Cognitive-Behavioral Therapy for

Post-Traumatic Stress Disorder:

Learning to think about the unthinkable, and to move ahead.

Cory F. Newman, Ph.D., ABPP

Center for Cognitive Therapy
University of Pennsylvania, Perelman School of Medicine
Philadelphia, Pennsylvania, USA
“The study of trauma confronts one with the
best and worst in human nature.”
--- Bessel van der Kolk

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“Psychological trauma is pain compounded
by an unwillingness to experience the pain.
It not only hurts, it damages.”

“Wisdom is gained by approach, not

avoidance.”
---Hayes, Strosahl, & Wilson (1999)

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“The reason that we ruminate about events
is because we are trying not to ruminate
about them…

The mere act of thought suppression

makes the thoughts more accessible and
difficult to dislodge from our minds.”
---James Pennebaker (1995)

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5
 Today’s Teaching Points (1)
1. Core components of PTSD.
2. Constructing a narrative of the trauma(s).
3. In-vivo exposures (and other homework).
4. Imaginal exposures.
5. Cognitive restructuring (with emotion).
6. The importance of the therapeutic
relationship.
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 Today’s Teaching Points (2)
7. Modifying PTSD treatment in the context
of co-morbid problems and complications.
8. Mostly focusing on one-on-one treatment
(though I will comment briefly on group
therapy for PTSD).
9. PTSD vignettes and demonstrations.
10. Cannot cover everything (e.g., EMDR).

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DSM-V Criteria

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 Criterion A: Stressor (One is required)

 The person was exposed to death, threatened

death, actual or threatened serious injury, or actual
or threatened sexual violence, as follows:

 1) Direct exposure
 2) Witnessing, in person

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 Criterion A (continued)
 3) Indirectly, by learning that a close relative or
close friend was exposed to trauma. (If death,
must be violent or accidental).
 4) Repeated or extreme indirect exposure to
aversive details of the event, usually in the
course of professional duties.

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 What Constitutes “Trauma”?

 Originally defined as an “unusual, catastrophic

stressor.”
 **The “trauma” is partly defined by the
individual’s subjective response to it.
 In the DSM-V, “trauma” is about exposure to (or
threat of) death, serious injury, and/or sexual
violence.
 Extreme responses to trauma are not necessarily
dysfunctional or pathological, especially at or near
the time of the traumatic experience itself.
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 Different Dimensions of Trauma (1)

 In the past, vs. ongoing.

 Discrete event, vs. re-traumatization.
 In “isolation,” vs. comorbid with
diagnosable emotional disorders.
 Degree of actual loss (e.g., witnessing a
catastrophe vs. losing a loved one in a
catastrophe).

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 Different Dimensions of Trauma (2)

 Degree of personal physical injury.

 How much time exposed to the traumatic
incident as it occurred?
 Whether or not the trauma was the result of
other human(s) intentionally causing harm.
 Subjective appraisal of the traumatic event.

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 Types of Trauma
(non-exhaustive list)
 Sexual abuse / assault / rape.
 Domestic violence (childhood and adulthood).
 Transportation accident (bike, car, train, boat, plane),
including being struck.
 War (as soldier, civilian, journalist, aid worker).
 Witnessing violence (e.g., seeing someone killed).
 Industrial accident (e.g., construction collapse).
 Natural disaster.
 Severe medical illness (e.g., cancer; AIDS)
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 Suicide Risk in
Sexual Trauma Victims
 40% of rape victims have contemplated
suicide.
 17% of rape victims have actually
attempted suicide since the rape.
 Exposure interventions and active
suicidality are a very risky combination.
-- data from P. Resick

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Criterion B: Intrusion (1 required)
1) Recurrent, involuntary and intrusive memories.
2) Traumatic nightmares.
3) Dissociative reactions (flashbacks*).
4) Intense prolonged distress after exposure to
reminders.
5) Marked physiological reactivity.
Note: Physical pain resulting from trauma is also an
“intrusion” which can worsen PTSD symptoms.

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 Flashbacks vs. Intentional Recall

 Flashbacks are involuntary, and consist

mainly of sensory impressions, rather than
thoughts. They feel as if they are being
experienced in the here-and-now.
 Intentional recall is voluntary, involves
appraising the memory, and integrates the
memory into its appropriate context. “You
control the memory.”
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Are Flashbacks per se Problematic?

 Flashbacks are subjectively distressing.

 Sufferers may begin to develop an ever-
broadening array of avoidance tactics.
 The results of the avoidance may be to interrupt
the potentially necessary cognitive processing and
integrating that intrusive memories may achieve.
 Thus, the flashbacks come to be all pain and no
gain for the trauma sufferers.

