Table of Contents

Goals of Trauma-Focused Therapies (CBT and EMDR).....................................1

Establish Safety and Stabilization...............................................................................................1
Process and Integrate Traumatic Memories.................................................................................1
Reduce Symptoms and Distress...................................................................................................1
Improve Emotional Regulation....................................................................................................1
Enhance Cognitive Functioning..................................................................................................2
Promote Resilience and Post-Traumatic Growth.........................................................................2
Introduction of CBT..........................................................................................3
CBT..............................................................................................................................................3
History.........................................................................................................................................3
Types of CBT...............................................................................................................................4
Trauma-Focused Cognitive Behavioral Therapy......................................................4

Cognitive Processing Therapy (CPT)...................................................................4

Prolonged Exposure Therapy (PE).......................................................................5

Trauma-Adapted CBT......................................................................................5

Hierarchy of CBT........................................................................................................................5
Exposure therapy............................................................................................5

Hierarchy.....................................................................................................................................7
Research and Case study.............................................................................................................8
Research.......................................................................................................8

Case study....................................................................................................9

Introduction of EMDR.....................................................................................10
EMDR........................................................................................................................................10
History.......................................................................................................................................10
Methods of EMDR.....................................................................................................................11
Preparation Phase.........................................................................................11
 Assessment Phase.........................................................................................11

Desensitization Phase.....................................................................................11

Processing Phases.........................................................................................11

Installation Phase..........................................................................................12

Body Scan Phase..........................................................................................12

Closure Phase..............................................................................................12

Re-evaluation Phase......................................................................................12

Additional techniques................................................................................................................12
Case study..................................................................................................................................12
Objectives..................................................................................................................................13
Method.......................................................................................................................................13
Result.........................................................................................................................................13
Conclusions................................................................................................................................13
References.....................................................................................................15
 1

Goals of Trauma-Focused Therapies (CBT and EMDR)

Establish Safety and Stabilization

The primary objective of Trauma-Focused Therapies is to establish safety and

stabilization. This initial goal involves creating a secure therapeutic environment where
individuals feel comfortable sharing their experiences. The therapist ensures the client's physical
and emotional safety, reducing feelings of danger or hypervigilance. Emotional regulation and
coping skills are enhanced to manage overwhelming emotions. Trust and a therapeutic alliance
are established, allowing clients to feel supported throughout the therapy process.

Process and Integrate Traumatic Memories

The second goal is to process and integrate traumatic memories. Clients confront and re-
experience traumatic events in a controlled environment, reducing avoidance behaviors.
Therapists help integrate traumatic memories into the client's narrative, promoting cognitive
restructuring. This process enables clients to reframe their experiences, gaining new insights and
perspectives. Through this goal, therapists aim to reduce avoidance behaviors, enhance cognitive
processing, promote emotional regulation, foster self-compassion, and integrate traumatic
memories into the client's narrative.

Reduce Symptoms and Distress

Reducing symptoms and distress is essential for improving daily functioning. Therapists
aim to decrease the frequency and intensity of PTSD symptoms, alleviate anxiety and
depression, and improve sleep quality. Enhanced daily functioning enables clients to engage in
activities and relationships previously avoided due to trauma. Strategies for achieving this goal
include teaching coping skills, enhancing emotional regulation, promoting relaxation, reducing
self-blame, and improving sleep hygiene.

Improve Emotional Regulation

Improving emotional regulation empowers clients to manage and modulate emotions.

Therapists enhance resilience and coping skills, reducing emotional dysregulation. Increased
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emotional awareness and expression enable clients to recognize and process emotions healthily.
Therapists teach emotional labeling, enhance mindfulness, foster emotional expression, promote
coping skills, and encourage self-compassion.

Enhance Cognitive Functioning

Enhancing cognitive functioning involves challenging negative thoughts and beliefs.

