Transcript Workshop: Cognitive Processing Therapy

Workshop:
Cognitive Processing Therapy
© Patricia A. Resick, Candice M. Monson & Kathleen M. Chard, 2006
First, let’s talk implementation
• What would it take for you to try this
therapy protocol?
• What barriers exist to impede your
learning to conduct a new therapy?
• What can you do to facilitate your
learning?
2
Let’s start with the current criteria
for PTSD
A: Stressor Criterion
B: Reexperiencing
C: Avoidance
D: Arousal
E: Time Criterion
F: Functional Impairment or Distress
3
Symptom Criteria for PTSD
Avoidance
Flashbacks
Thoughts, feelings &
Distressing recollections
conversations
Dreams
Activities/Places/People
Amnesia
Physiological
Detachment
reactivity
Loss of interest
1
3
Psychological distress
Restricted affect
PTSD
w/ reminders
Foreshortened
future
2
Reexperiencing
Post
Traumatic
S tress
D isorder
Sleep difficultiesHypervigilance
Irritability & anger
Startle
Concentration
Arousal
4
A new model of
posttraumatic stress
disorder
5
Think of PTSD as a failure to recover
from a traumatic event.
If the event is severe enough, nearly everyone
will have symptoms reflective of PTSD.
Let’s start with the most homogeneous
severe event:
rape
Normal Recovery
PTSD criteria met
Weekly PTSD
100
90
80
70
60
50
40
30
20
10
0
2
Rape
12
= Resick et al.
2
Assault
= Riggs et al.
12
7
PTSD Among Rape Victims
PTSD Severity Score
30
PTSD
Non-PTSD
25
20
15
10
5
0
1
2
3
4
5
6
7
Weeks
8
9
10 11 12
Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock, T. & Walsh, W. (1992). A prospective examination of
posttraumatic stress disorder in rape victims. Journal of Traumatic Stress, 5, 455-475.
8
So, what happens that either
facilitates or hinders recovery?
• The three symptom clusters of PTSD
have not held up to research
• Let’s rearrange and think about posttrauma symptoms a bit differently
9
1. Intrusive images and sensations
Sensory memories
E
V
E
N
T
Intrusions
Flashbacks
10
2. Cognitions and Cognitive Processes
Content
Processes
Attentional bias
Rumination
Assimilation
Accommodation
Overaccommodation
E
V
E
N
T
Cognitions
Autobiographical
memory
Schemas
Appraisals
Assumptions
Thoughts
Beliefs
Intrusions
11
3. Negative Affect and Hyperarousal
E
V
E
N
T
Intrusions
Emotions/Arousal
Cognitions
12
In normal recovery, intrusions and emotions decrease
over time and no longer trigger each other
Intrusions
Emotions/
Arousal
Cognitions
13
However, in those who don’t recover, strong
negative affect leads to escape & avoidance
Intrusions
Emotion/
Arousal
Cognitions
Core reactions
Escape/ Avoidance
14
4. Avoidance
Research supports association of a range of
behaviors with affect/tension reduction:
•
•
•
•
•
Substance abuse (Kilpatrick et al. 1997; Nishith et al. 2001)
Binging (Agras & Telch, 1998; Cools et al. 1992; Polivy et al. 1994)
Self-injury (Briere & Gil, 1998; Favazza & Conterio, 1989)
Dissociation (Bonanno et al. 2003; Feeney et al. 2000)
Social withdrawal (Riggs et al. 1998; Ruscio et al. 2002)
15
Avoidance Criterion
• This list is not
exhaustive
• Any behavior that
functions to
escape/avoid
negative traumarelated emotion
meets the
criterion.