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 Problems with Dissociation

 Creates emotional distance between self and

others. Communication is impeded.
 Prevents putting the traumatic experiences
in a more complete context.
 Does not improve the patient’s sense of
long-term self-efficacy or actual safety.
 There is no such thing as “local emotional
anesthesia.” It is always GENERAL.
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Dissociation: An Adaptational View.

According to van der Kolk (1996),

dissociative symptoms may reflect the
body’s release of endogenous opioids.

This reaction may be interpreted as an

adaptive evolutionary response that permits
management of pain during times of threat.
(But what if it goes on and on?)
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 Criterion C: Avoidance (1 required)

 Persistent effortful avoidance of trauma-

related stimuli:

 1) Thoughts and feelings.

 2) External reminders (people, places,

conversations, activities, situations, etc.)
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 Criterion D: Negative alterations in
cognition and mood (2 required)
1) Inability to recall key features of the event.
2) Persistent negative beliefs about oneself.
3) Persistent distorted blame (self or others).
4) Persistent negative emotions.
5) Markedly diminished activities.
6) Feeling alienated from others.
7) Constricted affect.
In general, joy, humor and connectedness are muted.
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 Criterion E: Alterations in arousal and
reactivity (2 required)
1. Irritable or aggressive behavior.
2. Self-destructive or reckless behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Concentration problems.
6. Sleep disturbance.

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 “Re-enactment” phenomena

1. Causing harm to others (the abused

becomes an abuser).

2. Self-destructiveness.

3. Re-victimization (of the self).

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 Duration of the disturbance is more than
one month, and causes significant distress
or impairment in important areas of
functioning.
 Specifier: With dissociative symptoms.
 Specifier: With delayed expression (full
diagnosis is not met).

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 Frequent Co-morbidity (1)

 Major Depression: 48% lifetime prevalence

 Alcohol misuse/dependence:
– In men, 52% lifetime prevalence.
– In women, 28% lifetime prevalence.
 Other drug misuse/dependence:
– In men, 35% lifetime prevalence.
– In women, 27% lifetime prevalence.

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 Frequent Co-morbidity (2)

 Disorders such as Generalized Anxiety

Disorder, Obsessive-Compulsive Disorder,
Major Depression, and Borderline
Personality Disorder can co-exist with
PTSD.
 Treatment for PTSD has been shown to
diminish symptoms of the disorders that are
co-morbid with PTSD.
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 Frequent Co-morbidity (3)

 “Self-medicating,” self-harming, numbing.

 Grief.
 Feelings of “going crazy.”
 Shame and guilt.
 Poor self-image.
 Relationship strain; problems with emotional
and/or sexual intimacy.

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 Alternative Views of PTSD

PTSD can also be conceptualized as a “normal”

reaction to abnormal circumstances, extending in
time and scope beyond its usefulness.
Some of the apparent psychological symptoms
seen in patients after they have experienced
trauma may in fact be medical symptoms, such as
the after-effects of head trauma. (But traumatic
brain injury can also co-exist with PTSD).

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Interventions

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Immediately After a Traumatic Event

Sometimes “less is more.”

We may need to provide only emotional

support and practical assistance, and
sometimes even the emotional support isn’t
the most important part.

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 Timing of the Intervention

According to Bryant & Harvey (2000), formal

treatment (including exposure, cognitive
restructuring, reliving, etc.) should probably not
begin until at least two weeks after a trauma.

The rationale is to give the patients the chance

to mobilize their own resources, and to separate
out the practical issues from the psychological.

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 Some Assessment Measures

 Impact of Event Scale (IES): (Horowitz,

Wilner, & Alvarez, 1979) – probably the
most popular index of the intrusive and
avoidance symptoms of PTSD.
 Post-Traumatic Cognitions Inventory
(PTCI): (Foa, Ehlers, Clark, Tollin, &
Orsillo, 1998). – indexes negative
cognitions about self, world, and blame.
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 Assessing Problematic Strategies

Ask the patients,

 “How are trying to live your life in spite of [the
traumatic event]?
 What do you think are the best ways to cope with
the trauma?
 How do you deal with the intrusions/nightmares?
 What do you now avoid?
 What do you think will happen if you let yourself
think about the trauma or feel upset about it?

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 The Therapeutic Relationship (1)

 We are bearing witness to our patients’

most extreme and emotionally painful
experiences. We must be reverential.
 We want to give our patients the best care
possible, but we also must give them a
sense of control over their own care.

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 The Therapeutic Relationship (2)

 Providing a thoughtful rationale for the

treatment procedures is vitally important.
 Treatment is not “all-or-none.” Sometimes
we are negotiating the “dosage” of our
cognitive-behavioral methods.
 “I want to give you the highest dose of CBT
that you can safely tolerate.”

