Adding Emotion Regulation to Trauma-Focused CBT for PTSD

Summary and Comment |
April 1, 2013

Adding Emotion Regulation to Trauma-Focused CBT for PTSD

  1. Deborah Cowley, MD

Training in emotion regulation lowers dropout rates and improves clinical outcomes.

  1. Deborah Cowley, MD

At least one third of patients do not respond to trauma-focused cognitive-behavioral therapy (CBT) for post-traumatic stress disorder (PTSD), leading researchers to suggest that some patients may require skills in tolerating emotion to benefit from CBT. These researchers conducted a randomized, controlled trial comparing two pretreatment approaches: emotion regulation training and supportive therapy.

The participants were 70 patients with PTSD due to motor vehicle accidents or nonsexual assault (age range, 18–65; 54% women). Therapy in both study arms consisted of 12 treatment sessions, starting with an introductory session and ending with 7 sessions of trauma-focused CBT. For sessions 2 through 5, each subject received either skills training in emotion regulation (distress tolerance, breathing retraining, and/or progressive muscle relaxation) or supportive therapy.

Completion rates were 83% in the skills/CBT group and 62% in the support/CBT group; 6-month follow-up rates were 58% and 32%, respectively. At 6-month follow-up, skills/CBT participants compared with support/CBT participants were less likely to still meet criteria for PTSD (28% vs. 50%), had lower symptom ratings, and showed lower levels of between-session distress during the exposure section of CBT.


This study is limited by high dropout rates, even in the emotion-tolerance training group. However, skills training in emotion regulation was associated with lower dropout rates, less between-session distress during exposure treatment, and better clinical outcomes. Clinicians should consider teaching emotion regulation to their patients with post-traumatic stress disorder before embarking on trauma-focused cognitive-behavioral therapy.


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