Therapists help reframe traumatic experiences, promoting adaptive coping strategies. Improved
self-esteem and confidence enable clients to re-engage in activities and pursue goals. Strategies
include cognitive restructuring, reframing negative self-talk, promoting problem-solving skills,
enhancing self-awareness, and fostering resilience.

Promote Resilience and Post-Traumatic Growth

Finally, promoting resilience and post-traumatic growth fosters personal growth and
empowerment. Therapists enhance sense of purpose and meaning, improve relationships and
social connections, and increase overall well-being and quality of life. Clients develop a renewed
sense of identity and direction. Therapists foster resilience, enhance self-awareness, promote
social connections, encourage purpose-driven activities, and foster post-traumatic growth
through reflection and self-discovery.
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Introduction of CBT

CBT

Cognitive behavioral therapy is a type of talking therapy which involves identifying and
challenging unhelpful thoughts. It works to help people learn alternative thinking patterns and
behaviors which can then improve the way they feel. CBT explores the relationship between
feelings, thoughts, and behaviors, and evolved from two distinct schools of psychology:
behaviorism and cognitive therapy. Its roots can be traced to these two approaches.

History

Cognitive Behavioral Therapy (CBT) has a rich history spanning over six decades. Its
roots lie in Sigmund Freud's psychoanalysis and behaviorism, which laid the groundwork for
later developments. In the 1950s, two pioneers, Aaron Beck and Albert Ellis, independently
developed cognitive-based therapies.

Aaron Beck introduced Cognitive Therapy in 1957, focusing on identifying and

challenging distorted thinking patterns. Beck's approach emphasized cognitive restructuring,
problem-solving, and coping skills. Around the same time, Albert Ellis developed Rational
Emotive Behavior Therapy (REBT), which targeted irrational thoughts and emotions. The 1970s
and 1980s saw significant advancements in CBT. Researchers like Donald Meichenbaum and
Marvin Goldfried contributed to its growth. Meichenbaum's Cognitive-Behavioral Modification
(1977) and Goldfried's Cognitive-Behavioral Therapy (1980) further refined the approach. In
1993, Marsha Linehan expanded CBT with Dialectical Behavior Therapy (DBT), incorporating
mindfulness and emotional regulation techniques. DBT addressed complex issues like borderline
personality disorder.

Modern CBT has evolved to incorporate mindfulness, acceptance, and positive

psychology principles. Mindfulness-Based Cognitive Therapy (MBCT), developed by Zindel
Segal (2002), integrates mindfulness practices with CBT. Acceptance and Commitment Therapy
(ACT), introduced by Steven Hayes (1999), focuses on values-based action.
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The digital age has transformed CBT, with online platforms, mobile apps, and virtual
reality-based therapies emerging. These innovations increase accessibility and convenience for
patients. Over six decades, CBT has evolved into a widely accepted, evidence-based treatment
for various mental health conditions, including anxiety disorders, depression, post-traumatic
stress disorder (PTSD), and substance abuse. CBT's effectiveness has been recognized by
organizations like the American Psychological Association (APA) and the National Institute of
Mental Health (NIMH). Today, CBT remains a dynamic and adaptable therapeutic approach,
continually evolving to address the complex needs of individuals seeking mental health support.

Types of CBT

Trauma-Focused Cognitive Behavioral Therapy

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a modified form of CBT

specifically designed for children and adolescents who have experienced trauma. This approach
focuses on helping clients process and integrate traumatic experiences into their narrative. TF-
CBT consists of seven components:

The first component, Psychoeducation, educates clients and caregivers about trauma,
TF-CBT, and coping skills. Emotional Regulation teaches relaxation techniques such as deep
breathing and progressive muscle relaxation. Cognitive Restructuring helps clients identify and
challenge negative thoughts related to trauma. Exposure involves gradual exposure to traumatic
memories and situations, while In Vivo Exposure focuses on exposure to situations or objects
triggering anxiety. Trauma Narrative involves creating a narrative of the traumatic event.
Finally, the Parent-Child Component enhances parenting skills and communication.