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 The Therapeutic Relationship (3)

 Therapy homework is one of the “curative

factors” of treatment. Therefore, we must
value it and promote it.
 Nonetheless, if the patients do not do the
homework, we cannot be judgmental, or
make the snap decision that the patient
“isn’t ready” for treatment or “doesn’t
really want to get well.”
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 The Therapeutic Relationship (4)

 Accurate empathy requires really knowing

the details of your patient’s life, and his or
her traumas.
 At the same time, it is an exquisite act of
empathy to respect the patient’s privacy,
even if that means that you aren’t getting all
the information you need.

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What do we do if our patient who
suffers from PTSD cannot or does not
wish to discuss or process his or her
trauma experience(s)?

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 Treat the co-morbid problems (e.g., mood
disorder; panic disorder; substance misuse).
 Focus on teaching general psychological
coping skills (e.g., problem-solving,
communication, rational responding).
 Facilitate patients’ self-care (e.g., medical,
dental, physical fitness, eating, household).
 Utilize adjuncts such as yoga; meditation.
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 Interviewing Traumatized Patients
(important considerations – 1.)
 Acknowledge the patient’s worst fears in an
environment of sensitivity, safety, and trust.
 Be mindful that we (as clinicians) are asking
patients to take what must seem to them to be an
enormous risk in facing the interview questions
(and thus, not avoiding).
 Be prepared to ease up and back off a little.
 Let us not add to the patient’s stress with a less-
than-sensitive assesment!

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 Interviewing Traumatized Patients
(important considerations – 2.)

 A full description of the patient’s traumatic

experiences is NOT required in the first
session (or even the first session following a
formal assessment).
 The first session needs to be about
establishing trust, safety, and a clear
rationale about a treatment plan.

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 Cognitive Model* of PTSD:
Key Factors (1)

 PTSD becomes persistent when individuals

process trauma in a way that leads to a sense of
serious, current threat.
 The above involves excessively negative
appraisals of the trauma and its sequelae.
 PTSD involves poor autobiographical recall, poor
elaboration, and poor contextualization, but strong
associations and perceptual priming.
*Ehlers, A., & Clark, D.M. (1999). A cognitive model of posttraumatic stress
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disorder. BEHAVIOUR RESEARCH AND THERAPY, 38, 319-345
 Cognitive Model of PTSD:
Key Factors (2)
 Generalization of subjective sense of threat
leads to hyperarousal, hypervigilance, and
exhaustion.
 The person’s own physiology becomes a
source of fear.
 Therapeutic changes in the above are
hampered by the patient’s avoidance.

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 Cognitive Model of PTSD:
Key Factors (3)

 Poor recall for positive memories.

 Impaired ability to draw upon past

experiences in order to problem-solve
current difficulties.

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 Heightened Appraisal of Threat

 Sense of serious, current threat.

 External threat (e.g., the world is a
dangerous place).
 Internal threat (e.g., “I am not capable of
protecting myself.” “I’ll never get over
this.” “I’m dead inside.” “I am permanently
damaged”).
 Thought suppression makes it worse.

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 Interpretations that Create
Self-Blame
 Survivor guilt (“Why did I live?) Try to convert
into “survivor pride.” (Similarly, think in terms of
“post-traumatic GROWTH”).
 Shame over actions not taken (I should have done
something). Requires a realistic re-appraisal.
 Assuming that other people are judgmental against
the patient, and that it is “deserved.”

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 Maladaptive Attempts to
“Control” the Threat (1)
 Thought suppression: Actually results in an
increase in intrusive experiences.
 Symptom “swapping”: (e.g., go to bed late
to avoid nightmares, wind up feeling more
irritable and alienated from others by day).
 Safety behaviors: Hypervigilance prevents
disconfirmation of the belief that the safety
behavior is necessary to prevent disaster.

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 Maladaptive Attempts to
“Control” the Threat (2)

 Self-medication: Use of alcohol and other drugs

exacerbates the fear of losing control in response
to strong feelings.
 Giving up old activities: May reduce some
“stress” but worsens a sense of having been
changed or damaged by the trauma.
 Dissociation: Numbing and “blanking” prevent
integration of the memory into its proper context.

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Common Belief About Processing
the Traumatic Memories

“I should not have to be exposed any further

to the memories of my trauma. After all, I
constantly think about, talk about, and
envision the trauma, and it never helps me
feel any better.”

Clinical Response: We must evaluate and

change the ways you process the memories.
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 Three Major Treatment Goals
1. To reduce intrusive re-experiencing, the trauma memory
needs to be elaborated and integrated into the individual’s
preceding and subsequent experience (the full “lifeline”
and narrative).
2. Problematic appraisals of the trauma and/or its sequelae
must be reappraised.
3. Dysfunctional strategies that prevent memory elaboration
and impede the reevaluation of problematic beliefs must
be dropped (i.e., reduce avoidance strategies).