16
Successful Avoidance = Chronic PTSD
Intrusions
Emotion/
Arousal
Cognitions
Core reactions
Escape/ Avoidance
17
Very Successful Avoidance =
Chronic Subthreshold PTSD
Intrusions
Emotion/
Arousal
Cognitions
Core reactions
Escape/ Avoidance
18
Mediators and Moderators
E
V
E
N
T
Pretrauma
Intrusions
Cognitions
Emotions/
Arousal
Escape/ Avoidance
Post trauma environmental factors
Social support (+/-)
Resource strain/loss
Externally imposed inhibition of processing
19
Simple versus Complex PTSD
Externalizing
Intrusions
Cognitions
Emotions/
Arousal
Simple
Internalizing
Core Reactions
Coping with Escape
And Avoidance
Simple vs Complex
PTSD
20
Developing Axis I and Axis II
Comorbid Disorders
SUD
Cluster B
Bulimia
ADHD
Intrusions
Cognitions
Emotions/
Arousal
Avoidance
Simple
Fear
Anxiety
Disorders,
Avoidant-PD
Anxious Misery
MDD
GAD
Schizoid
Somatization
Core Reactions
Coping with Escape
And Avoidance
Simple vs Complex
PTSD
Comorbid
Axis 1 or
Axis 2 Disorders
21
Two examples
…and why they look so different
•
Jim was physically abused by his father as a
child. He tended to blame other people for
his problems and began drinking with friends
in adolescence
•
Jen had an episode of depression in her early
20s. She grew up thinking that when things
went wrong, it must have been her fault
•
Both of them were victims of sexual abuse
22
Jim
Abuse
Externalizing
SUD
Cluster B
Bulimia
ADHD
Simple
Fear
Anxiety
Disorders,
Avoidant-PD
Angry
Intrusions
Emotions/
Arousal
“Others bad”
Cognitions
Anxious Misery
Internalizing
ExternalCore Reactions
Coping with Escape
And Avoidance
MDD
GAD
Schizoid
Somatization
Comorbid
Simple vs Complex
Axis 1 or
PTSD
Axis 2 Disorders
23
Jen
Abuse
Sad, guilt
Externalizing
Intrusions
“I’m bad”
Emotions/
Arousal
Cognitions
Simple
SUD
Cluster B
Bulimia
ADHD
Fear
Anxiety
Disorders,
Avoidant-PD
Anxious Misery
Internalizing
InternalCore Reactions
Coping with Escape
And Avoidance
Simple vs Complex
PTSD
MDD
GAD
Schizoid
Somatization
Comorbid
Axis 1 or
Axis 2 Disorders
24
PTSD as a Mediator
SUD
Cluster B
Bulimia
ADHD
Intrusions
Emotions/
Arousal
Avoidance
Simple
PTSD
Cognitions
Fear
Anxiety
Disorders,
Avoidant-PD
Health
Social
Family
Work
Anxious Misery
MDD
GAD
Schizoid
Somatization
Core Reactions
Coping with
Escape
And Avoidance
Simple vs.
Complex
PTSD
Comorbid
Axis 1 or
Axis 2
Disorders
Functional
Outcomes
25
Treatment of PTSD
Intrusions
Emotions/
Arousal
Cognitions
Core Symptom Clusters
Escape/ Avoidance
26
1. Prevent Avoidance
Intrusions
Cognitions
Emotions/
Arousal
Core Symptom Clusters
Escape/Avoidance
27
2. Intervene into one or more of core
symptom clusters
Nightmare rescripting
MEDs
PE
Intrusions
Cognitions
Emotions/
Arousal
CT
CPT
Escape/ Avoidance
28
Research on CPT
•
•
•
•
There have been four randomized clinical
trials of CPT and several effectiveness
studies. See the manual for the exact
references.
Randomized Clinical Trials
1. Rape victims (Resick et al., 2002, JCCP)
2. Child Sexual abuse (Chard, 2005, JCCP)
3. Veterans (Monson et al., 2006, JCCP)
4. Rape and assault (Resick et al. 2006
unpublished)
29
Study
CPT
Sample
ITT
Resick et al.
(2002)
82 rape victims
(86% had
other crimes)
Chard (2005)
36 adult
survivors of
CSA (57%>
100 incidents)
40%
Monson et al.
(2006)
30 Combat
veterans (78%
Vietnam)
53%
93% male/
54.9
Treatment as
usual
Resick et al.