Cognitive Processing Therapy (CPT)

Cognitive Processing Therapy (CPT) is a 12-session CBT approach specifically designed

for post-traumatic stress disorder (PTSD). CPT aims to help clients process and integrate
traumatic experiences into their narrative. The therapy begins with Assessment, identifying
traumatic events and symptoms. Psychoeducation educates clients about CPT, trauma, and
cognitive processing. Identifying Stuck Points helps clients recognize negative thoughts and
emotions.
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Challenging Questions encourages clients to challenge negative thoughts and

assumptions. Cognitive Restructuring replaces negative thoughts with balanced ones. Writing
Exercises involves writing about traumatic experiences. Progress Monitoring tracks symptoms
and progress throughout the therapy.

Prolonged Exposure Therapy (PE)

Prolonged Exposure Therapy (PE) is a 10-15 session CBT approach specifically designed
for PTSD. PE aims to help clients process and integrate traumatic experiences into their
narrative. Initial Assessment identifies traumatic events and symptoms. Psychoeducation
educates clients about PE, trauma, and exposure. Imaginal Exposure involves vividly imagining
traumatic scenarios. In Vivo Exposure involves gradual exposure to situations or objects
triggering anxiety. Processing discusses emotions and thoughts after exposure. Cognitive
Restructuring challenges negative thoughts. Relaxation Techniques teach relaxation skills.

Trauma-Adapted CBT

Trauma-Adapted CBT is a modified form of CBT specifically designed for adults who
have experienced trauma. This approach focuses on establishing safety and trust. The first
component, Safety Establishment, establishes trust and safety. Mindfulness teaches mindfulness
techniques such as grounding and relaxation. Emotional Regulation enhances emotional
regulation. Cognitive Restructuring challenges negative thoughts. Trauma Narrative involves
creating a narrative of the traumatic event. Dissociation Management addresses dissociative
symptoms. Finally, Self-Care encourages self-care and stress management. These trauma-
focused CBT approaches share common goals: processing traumatic experiences, challenging
negative thoughts, and enhancing emotional regulation. Each approach tailors its techniques to
meet the unique needs of diverse client populations.

Hierarchy of CBT

Exposure therapy

Exposure therapy is a psychological treatment that was developed to help people confront
their fears. When people are fearful of something, they tend to avoid the feared objects, activities
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or situations. Although this avoidance might help reduce feelings of fear in the short term, over
the long term it can make the fear become even worse. In such situations, a psychologist might
recommend a program of exposure therapy in order to help break the pattern of avoidance and
fear. In this form of therapy, psychologists create a safe environment in which to “expose”
individuals to the things they fear and avoid. The exposure to the feared objects, activities or
situations in a safe environment helps reduce fear and decrease avoidance.

Exposure therapy has been scientifically demonstrated to be a helpful treatment or treatment

component for a range of problems, including:

1. Phobias
2. Panic Disorder
3. Social Anxiety Disorder
4. Obsessive-Compulsive Disorder
5. Posttraumatic Stress Disorder
6. Generalized Anxiety Disorder

There are several variations of exposure therapy. Your psychologist can help you determine
which strategy is best for you. These include:

In vivo exposure. Directly facing a feared object, situation or activity in real life. For
example, someone with a fear of snakes might be instructed to handle a snake, or
someone with social anxiety might be instructed to give a speech in front of an audience.

Imaginal exposure. Vividly imagining the feared object, situation or activity. For
example, someone with Posttraumatic Stress Disorder might be asked to recall and
describe his or her traumatic experience in order to reduce feelings of fear.