See:
Rothbaum, B., Foa, E., & Hembree, E. (2007).
RECLAIMING YOUR LIFE FROM A TRAUMATIC
EXPERIENCE. Oxford University Press. 51
 Rationale for Treatment (Overall)

 Explain that the PTSD symptoms of intrusions,

numbing, hyperarousal, etc. are common reactions
to an abnormal event.
 Their typical efforts to cope may be useful for
milder stressors, but may actually unwittingly
make things worse in the case of extreme stressors
such as trauma.
 A key element of treatment will involve thinking
about the trauma and discussing it in detail.
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 Educating the Patient
(about the recovery process)

 Intrusive ideation is the brain’s attempt to

assimilate the traumatic experience, and to
make sense of it.
 Denial and numbing are ways the mind
takes a “time out” from the stress.
– The “wisdom of the body.”
– “Denial is one of nature’s small mercies.”
 The patient has NOT become crazy.
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 Rationale for Exposures
(to memories, activities, narratives)
 “When you avoid, you deny yourself the chance to
process your experiences and heal.”
 When explaining avoidance, engage the patients
by asking them to describe their own avoidance
behaviors.
 To focus on hopefulness and strength, ask the
patients to recall and describe a time when they
overcame something they feared and avoided.
Foa, E., Hembree, E., & Rothbaum, B. (2007).
PROLONGED EXPOSURE THERAPY FOR PTSD.
Oxford Univ.ersityPress. 54
 Rationale for Exposures
(to memories, activities, narratives)
 By writing, talking, (and doing artwork) about the
trauma, patients convert the seemingly random,
senseless reliving of the past to a meaningful,
controllable portion of one’s biographical
narrative.

 High emotionality is needed in order to fully

process the traumatic memory and its related,
problematic meaning structures.

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 Rationale for Exposures
(to memories, activities, narratives)
“Exposures” include:
 Written narratives, with ever greater detail,
and interpretative commentary.
 In-vivo activities associated with the
trauma, or with a past sense of self.
 Imagery and description of the trauma, in
the present tense, first person. (Also,
imagery re-scriptings).
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 Rationale for Exposures
(to memories, activities, narratives)
 Ultimately experience a decrease in
anxiety.
 Begin to distinguish safe vs. unsafe
situations.
 Increase self-confidence.
 Improve quality of life by increasing
activities, capabilities, and connections.

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 Emotional Processing
 See Foa & Kozak (1985; 1986)
 Treatment must activate the fear in order to
modify the experience and the meanings.
 When patients confront trauma reminders
and they remain safe, new adaptive learning
can take place.
 Fear decreases; self-efficacy increases.

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Merely reliving memories is not enough.
They need to be modified and transformed.
Some new information that is incompatible
with the rigid, harmful beliefs associated
with the traumatic memory must be
introduced.

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“At the end of treatment the patient will be
able to recall the negative experience, but
with a new understanding of the meaning of
the experience, perhaps the knowledge that
they survived, that they coped with it as best
they could, or that it wasn’t their fault.”

J. Wheatley & A. Hackmann (2011)

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 The “SUDS”
 “Subjective Units of Distress Scale”
 Ranges from 0 to 100.
 Develop a list of avoided situations and ask
patient to rate SUDS on each.
 Arrange the situations in a hierarchy
according to SUDS.

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Video Demonstration:
Orienting the patient to treatment and
presenting the rationale.

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 Participant Role-Play:
Presenting the rationale for treatment
(to a patient who is apprehensive).

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 Key Points in the Role-Play
 Goal: Improve your ability to live your life more fully in
spite of the trauma.
 “Forgetting and avoiding is not healing.” Strive for growth.
 Therefore, exposures are needed (gradually, with support
and with new learning).
 Think, talk, and write about the trauma. Imagine the
trauma. Change the narrative to be more compassionate.
Put the trauma in its place. Your life is bigger than that.
 The trauma does not define your identity.
 (Also see slide 34 for key assessment questions.)

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 Intervention Caveats (1)

According to Meichenbaum (Stress-

Inoculation Training paradigm), it is vital to
build up the patient’s anxiety management
skills as part of the process of reliving and
reconstruing the trauma.

However, be aware of “paradoxical”

reactions to relaxation in some patients.

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 Anxiety reduction (physiological)

 Relaxation training: Especially if patients

are highly anxious at the outset of therapy.

 Controlled breathing: For sense of control

over one’s arousal level, and for increased
mindfulness.

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 Intervention Caveats (2)

Be very careful about providing exposure

therapy to PTSD patients if they are actively
engaging in alcohol and other drug misuse.
Both problems CAN be helped
simultaneously, but they can just as easily
be WORSENED.