(unpublished)
Rape or assault
58 CPT, 51 CT,
55 WE
50%
Female/35.4
Dismantling
study
Compared
Depression
Gender/Age
Comorbidity
to:
44%
Female/32
Female/32.8
Prolonged
exposure,
wait list
Delayed
treatment
17 wk
protocol
30
CAPS severity pre and post-treatment (ITT)
80
Pre
Post
70
60
50
40
30
20
10
0
Resick
2002
Chard
2005
Monson Resick Resick
2006
2006 2006 CT
CPT
31
CAPS severity pre and post-treatment:
Tx Completers
80
Pre
Post
70
60
50
40
30
20
10
0
Resick
2002
Chard
2005
Monson Resick Resick
2006
2006 2006 CT
CPT
32
CAPS diagnosis pre and post-treatment
100
90
80
70
60
50
40
30
20
10
0
(ITT)
Pre
Post
Resick
2002
Chard
2005
Monson Resick
2006
2006
CPT
Resick
2006
CT
33
CAPS diagnosis pre and post-treatment
(Tx
completers)
100
90
80
70
60
50
40
30
20
10
0
Pre
Post
Resick
2002
Chard
2005
Monson Resick
2006
2006
CPT
Resick
2006
CT
34
BDI pre and post-treatment
(ITT)
30
Pre
Post
25
20
15
10
5
0
Resick
2002
Chard
2005
Monson Resick
2006
2006
CPT
Resick
2006
CT
35
BDI pre and post-treatment
(TX
completers)
30
Pre
Post
25
20
15
10
5
0
Resick
2002
Chard
2005
Monson
2006
Resick
2006
CPT
Resick
2006
CT
36
Chard (2006): Effectiveness of CPT in
VA Residential Program
• 7 week residential program
• CPT conducted twice a week in individual and
group treatment
• 23 other hours of psych. programming
• Pre-post data on 82 residents, 59 men and 23
women admitted as cohorts of 12
• Next slides compare this program with the
RCT with veterans by Monson et al. (2006)
Chard, Unpublished data
37
CAPS pre and post-treatment
(TX completers)
Pre
Post
80
70
60
50
40
30
20
10
0
Monson (outpatient)
Chard (residential)
38
BDI pre and post-treatment
(TX completers)
Pre
Post
35
30
25
20
15
10
5
0
Monson (outpatient)
Chard (residential)
39
Some other findings of note…
1.
Can We Cure PTSD?
Long-term Follow-up of a Clinical Trial
Comparing CPT and PE.
Patricia A. Resick, Lauren Williams
Robert Orazem and Cassidy Gutner
ISTSS & ABCT, Nov., 2005
Long term follow-ups
• Follow-up conducted at five + years post-treatment
(M= 6 yrs, range 5-10).
• 171 women were in the intent-to-treat sample.
• We did not locate 25 and 3 were deceased.
• Of the 143 we located:
17 refused to participate (12%)
2 were located but were not appropriate.
• We conducted at least the diagnostic interviews on
124 and have complete assessments on 119.
• 88% participation rate
41
ITT CPT and PE “cross-sectional”
CPT
80
PE
70
60
50
40
30
20
10
0
Pre
CPT, N= 83
PE, N= 88
Post
55
55
3 mo
50
51
9 mo
41
39
5+ yr
63
64
42
CPT and PE on CAPS
across 5 years (all assessments)
CPT
80
PE
70
60
50
40
30
20
10
0
Pre
CPT, N= 35
PE, N= 32
Post
3 mo
9 mo
5+ yr
43
CPT & PE ITT on PTSD Diagnosis at
Pretreatment and long term
CPT (n=63)
PE (n=64)
CAPS Diagnosis
100
80
60
40
20
0
Pre
long term
44
2. A Dismantling Study
of the Components of Cognitive
Processing Therapy
Patricia A. Resick
National Center for PTSD, Boston VA Healthcare System and Boston
University
Tara Galovski, Kelly Phipps, Mary Uhlmansiek,
Jennifer Ansel and Michael Griffin
University of Missouri- St. Louis
ITT CAPS Severity
(no differences between groups)
80
CPT (n= 53)
CPT-W (n= 50)
CPT-C (n= 47)
70
60
50
40
30
20
10
0
PRETX
POSTTX
6 MO
46
Random Regression of PDS
PDS total with categorical assessment interval
30
CPT
CPT-W
CPT-C
28
26
24
22
20
18
16
14
12
10
baseline
week1
week2
*
week3
week4
*
*
week5
*
week6
post -t reat ment
f ollow-up
*
47
Cognitive Processing Therapy
Resick, P.A., Monson, C.M., & Chard, K. M. (2006)
Cognitive Processing Therapy
Veteran/Military Version
Produced by VA Office of Mental Health, VA National Center for PTSD/
VA Boston Healthcare System and Cincinnati VA Medical Center
Pre-treatment Issues
• Please assess patients formally to
determine whether they have PTSD,
and if needed, other comorbid
conditions.
