether in another building, on TV, or through the papers, need not suffer in isolation. Professional therapy, behavior therapy in particular, can provide hope and practical ways of enjoying life again after the horror of a traumatic event.


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