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 Intervention Caveats (3)

 The patient may dissociate in session. If this

happens, take a step back; offer support.
 Later, the therapist can try to ask the patient to
describe other people’s responses to the same
trauma (as a “shaping” intervention).
 Later still, ask the patient to magine a non-
traumatic but highly emotional situation, and then
switch over to the traumatic memory while in that
state.
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 Intervention Caveats (4)
Beware the “recovered memory”

 Memory, especially childhood memory, is fallible,

but not necessarily incorrect.
 Documented traumatic events are sometimes
forgotten.
 Forgotten memories of documented traumatic
events are sometimes recovered.
 Amnesia can co-exist with vivid recollections.
Thus, listen well, but do not suggest casually.

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 The Written “Narrative”

Writing about the traumatic events…

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 The Written “Narrative”
 Begins the process of habituation.
 Allows the patient to slow down and
organize the process of remembering the
trauma(s).
 Provokes the emergence of more details.
 Fleshes out personal meanings.
 Helps the therapist to “bear witness.”
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 The Written “Narrative”
 Is usually written for homework, and read
aloud and processed in session.
 An early assignment can be construed as an
“impact statement” (e.g., “spoken” to a
perpetrator).
 With each new assignment, the narrative is
“filled out” with new details.
 Over time, the patient feels stronger.
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 The Written “Narrative”
 Is not just a factual recounting of the
event(s) (though it may begin like that).
 It involves describing thoughts, feelings,
and sensations (e.g., tactile, olfactory).
 Does not have to be done in one sitting
(breaks are okay, as long as the patient
comes back to it and does not avoid).

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 Writing about the trauma
 See Resick’s Cognitive Processing Therapy.
 The writing is repeated. Successive
iterations provide more detail.
 The writing is done for homework, and read
and processed in session.
 Addresses topics such as safety, trust,
intimacy, power, and control.

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 The Written “Narrative”
 With cognitive restructuring:
– Write a detailed account of the event (in
tolerable doses of awareness).
– Offer support during the process.
– Spot the inherent negative appraisals within the
text (looking for signs of self-blame,
helplessness, and hopelessness).

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 Typical Problematic Beliefs
(targets for cognitive restructuring)

 “I could have (should have) done something

to prevent or interrupt (the traumatic event).
It’s my fault.”
 “I will never sleep (relax, laugh) again.”
 “Others can never understand, and therefore
I will always feel separated from others.”
 “I will be haunted forever.”

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 Typical Problematic Beliefs
(targets for cognitive restructuring)

 “I can never trust anyone again.”

 “I will never be able to trust myself again.”
 “I will never be able to forgive.”
 “I cannot let others get close to me because
I will only hurt them.”
 “My former self is gone forever.”
 “Everything I believed in is destroyed.”
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 Encourage the patient to write a:

Narrative of Coping.
 Compose a “rainy day” letter to self. Mention:
 The skills that are intact and even improved.
 Relationships that are still strong.
 Future goals and “missions.”

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 Physiological Benefits of
Reliving and Emotional Disclosure

According to Pennebaker (1995), in the lab,

talking and writing about one’s traumatic
experiences leads to…

Blood pressure, muscle tension, GSR.

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Video Demonstration

80
 Flashbacks: Treatment Objectives

 Accept and integrate the experience embedded in

the flashback.
 Learn to moderate reactions to flashbacks, so as to
disempower them.
 Learn to create the memory voluntarily, rather
than being surprised by involuntary flashbacks.
 Modify the personal meanings involved.
 Flashbacks cannot be eliminated entirely.

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 Clinical responses to flashbacks

 Identify triggers of intrusive memories and

emotions:
– Enhance discrimination between stimuli that
occurred with the trauma and those encountered
at present.
– Examine similarities and differences between
trauma stimuli and current stimuli in great
detail.
– Anniversary phenomenon.

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 Clinical responses to flashbacks

 Take “data” on the flashbacks (objectify them and study

them, rather than fear them)
– When? Where? With whom? For how long? Triggers?
– Associated thoughts and feelings about the flashback.
 Getting “grounded. When the flashback occurs:
– Focus on one’s actual surroundings.
– “Narrate” one’s current activities and experience.
– Use an associational cue (e.g., key word, phrase, tune).
– Utilize a “safe place,” either externally or internally.

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 Flashbacks regarding sexual trauma
(during consensual sex)

 Open eyes and orient to person, place, time.

 Notice differences between current love
partner and the perpetrator of the assault.
 Focus on a symbol for comfort and security.
 Stop attempting to respond sexually until
the flashback is over. Inform partner.
 Ask partner to offer mutually agreed-upon,
reassuring words.
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 What Is the “Right” Amount of
Exposure?
Ideally, the exposure (e.g., writing about the
trauma, imagining the trauma, going to the
site of the trauma) should continue until the
patient’s fear has peaked and is subsiding.
This will bring about habituation with
repetitions*. Stopping too soon may
reinforce the sense of helplessness.