• Describe the therapy you are offering,
how it might differ from other former
treatment.
• Therapist contract.
49
Other pretreatment issues
• CPT for whom and when
•
•
•
•
– Substance abuse/dependence
– Self-harm/suicidality/homicidality
– Dissociation
– Literacy
– Other comorbidity
Medications and other treatments
How early can you start?
Risk to re-exposure (redeployment)
Sufficient skills needed to start?
50
Recommended
Assessment Measures
• CAPS interview for diagnosis, frequency
and severity (pre and post-treatment)
• Self-report scales (weekly)
• PTSD Checklist (PCL)
• Beck Depression Inventory or other
depression checklist
• www.ncptsd.va.gov
51
Structuring Sessions
• Brief update (mood and PTSD symptoms)
– Objective symptom measures
– Complete Practice Assignment Review (“How did
your practice go?” rather than “How was your
week?”
• Review of Practice Assignment
– Reviewing practice reinforces completion
– Content is the “meat” of the session
– Use Socratic questioning and model challenging
thoughts
– Use relevant forms regardless of the content
52
Structuring Sessions (cont.)
• Setting new practice assignment
– Review rationale
– Explain the concept and new assignment
– Start assignment in session
– Problem solve any barriers to assignment
completion
53
Session 1. Symptoms and Rationale
•
•
•
•
Describe symptoms of PTSD (handout)
PTSD as a disorder of non-recovery
Fight-flight-freeze reactions
Cognitive theory of PTSD
– Just world belief
– Assimilation versus over-accommodation
– Goal of accommodation
54
Assimilation
• Traumatic event is remembered differently to preserve
original beliefs and assumptions
Original Belief
Rape=Stranger
Traumatic Event
Raped by friend
Assimilation
Misunderstanding
• Modified memory of the traumatic event doesn’t fit with
emotions experienced
• Creates disconnect between the memories and the
emotions
Undoing and Self-Blame
55
Over-accommodation
• Overall beliefs and assumptions about self and the
world change too much following the traumatic
event and are no longer accurate
Original Belief
World=Safe
Traumatic Event
Assaulted
Over-accommodation
World=Dangerous
56
Session 1. Symptoms and Rationale
• Types of emotions
– Goal for natural emotions
– Goal for manufactured emotions
• Choosing index traumatic event
58
Session 1. Symptoms and
Rationale
• Stuck points
– Handout
– Log
• Anticipating avoidance and
increasing practice compliance
• Overview of treatment
60
Session 1. Group Notes
• Discuss group rules
– Allow patients to create their own and add to
their list (e.g. confidentiality, timeliness, no
cross talking)
• Discuss patient responsibilities in group
– Attending, participating, doing practice
• Ask if group members would like a phone
list (if outpatient group)
61
Session 1. Group Notes
• Discuss group rules
– Allow patients to create their own and add to
their list (e.g. confidentiality, timeliness, no
cross talking)
• Discuss patient responsibilities in group
– Attending, participating, doing practice
• Ask if group members would like a phone
list (if outpatient group)
62
Session 1. Practice Assignment
“Please write at least one page on why you
think this traumatic event occurred. You are
not being asked to write specifics about the
traumatic event. Write about what you have
been thinking about the cause of the worst
event. Also, consider the effects this
traumatic event has had on your beliefs about
yourself, others, and the world in the
following areas: safety, trust, power/control,
esteem, and intimacy. Bring this with you to
the next session. Also, please read over the
handout I have given you on stuck points so
that you understand the concept we are
talking about.”
63
Session 1a. Traumatic Bereavement
• Patient reads Impact Statement and therapist
begins to identify stuck points
• Therapist provide education on normal
bereavement
• Therapist looks for stuck points that are
interfering with normal bereavement
• Therapist reviews Myths of Mourning Handout
• Therapist assigns practice assignment on
Impact Statement related to traumatic
bereavement
65
Session 2. Impact statement
• Patient reads impact statement.
• Discuss implications of statement.
