Computerized Cognitive Behavioral Therapy for PTSD

Trauma & Recovery · Andreas Grivas, MSc Clinical Psychologist · June 18, 2023

Computerized Cognitive Behavioral Therapy for PTSD

Post-traumatic stress disorder (PTSD) can develop after exposure to a traumatic event such as an assault, a serious accident, combat, a disaster or the sudden loss of a loved one. In DSM-5 terms, its symptoms fall into four clusters: intrusive memories, nightmares and flashbacks; avoidance of reminders of the trauma; negative changes in thoughts and mood, such as persistent guilt, shame or the belief that the world is entirely dangerous; and heightened arousal, including irritability, hypervigilance and sleep problems. Many people experience some of these reactions in the weeks after a traumatic event and recover naturally. When symptoms persist and disrupt daily life, effective treatment is available, yet many people with PTSD face long waits or never reach a trauma specialist.

The treatments with the strongest evidence are psychological therapies with a trauma focus. A systematic review and meta-analysis of 114 randomized trials involving 8,171 participants found robust evidence for trauma-focused Cognitive Behavioral Therapy (CBT) and for Eye Movement Desensitization and Reprocessing (EMDR) (Lewis et al., 2020). Among the specific CBT protocols, Cognitive Processing Therapy, Cognitive Therapy for PTSD and Prolonged Exposure had the strongest support. These approaches help people process the traumatic memory rather than avoid it, update the frightening or self-blaming meanings attached to the event, and gradually reduce avoidance so that life can expand again. The same review also found some evidence supporting guided internet-based CBT.

Internet-based programs try to deliver these components through structured online modules, writing exercises and homework, often with a therapist who provides brief guidance by message or phone. An early meta-analysis of 20 randomized trials found that internet-based CBT produced medium to large effects on PTSD symptoms compared with passive control conditions such as waiting lists (g between 0.66 and 0.83), but was not superior to active control conditions (Kuester et al., 2016). A later review limited to people who met full diagnostic criteria for PTSD included 10 trials with 720 participants and found a clinically important reduction in symptoms compared with waiting lists (standardized mean difference -0.60), with larger effects for programs that had a trauma focus and for those that included therapist guidance (Lewis et al., 2019). However, the authors rated the quality of the evidence as very low and found insufficient data to show that improvements were maintained 3 to 6 months later.

Two more recent trials from the UK have strengthened the evidence considerably. In the RAPID trial, 196 adults with mild to moderate PTSD related to a single traumatic event were randomized to either up to 12 sessions of face-to-face trauma-focused CBT or an eight-step guided online program with up to three hours of therapist contact (Bisson et al., 2022). At 16 weeks, the online program was non-inferior to face-to-face therapy, and improvements of more than 60% in clinician-rated PTSD symptoms were maintained in both groups at one year, although the non-inferiority comparison at that point was inconclusive. The guided online format was also significantly cheaper, and the authors concluded that it should be considered a first-line option for this group.

The STOP-PTSD trial compared two therapist-assisted online treatments in 217 adults with PTSD after single or multiple traumatic events (Ehlers et al., 2023). An internet version of Cognitive Therapy for PTSD, which works directly with trauma memories and their meanings, was superior to an online stress-management program focused on coping skills (d = 0.38). Both treatments clearly outperformed a waiting list, fewer than 10% of participants dropped out of each treatment, and no serious adverse events were reported. The advantage of the trauma-focused program was greater for people with high dissociation or complex PTSD symptoms, and both treatments appeared to work by changing negative meanings of the trauma, unhelpful coping strategies and flashback memories.

Smartphone apps form a separate, lighter category. PTSD Coach, a free app offering psychoeducation and CBT-based coping tools, was tested in a randomized trial of 120 adults over three months (Kuhn et al., 2017). App users showed greater improvement in PTSD symptoms, depression and psychosocial functioning than people on a waiting list, and more of them achieved clinically significant improvement, yet the difference between groups in mean scores at the end of the study was not significant. Such apps can support self-management and help people take a first step, but they are not a substitute for trauma-focused therapy. Evidence on chatbots specifically designed for PTSD remains limited.