*Habituation does not have to occur

in any given exposure in order for 85
exposures to be effective over time.
 Why does exposure work?
Hypotheses:

 Connects previously fragmented parts of the

trauma memory (reduces the likelihood that
isolated parts of the memory will be triggered).
 Facilitates retrieval of elements of the memory
that are difficult to access.
 Facilitates discrimination between “then and
“now.”
 Verbal recall may become more dominant than
sensory recall.
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 Exposure: The Need for Repetitions

 Repetitions (of the writing, reading,

restructuring, etc.) facilitate habituation.
 Some patients will not or cannot recall all
the salient aspects of the traumatic
memories the first or second time around.
 Some patient cannot tolerate the “whole
truth” the first of second time around.

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 Items on the In-Vivo Hierarchy (1)
 Activities that are reminders of the trauma.
 Situations anticipated to cause distress, even
though they are benign for the non-sufferer (sense
of threat is over-generalized for the patient).
 The site of the trauma itself.
 Sensory triggers (feelings, sounds, sights, smells).

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 Items on the In-Vivo Hierarchy
(Positive activities!)

 Activities for increased sense of

accomplishment and enjoyment (similar to
intervention in CBT for depression).
 Activities that increase social interaction
and support (can include support group).
 Activities that represent the healthy patient.

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 Implementing In-Vivo Exposure

 Present the rationale.

 Provide examples.
 Re-introduce the SUDS.
 Create in-vivo hierarchy.
 Assign homework, starting in 50-70 range.
 Repeat multiple times to reduce SUDS.

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 Sample items on In-Vivo Hierarchy
(for an adult rape survivor)

Behavior SUDS at start SUDS after exposures

Running errands alone. 50 10
Going out at night with 55 5
friends.
Having a conversation 65 30
one-on-one with a man.
Writing a mock letter 75 20
(“impact statement”) to
the perpetrator.
Going out on a date. 90 (not yet done)
Hugging a man. 90 (not yet done)
Being sexually intimate. 100 (not yet done)
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 Tips on In-Vivo Exposure (1)
 Specificity helps.
 For example, don’t just say, “Go to a place
your have been avoiding.” Instead, generate an
item such as, “For homework, you will meet
your friend Alice for lunch, in town” (near
where she had been mugged late at night).
 The exposure should be perceived as
“dangerous,” but not actually dangerous.

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 Tips on In-Vivo Exposure (2)
 The best in-vivo exposures naturally address
the patient’s negative beliefs (e.g., about being
“capable” of driving in a car again; about
being able to sleep safely without the light
and/or television on).
 If the patient has difficulties with the in-vivo
exposures, break the target behaviors into
smaller, more manageable chunks.

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 Tips on In-Vivo Exposure (3)
 Be aware of “safety behaviors” and “safety
people” reducing the patient’s acquisition of
self-efficacy in the exposures.
 The patients may attribute their ability to do
the target behavior because a given person
was with them, or because they did
something ritualistic (superstitious).
 Be humanistic/empathic about this.
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 Tips on In-Vivo Exposure (4)
 The “safety person” can be construed as a
“coach.”
 The “coach” is systematically involved less
and less with each in-vivo exposure.
 For example, “coach” accompanies patient
to a feared location at first; then the “coach”
only talks to the patient by phone; then the
“coach” is available for support afterward.
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Participant Role-Play:
Helping the patient to construct
an in-vivo exposure list.

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 Key Points
 Teach the patients about SUDS ratings.
 The in-vivo exposures should ideally produce
middle-range SUDS (e.g., near 50) at first. Fear
needs to be activated for learning to take place, but
not too much.
 You will go up the scale over time.
 The exposures should improve the patient’s life.
(increase self-efficacy; enrich experiences).

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 Rationale for Imaginal Exposure

 Safely revisit the trauma (voluntarily), using

imagination.
 Contrast the above with the patient’s involuntary
re-experiencing symptoms.
 Re-iterate that trying to push away the memories
maintains the PTSD.
 The symptoms are a sign that “unfinished
business” needs to be addressed.

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 Rationale for Imaginal Exposure
 Process and organize the memories, and put them
in their specific place in the narrative of your life,
which involves so much more.
 Access fear and related cognitions (for change).
 Learn that the memories themselves are not
dangerous, and discomfort can be tolerated.
 Habituate to the memories.
 Be in charge of the memories, instead of the
memories being in charge of you.
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“Our sense of self and our memories are
closely intertwined (Stopa, 2009), and so
working on key memories may lead to
reappraisals of negative or traumatic
experiences that can result in fundamental
shifts in how patients see themselves”

J. Wheatley & A. Hackmann (2011)

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Implementing Imaginal Exposure (1)

 Audio-record the session. (Listen for HW!)