• Review material from first session.
• Introduce events-thoughts-feelings
relationship.
66
Session 2. Patient reads impact
statement
• If patient doesn’t do practice
assignment
– 1. Discuss the role of avoidance in
maintenance of symptoms
– 2. Have the patient say what they would
have written if they had done so
– 3. Therapist asks patient to write impact
statement for next week
– 4. Therapist also assigns the next practice
assignment as well.
67
Session 2. Patient reads impact
statement
• Goal: Patients examine the impact of the
traumatic event on their lives. Therapist’s
role is to determine whether this has been
achieved and to use this examination to
increase motivation for change
• Help identify stuck points in statement
• Ask about other areas that were not
touched upon
• Highlight connection between thoughts
and feelings
68
Session 2. Introduce ABC worksheet
• Using an example from the impact
statement or something that the patient
has mentioned, introduce the concept
of labeling events, thoughts and
emotions.
• Use an example from life of how most
events are open to interpretation. Put
on worksheet.
70
A-B-C Sheet
Date: ___________ patient #: ______
ACTIVATING EVENT
A
“Something happens”
BELIEF
B
“ I tell myself something”
CONSEQUENCE
C
“I feel something”
Is it reasonable to tell yourself “B” above? _____________________
_________________________________________________________
What can you tell yourself on such occasions in the future? ________________________________________
_____________________________________________________________________________
71
Session 2. Group Notes
• Introduce check-in and asking for group
time ideas
• Pass out written group rules
• Have members read impact statements to
group and look for stuck points
• Pass out phone list and ask everyone to
call the person below them on the list
72
Session 2. Practice Assignment
“Please complete the A-B-C Worksheets to
become aware of the connection between
events, your thoughts, feelings, and behavior.
Complete at least one worksheet each day.
Remember to fill out the form as soon after
an event as possible. Complete at least one
worksheet about the worst traumatic event.
Also, please use the Identifying Emotions
Handout to help you determine what
emotions you are feeling.”
73
Session 3. Events, Thoughts & Emotions
• Review A-B-C sheets.
• Using Socratic questions, help
patient generate alternative
thoughts and consequent feelings.
• Gently begin to challenge undoing
or self-blame statements.
74
A-B-C Sheet
Date: ___________ patient #: ______ Mr.A
ACTIVATING EVENT
A
“Something happens”
I get hit by an IED
BELIEF
CONSEQUENCE
B
“ I tell myself something”
How did I make it and the
guy next to me lost his leg?
C
“I feel something”
Confused
Scared.
Is it reasonable to tell yourself “B” above? _____________________
_____________________________________________________________________
What can you tell yourself on such occasions in the future? ___________________________
__________________________________________________
75
A-B-C Sheet
Date: ___________ patient #: ____ Mr.
ACTIVATING EVENT
A
“Something happens”
Child dies in my arms.
BELIEF
B
“ I tell myself something”
“It was my fault that she
died.”
B___
CONSEQUENCE
C
“I feel something”
I feel incompetent and
helpless. I avoid holding
children and getting close to
anyone.
Is it realistic to tell yourself “B” above? _No. I did what I could to save her.____
What can you tell yourself on such occasions in the future? It wasn’t my fault. I did the best I could
for her.
76
A-B-C Sheet
Date: ___________ patient #: ____ Ms.
ACTIVATING EVENT
BELIEF
A
“Something happens”
My grandfather abused me
and I was hurt by other men
in different ways
CONSEQUENCE
B
“ I tell myself something”
“It was my fault because I
looked like my grandmother
and mother. All men cannot
be trusted.
C
C
“I feel something”
Guilt
Fear
Rage
Disgust
Is it realistic to tell yourself “B” above? _ The guilt was unreasonable- it wasn’t my fault- All men can’t be
trusted is an unreasonable statement.
What can you tell yourself on such occasions in the future? Each man is an individual- some men can’t be
trusted, but not all.
77
Session 3. Socratic questions
• At this point in therapy we do not
strongly challenge maladaptive
statements
• More important to help clarify
thoughts and feelings
• Work gently with assimilation (selfblame & undoing)
79
A-B-C Sheet
Date: ___________ patient #: ______
ACTIVATING EVENT
A
“Something happens”
BELIEF
B
“ I tell myself something”
CONSEQUENCE
C
“I feel something”
Is it reasonable to tell yourself “B” above? _____________________
_________________________________________________________
What can you tell yourself on such occasions in the future? ________________________________________
_____________________________________________________________________________
83
Session 3. Group Notes
• Check-in/Group time
• Process the A-B-C sheets – each member
shares at least one.