Virtual reality exposure. In some cases, virtual reality technology can be used when in
vivo exposure is not practical. For example, someone with a fear of flying might take a
virtual flight in the psychologist's office, using equipment that provides the sights, sounds
and smells of an airplane.
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Interoceptive exposure. Deliberately bringing on physical sensations that are harmless,

yet feared. For example, someone with Panic Disorder might be instructed to run in place
in order to make his or her heart speed up, and therefore learn that this sensation is not
dangerous.

Exposure therapy can also be paced in different ways. These include

Graded exposure. The psychologist helps the client construct an exposure fear
hierarchy, in which feared objects, activities or situations are ranked according to difficulty.
They begin with mildly or moderately difficult exposures, then progress to harder ones.

Flooding. Using the exposure fear hierarchy to begin exposure with the most difficult
tasks.

Systematic desensitization. In some cases, exposure can be combined with relaxation

exercises to make them feel more manageable and to associate the feared objects, activities or
situations with relaxation.

Hierarchy

Trauma-focused systematic desensitization is a therapeutic approach designed to help

individuals overcome traumatic experiences. This technique involves creating a hierarchy of
triggers related to the traumatic event and gradually exposing the individual to these triggers
while using relaxation techniques. To begin, specific situations, objects, or memories that trigger
anxiety or distress related to the traumatic event must be identified. For instance, consider Sarah,
who was involved in a car accident six months ago. Her triggers might include seeing a similar
car model, hearing sirens, driving near the accident location, remembering the sound of
screeching tires, or smelling gasoline or burnt rubber.

Once these triggers are identified, the individual rates the anxiety or distress level for
each trigger on a scale of 0 to 100, known as the Subjective Units of Distress Scale (SUDS)
rating. This helps determine the relative intensity of each trigger. For Sarah, seeing a similar car
model might rate at 40, hearing sirens at 60, driving near the accident location at 80,
remembering the sound of screeching tires at 90, and smelling gasoline or burnt rubber at 95.
 8

Next, the triggers are arranged in order from least to most anxiety-provoking, based on SUDS
ratings. This hierarchy guides the systematic desensitization process. For example, Sarah's
hierarchy might include:

Starting with looking at photos of similar car models, then listening to recordings of
sirens at low volume, imagining driving near the accident location, watching videos of car
accidents, driving near the accident location with a therapist, imagining the sound of screeching
tires, and finally creating a narrative of the traumatic event. With the hierarchy in place, the
individual begins systematic desensitization at the lowest level, practicing relaxation techniques
such as deep breathing or progressive muscle relaxation while focusing on staying calm. They
progress to the next level only when comfortable with the current step.

This process may require multiple sessions, but gradually, the individual should feel more
comfortable with each level, and their distress response should decrease as they move up the
hierarchy. Trauma-focused systematic desensitization relies on several key principles: gradual
exposure to trauma-related stimuli, relaxation techniques to manage anxiety, hierarchy-based
progression, individualized approach, and self-paced progression.

This therapeutic approach offers numerous benefits, including effective reduction of

trauma symptoms, enhanced sense of control and confidence, reduced anxiety and distress
responses, improved coping skills, and gradual exposure to trauma-related stimuli. However, it is
essential to note that trauma-focused systematic desensitization should only be conducted under
the guidance of a trained mental health professional, as traumatic experiences can be complex
and sensitive.

Research and Case study

Research

Trauma-focused CBT-based guided self-help (CatCBT GSH) for female victims of

domestic violence in Pakistan. Out of 60 clients who met DSM-5 criteria for post-traumatic
stress disorder (PTSD), 56 (93.3%) agreed to participate in the study. Retention to the
intervention group was excellent, with 92% (23/25) attending more than six sessions.
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Statistically significant differences were noted post-intervention in secondary outcomes in favour

of the intervention.