 Close eyes (perhaps do controlled
breathing).
 Imagine the traumatic event(s), and allow
natural emotions reactions. Recount as
many details as possible.
 Stay in “first-person, present tense.”

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Implementing Imaginal Exposure (2)

 Include what you are thinking and feeling in the

process of recalling the trauma (use the SUDS as
well).
 Repeat the narrative (in session, and across
sessions). [“The first is the worst”]
 First-time application should be largely patient-
guided. Therapist becomes more involved in
successive repetitions.

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Implementing Imaginal Exposure (3)

 If the patient becomes emotionally

overwhelmed (e.g., inconsolable crying or
dissociating), be willing to pause the
procedure and go into supportive mode, but
do not conclude that the procedure should
be abandoned.
 If the patient expresses anger, try to convert
it into energy to overcome PTSD.
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 Implementing Imaginal Exposure (4)

 Remind the patients that they survived the

trauma, and they can survive the exposure
intervention too, this time with a
strengthening effect.
 Do not terminate the session if the patient
becomes distressed. Calmly, caringly help
the patient to process their reactions.

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Implementing Imaginal Exposure (5)

 With cognitive restructuring:

– Address problematic thoughts and beliefs.
– Be empathic and encouraging, not pushy!
– Teach the patients to give themselves
reassurance during the induction (in the form of
hopeful, self-supporting, constructive
comments).

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 Imagery Rescripting (1)
 A variation of imaginal exposure that
allows for “artistic license” to change the
events of the traumatic experience(s) in a
way that promotes patient empowerment.
 The patient has control.
 The toxic meanings of the trauma are
modified.

106
 Imagery Rescripting (2)
 Memories of childhood and adult traumatic
events respond equally well to rescripting.
 Rescripting seems to be most effective
when intrusive memories are frequent.
 While reliving a distressing memory, the
patient should have “one foot in the
memory and one foot in the room.”

107
 Imagery Rescripting (3)
 Provide a rationale: To learn to see the bad
memories as no longer able to hurt you.
 Decide on an image/memory, its
characteristics and sensations, and what
needs to be modified in its retelling.
 Walk through the actual image/memory
(eyes closed, first person, present tense).

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 Imagery Rescripting (4)
 Explore the meanings of the
image/memory.
 SUDS ratings throughout.
 Practice the memories in their rescripted
form (repetitions are important).
 Assess for associated memories that may
have been re-activated.

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Imaginal Exposures (“post-script”)

 Converting the abstract style of rumination

into an actual experience of discrete
emotions, sensations, and thoughts that can
be processed and re-evaluated.
 Changing fearful avoidance of memories
into more self-confidence in dealing with
trauma, and enhancing ability to look ahead
to an improved life.
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 Multiple Images/Memories to
Process?
 Not necessary to process every traumatic
incident or memory, as therapeutic
generalization has been found to occur through
each positively processed image/memory.
 Re-processing of the meanings of the trauma
memories seems to be at the thematic level
(e.g., vulnerability, trust, lovability).

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Demonstration Video

112
 Clinical Issues That Often
“Preempt” or Contraindicate Exposure Work (1)

 Psychiatric emergency (e.g., full-blown manic

episode, serious self-harming behavior, active
suicidality or homicidality).
 Serious alcohol and/or other drug dependence.
 Comorbid disorder that requires prioritization
(e.g., schizophrenia)
 Crisis (or ongoing dangerous situation) in the
home or workplace that demands prompt
attention.
 Insufficient memory of the traumatic event(s).
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 Clinical Issues That Often
Preempt or Contraindicate Exposure Work (2)

Examples
 Patient whose PTSD stems from an abusive
domestic situation, and she is still at risk for
further abuse in the same situation.
 During detox for alcohol and/or other drugs, and
aftercare rehab. (Beware! Trauma symptoms may
worsen in early stages of sobriety, owing to to the
cessation of self-medicating).
 Patient is unsure what really happened. Harbors
doubts about the “memory.”
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 Special Considerations

Patients who are particularly likely to require

extensive use of imagery, and cognitive
restructuring, are those who:
 Evidence significant anger, guilt, shame.
 Interpret their reactions during the traumatic
event as being a negative mark on their
character or “goodness.”
 Experienced prolonged violence.

115
 Special Considerations (continued)

 Dealing with traumatized people often

requires a staged process of treatment that is
responsive to how much the individuals can
reasonably tolerate without the
interventions becoming iatrogenic.
 The way victims of trauma are treated is
reflective of the society’s general attitudes
to promoting the well-being of its citizens.
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Special Considerations (continued)

Often the sessions in which “reliving” is

done must be longer than the standard “50-
minute hour.” Up to two hours may be
needed in order to set the stage, do the
relaxation, go through the imagery, do the
post-image reprocessing, and lower the
patient’s state of arousal.