• Make process statement regarding silence
and how that continues the trauma.
• Discuss ways patients avoid in group (e.g.,
story telling, silence, disruptive behavior).
• Have patients call the person 2 down on
the phone list.
84
Session 3. Practice Assignment
“Please begin this assignment as soon as possible. Write a
full account of the traumatic event and include as many
sensory details (sights, sounds, smells, etc.) as possible.
Also, include as many of your thoughts and feelings that
you recall having during the event. Pick a time and
place to write so you have privacy and enough time. Do
not stop yourself from feeling your emotions. If you
need to stop writing at some point, please draw a line
on the paper where you stop. Begin writing again when
you can, and continue to write the account even if it
takes several occasions.“ Read the whole account to
yourself every day until the next session. Allow yourself
to feel your feelings. Bring your account to the next
session.
Also, continue to work with the A-B-C Worksheets every
day.”
85
Session 4. First Account
• Patient reads account aloud to
therapist.
• After patient reads account, patient
and therapist discuss reactions to
writing it/reading it.
• First work on emotions. Sit with
them, name them.
• Then therapist gently challenges
self-blame and hindsight bias.
88
Session 4. Group Notes
• Check-in/ Group time
• Discuss what is was like to write accounts.
What new Stuck Points were found?
• For mixed traumas - remind patients not
to share explicit details of their trauma in
group
• Continue using ABC sheets and help
challenge stuck points regarding selfblame, undoing, other assimilation.
• Call 3 down on the phone list
92
Session 4. Practice Assignment
“Write the whole incident again as soon as
possible. If you were unable to complete the
assignment the first time, please write more
than last time. Add more sensory details, as
well as your thoughts and feelings during the
incident. Also, this time write your current
thoughts and feelings in parentheses (e.g.,
“I’m feeling very angry”). Remember to read
over the new account every day before the
next session.
Also, continue to work with the A-B-C
Worksheets every day.”
93
Session 5. Second Account
• Patient reads second account of
incident.
• Patient and therapist continue to
process any remaining self-blame or
undoing.
• Therapist introduces Challenging
Questions Worksheet.
94
Challenging Questions Worksheet
Below are a list of questions to be used in helping you
challenge your maladaptive or problematic beliefs. Not
all questions will be appropriate for the belief you
choose to challenge. Answer as many questions as
you can for the belief you have chosen to challenge
below.
Belief:_________________________________________
1. What is the evidence for and against this idea
2. Is your belief a habit or based on facts?
3. Are your interpretations of the situation too far removed
from reality to be accurate?
4. Are you thinking in all-or-none terms?
96
Challenging Questions Continued
5. Are you using words or phrases that are extreme or
exaggerated? (i.e., always, forever, never, need,
should, must, can’t and every time).
6. Are you taking selected examples out of context and
only focusing on one aspect of the event?
7. Is the source of information reliable?
8. Are you confusing a low probability with a high
probability?
9. Are your judgments based on feelings rather than
facts?
10. Are you focusing on irrelevant factors?
97
Session 5. Group Notes
• Check-in/Group time
• If needed, normalize that all emotions
are permitted in group, including anger
at group leaders. Discuss.
• Do 1 challenging questions sheet
together in group on a common topic
such as “I am never safe” or “ I don’t
trust other people.”
• Have patients call anyone on phone list.
98
Session 5. Practice Assignment
“Please choose one stuck point each day and
answer the questions on the Challenging
Questions Worksheet with regard to each of
these stuck points. There are extra copies of
the Challenging Questions Worksheets
provided, so you can work on multiple stuck
points. If you have not finished your accounts
of the traumatic event(s), please continue to
work on them. Read them over before the
next session and bring all of your worksheets
and Trauma Accounts to the next session.”
99
Session 6. Challenging Questions
• Patient and therapist review Challenging
Questions Worksheets to question single
statements or beliefs.
• Therapist introduces Patterns of
Problematic Thinking Sheet to see if there
are typical patterns of cognition.