Case study

Treating Post Traumatic Stress Disorder with Cognitive Behavior Therapy. Death of
loved one has put MS. HG in post traumatic stress disorder (PTSD) which incapacitates her
physical, emotional, cognitive functioning for last three months after the traumatic loss. Present
research was conducted to find out the either cognitive behavior therapy (CBT) was useful for
treatment of post-traumatic stress disorder. Standardized assessment tools and clinical interview
intake were used for assessment. Depression anxiety stress scale (DASS) and post traumatic
stress symptoms Interview scale (PSSI) were used for establishing pre-post treatment
measurement.

Patient has severe level of PTSD before treatment, and after treatment her symptoms
reduce to moderate level, and were fully remitted at one-month follow-up session after receiving
trauma focused cognitive behavior therapy. Trauma focused CBT techniques trauma narration
and cognitive reprocessing techniques found effectual in treating symptoms of trauma
(nightmares, excessive worry, irritability, inability to experience positive emotion, negative
cognition about trauma). While behavioral activation helped client in improving interpersonal
relationship and overall mental health.
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Introduction of EMDR

EMDR

Eye Movement Desensitization and Reprocessing (EMDR) is a therapy that helps

individuals heal from traumatic experiences and distressing memories. It uses Dual Attention,
focusing on the memory and bilateral stimulation (eye movements, tapping, or sounds), to
reprocess traumatic memories. The Adaptive Information Processing (AIP) Model explains
EMDR's effectiveness. Traumatic experiences disrupt the brain's processing system, causing
memories to become "stuck." EMDR helps the brain integrate these memories in a more adaptive
way.

EMDR reduces PTSD and anxiety symptoms, enhances emotional regulation, improves
cognitive functioning, and increases sense of control. Recognized by the American Psychological
Association, International Society for Traumatic Stress Studies, and World Health Organization,
EMDR is an effective treatment for trauma-related disorders.

History

The history of Eye Movement Desensitization and Reprocessing (EMDR) began in 1987
when Dr. Francine Shapiro discovered the benefits of eye movements on reducing anxiety and
trauma-related distress. Shapiro, an American psychologist, observed that eye movements
seemed to alleviate her own distressing memories. This chance observation sparked a new
approach to treating trauma.

Shapiro's initial research (1989) laid the groundwork for EMDR's development. Her
findings showed that eye movements could significantly reduce post-traumatic stress disorder
(PTSD) symptoms. In the 1990s, further studies confirmed EMDR's effectiveness in treating
PTSD, trauma, and anxiety disorders.

As EMDR's efficacy became more widely recognized, international organizations took

notice. In the 2000s, the American Psychological Association (APA), World Health Organization
(WHO), and International Society for Traumatic Stress Studies (ISTSS) endorsed EMDR as an
evidence-based treatment for trauma. The APA recognized EMDR as an effective treatment for
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PTSD in 2004. The WHO included EMDR in its 2013 guidelines for stress-related conditions.
The ISTSS also acknowledged EMDR's effectiveness in treating trauma. Today, EMDR is widely
practiced globally, with thousands of trained therapists. Shapiro's discovery has transformed the
lives of millions, offering hope and healing for trauma survivors.

Methods of EMDR

Preparation Phase

The Preparation Phase is the initial stage of EMDR therapy, where the therapist lays the
groundwork for effective treatment. This phase involves conducting a thorough client history to
assess the individual's background and traumatic experiences. The therapist also obtains
informed consent, explaining the EMDR process, potential risks, and benefits. Establishing trust
and ensuring safety is crucial, creating a supportive environment for the client to process
traumatic memories. Finally, the therapist identifies specific traumatic memories to target during
therapy.

Assessment Phase

During the Assessment Phase, the therapist conducts an initial assessment to evaluate the
client's symptoms and functioning. This phase aims to understand the client's current mental
state, identifying negative cognitions and distorted thinking patterns. The therapist develops a
treatment plan, outlining specific goals and objectives tailored to the client's needs.