117
 Special Issues of Which to be Aware (1)

 Exposure interventions may not be appropriate

while the patient is still actively dealing with
injuries and other medical complications (e.g,
burns) associated with the traumatic event.
 Many patients still perceive ongoing threat, and in
some cases this is realistic.
 **Cross-cultural differences must be assessed.
 Patients may be trying to be “the strong one” for
their children and other family members.

118
 Special Issues of Which to be Aware (2)

 Attendance to sessions is very important,

and needs to be addressed directly (with
sensitivity) as a relevant clinical issue if it
becomes sporadic.
 Homework is also of critical importance
(e.g., listening to the session recordings;
writing narratives; doing in-vivo exposures;
engaging in important activities).
119
 Maintenance of Gains

 Involve significant others in session.

 Ongoing support groups.
 Have the patient coach someone with a
similar problem (e.g., in an open group).
 “Never make an important decision based
on avoidance.”
 Do not catastrophize breakthrough
symptoms.
120
 Important Goal!

“Reclaim one’s former self”: Reinstitute

activities that had once been part of the
patient’s life (or similar activities, if physical
limitations have resulted from the trauma).

121
 Two of the most important “outcome”
variables in the treatment of traumatized
patients are their…

1. Tolerance for intimacy.

2. Level of trust in their own perceptions and
capabilities.

122
What about children?

123
 Children and Trauma (1)

 Children also suffer from PTSD.

 Children’s response to trauma can be

significantly influenced by family
environment (for better or worse).

124
 Children and Trauma (2)

 At this point, we cannot assume that the

standard treatments for adults with PTSD
should be applied to children, especially as
they may be experiencing ongoing abuse.

 Developmental issues must be considered in

evaluating symptomatology.

125
 Childhood Sexual Abuse (CSA):
Some basic facts
 Although only a minority of survivors of CSA
become psychiatric patients, a large proportion
(40%-70%) of adult psychiatric patients are
survivors of abuse. (J. Herman)
 70% of patients diagnosed with borderline
personality disorder have experienced CSA.
 PTSD risk higher when CSA is high-frequency,
long duration, perpetrated by close relative, and
when maternal support is low or absent.
126
 Childhood Sexual Abuse (CSA):
Some basic facts (continued)

Trauma interferes with children’s capacity

to regulate their arousal levels. This may be
related to the full scope of problems seen at
the time of the trauma, throughout
development, and into adulthood, such as
learning disabilities, behavioral problems,
impulsivity, self-harming behaviors, and
emotional lability (e.g., anger dyscontrol).
127
 Childhood Sexual Abuse (CSA):
Some basic facts (continued)

Some converging findings suggest that early

adversity, from neglect to profound trauma,
causes biological disruption in the
developing child (e.g., neuro-endocrine
anomalies).

128
 CSA Interventions:
Special considerations (1)
 Early intervention is best (e.g., Deblinger’s
Center for Children’s Support).
 Involve and educate the non-offending
parent in the context of the child’s therapy.
 Build on the child’s strengths and skills.
 Combat shame and secrecy.
 Use gradual exposure in talking through the
abusive events.
129
 CSA Interventions:
Special considerations (2)
 Validate memories of CSA and normalize
responses, including involuntary sexual responses,
and ambivalence toward the perpetrator.
 Use expressive-creative methods (e.g., songs,
poems, drawing pictures, writing journals, etc.)
 Discuss proper standards of sexual attitudes and
behaviors. Teach principles of appropriate limits
and boundaries. Teach personal safety skills.
 Help the non-offending parent to learn to cope
with their child’s CSA, and to give support.
130
131
 Grief and PTSD

 Among those who lose loved ones as a

result of catastrophic events (e.g., terrorism,
murder, missing persons, freak accidents),
the capacity to mourn is often impaired as a
result of the traumatization. PTSD
symptoms can result.
 Therapists can feel especially helpless when
treating such bereaved individuals.
132
When a patient has lost a loved one in a
traumatic incident, the issues of grief and
loss take precedence over the issues of post-
traumatic reactions per se.

It is probably best not use exposure

techniques during the early, intense period
of dealing with sudden bereavement.

133
 Assisting the “Normal” Process of
Grieving.

 Utilize rituals (e.g., religious, personal)

– Ceremony (tribute, memorial, etc.)
– Prayer and remembrance.
– Symbolic ways of saying goodbye.
 Mementos
– Shared with therapist in session.
– Keepsakes, heirlooms, photos, etc.

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135
If you would like more information (such as
specific references), feel free to contact me
directly at the following e-mail address:

psydoc@mail.med.upenn.edu

136