These findings come with important caveats. Much of the strongest evidence concerns guided programs, not fully self-guided ones, and the RAPID trial included only people with mild to moderate PTSD linked to one traumatic event. Working through trauma memories can temporarily intensify distress, which is one reason human support matters. Digital programs are generally not appropriate as the main treatment for people who are still in an unsafe situation, such as ongoing domestic violence, those with active suicidal thoughts or self-harm, severe dissociation, psychotic symptoms or serious substance misuse, or for people with complex and repeated trauma who need a carefully paced therapeutic relationship.

Consider seeking professional help if intrusive memories, nightmares, avoidance or constant tension persist for more than about a month after a traumatic event, or if they affect your work, relationships, sleep or sense of safety. A clinical psychologist or psychiatrist with trauma training can carry out an assessment and recommend a suitable trauma-focused treatment, whether face-to-face, online or blended. If you are in danger, have thoughts of ending your life or feel unable to stay safe, contact your local emergency number or a crisis line immediately rather than relying on an app.

In summary, guided, trauma-focused internet CBT has moved from a promising idea to an evidence-based option for many adults with PTSD, with results that can approach those of face-to-face therapy for mild to moderate presentations. Self-help apps may offer useful coping support, but their effects are more modest. Digital tools work best as part of a stepped, professionally supported pathway rather than as a replacement for specialist trauma care.

References

  • Bisson, J. I., Ariti, C., Cullen, K., Kitchiner, N., Lewis, C., Roberts, N. P., Simon, N., Smallman, K., Addison, K., Bell, V., Brookes-Howell, L., Cosgrove, S., Ehlers, A., Fitzsimmons, D., Foscarini-Craggs, P., Harris, S. R. S., Kelson, M., Lovell, K., McKenna, M., … Williams-Thomas, R. (2022). Guided, internet based, cognitive behavioural therapy for post-traumatic stress disorder: Pragmatic, multicentre, randomised controlled non-inferiority trial (RAPID). BMJ, 377, e069405. https://doi.org/10.1136/bmj-2021-069405
  • Ehlers, A., Wild, J., Warnock-Parkes, E., Grey, N., Murray, H., Kerr, A., Rozental, A., Thew, G., Janecka, M., Beierl, E. T., Tsiachristas, A., Perera-Salazar, R., Andersson, G., & Clark, D. M. (2023). Therapist-assisted online psychological therapies differing in trauma focus for post-traumatic stress disorder (STOP-PTSD): A UK-based, single-blind, randomised controlled trial. The Lancet Psychiatry, 10(8), 608–622. https://doi.org/10.1016/S2215-0366(23)00181-5
  • Kuester, A., Niemeyer, H., & Knaevelsrud, C. (2016). Internet-based interventions for posttraumatic stress: A meta-analysis of randomized controlled trials. Clinical Psychology Review, 43, 1–16. https://doi.org/10.1016/j.cpr.2015.11.004
  • Kuhn, E., Kanuri, N., Hoffman, J. E., Garvert, D. W., Ruzek, J. I., & Taylor, C. B. (2017). A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. Journal of Consulting and Clinical Psychology, 85(3), 267–273. https://doi.org/10.1037/ccp0000163
  • Lewis, C., Roberts, N. P., Andrew, M., Starling, E., & Bisson, J. I. (2020). Psychological therapies for post-traumatic stress disorder in adults: Systematic review and meta-analysis. European Journal of Psychotraumatology, 11(1), 1729633. https://doi.org/10.1080/20008198.2020.1729633
  • Lewis, C., Roberts, N. P., Simon, N., Bethell, A., & Bisson, J. I. (2019). Internet-delivered cognitive behavioural therapy for post-traumatic stress disorder: Systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 140(6), 508–521. https://doi.org/10.1111/acps.13079