Desensitization Phase

The Desensitization Phase utilizes Bilateral Stimulation (BLS) to process traumatic

memories. BLS involves simultaneous stimulation of both hemispheres using eye movements,
tapping, sound, vibration, or visual aids. Dual Attention focuses on the traumatic memory while
receiving BLS, enabling the brain to reprocess traumatic experiences.

Processing Phases

The Processing Phases facilitate comprehensive trauma processing through four key
components. Imaginal exposure involves vividly imagining traumatic scenarios, while cognitive
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restructuring challenges negative thoughts. Emotional processing explores and manages

emotions, and somatic processing focuses on bodily sensations.

Installation Phase

The Installation Phase reinforces positive changes, strengthening balanced thinking and
emotional regulation. The therapist helps the client reinforce positive cognition, enhancing
emotional regulation and managing emotions.

Body Scan Phase

The Body Scan Phase promotes relaxation and awareness, reducing tension and noticing
physical sensations. Relaxation techniques, such as deep breathing or progressive muscle
relaxation, calm the body and mind.

Closure Phase

The Closure Phase ensures stability and safety, maintaining emotional stability and
reinforcing coping skills. The therapist helps the client re-establish safety, ensuring they can
manage emotions and triggers.

Re-evaluation Phase

The Reevaluation Phase assesses progress, monitoring symptoms and functioning. The
therapist adjusts the treatment plan, refining goals and objectives as needed.

Additional techniques

Trained therapists may use additional techniques to enhance EMDR effectiveness.

Resource installation enhances resilience, while future templating imagines positive future
scenarios. Cognitive interweave challenges negative thoughts, and containerization manages
overwhelming emotions.

Case study

Efficacy of Eye movement desensitization and reprocessing beyond complex post

traumatic stress disorder.
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Objectives

To demonstrate the efficacy of EMDR in complex multiple psychological trauma after

failed drug treatment from selective serotonin reuptake inhibitor (SSRI) in a diagnosed case of
post-traumatic stress disorder (PTSD).

Method

Single participant of this case study, a sitting session judge of judicial governmental
scaffold reported to this mental health tertiary care facility at his own accord with features of
intense anxiety, depression, maladjustment issues and post-traumatic stress for a duration of
several months. As a partial responder to full trial of SSRI he was enrolled for EMDR therapy to
address his symptoms of intense anxiety, panic attacks, being overwhelmingly fearful, depressed,
low self-esteem, inappropriate feelings of guilt, flashbacks, avoidance, nightmares, hyper-arousal
and inability to perform as a judicial head in active war stricken area of northern Pakistan.

Complete psychiatric evaluation was carried out and after the discontinuation of SSRIs he
was scored on Impact of Event Scale (IES). He fulfilled the diagnostic criteria for PTSD as
evaluated by the English version of the PTSD module of the Structured Clinical Interview for
DSM-I administered once before commencement of EMDR. Safe place of the client was
established and 8 staged protocol of EMDR was started with him. Multiple EMDR sessions were
conducted.

Result

The case presented in this paper had multiple psychological trauma forms and failed drug
treatment and yet it was observed that EMDR provided marked improvement in all the domains
of his deficits and this was at a prompt speed as compared to cognitive behavioural therapy
(CBT) which usually takes longer duration of therapy to achieve similar results.

Conclusions

EMDR provides marked improvement in all domains of complex mental trauma and
traumatic memories. Improvement attained was prompt and enduring as compared to other forms
 14

of established therapies and drug treatment indicating permanent changes happening at

neurobiological levels of brain.
 15

References

Cohen, J. A., Mannarino, A. P., & Perel, J. M. (2012). Trauma-focused cognitive-behavioral

therapy for posttraumatic stress disorder in children. Journal of Clinical Child &

Adolescent Psychology, 41(5), 654-665.

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for

posttraumatic stress disorder. Journal of Clinical Psychology, 73(1), 1-13.

Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of

traumatic memories. Journal of Traumatic Stress, 2(2), 199-223.

Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols,

and procedures. Guilford Press.