100
Patterns of Problematic Thinking
Listed below are several types of patterns of problematic
thinking that people use in different life situations.
These patterns often become automatic, habitual
thoughts that cause us to engage in self-defeating
behavior. Considering your own stuck points, find
examples for each of the patterns. Write in the stuck
point under the appropriate pattern and describe how it
fits that pattern. Think about how that pattern affects
you.
1. Jumping to conclusions when evidence
is lacking or even contradictory.
2. Exaggerating or minimizing the meaning
of an event.
102
Patterns of Problematic Thinking
3. Disregarding important aspects of a
situation.
4. Oversimplifying events or beliefs as
good/bad or right/wrong.
5. Over-generalizing from a single
incident.
6. Mind-reading.
7. Emotional reasoning.
103
Session 6. Group Notes
• Check-in/Group time
• Have members share a Challenging
Questions worksheet with the group. Do
another one as a group if needed.
• As they do multiple worksheets, are they
detecting any themes across them?
• Have patients discuss items they wish they
would have brought up in past groups.
• Have patients call anyone on the list.
104
Session 6. Practice Assignment
“Consider the stuck points you have identified
thus far and find examples for each of the
problematic thinking patterns listed on the
worksheet in your day to day life (or over the
course of the next week). Look for specific
ways in which your reactions to the traumatic
event may have been affected by these
habitual patterns.
Continue reading your accounts if you still have
strong emotions about them.”
105
Session 7. Problematic Patterns
• Patient and therapist review Patterns
of Problematic Thinking.
• Therapist introduces Challenging
Beliefs Worksheets.
• Therapist introduces Safety module.
106
Challenging Beliefs Worksheet
A. Situation
B. Thoughts
D. Challenging
Thoughts
E. Problematic
patterns
F. Alternative Thought
Describe the
event, thought
or belief
leading to the
unpleasant
emotion(s).
Write thought(s)
related to Column A.
Rate belief in each
thought below from 0100%
(How much do you
believe this thought?)
Use Challenging
Questions to examine
your automatic
thoughts from Column
B. Is the thought
balanced and factual or
extreme?
Use the Problematic
Thinking Patterns
sheet to decide if this
is one of your
problematic patterns
of thinking.
What else can I say
instead of Column B?
How else can I interpret
the event instead of
Column B?
Rate belief in alternative
thought(s) from 0-100%
Evidence?
Jumping to conclusions
Habit or Fact?
Exaggerating or
minimizing
Interpretations not
accurate?
All or none?
Extreme or exaggerated?
Out of context?
C. Emotion(s)
Specify sad, angry, etc.,
and rate how strongly you
feel each emotion from 0100%
Jumping to conclusions
Exaggerating or minimizing
Disregarding important
Disregarding important
aspects
aspects
Oversimplifying
Source unreliable?
Overgeneralizing
Low versus high
probability?
Mind reading
Based on feelings or facts?
Emotional reasoning
Irrelevant factors?
G. Re-rate how much you now
believe the thought in Column B
from G.
0-100%
Re-rate old thoughts
H. Emotion(s)
Now what do you feel? 0-100%
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Challenging Beliefs Worksheet
A. Situation
B. Thoughts
D. Challenging Thoughts
E. Problematic
patterns
F. Alternative Thought
Describe the
event, thought
or belief
leading to the
unpleasant
emotion(s).
Write thought(s)
related to Column A.
Rate belief in each
thought below from
0-100%
(How much do you
believe this
thought?)
Use Challenging
Questions to examine
your automatic thoughts
from Column B. Is the
thought balanced and
factual or extreme?
Use the Problematic
Thinking Patterns
sheet to decide if this
is one of your
problematic patterns
of thinking.
What else can I say
instead of Column B?
How else can I interpret
the event instead of
Column B?
Rate belief in alternative
thought(s) from 0-100%
Evidence?
Jumping to conclusions
I feel
uncomfortable
and unsafe
with Asian
people
While I was in VN I
couldn’t tell friend
from foe. It was
impossible to tell
who was the enemy
and might try to kill
me. 80%
For: This did happen in
VN..
Against: That was a long
time ago in a totally
different environment.
Habit or Fact?
It has become a habit to
distrust all people,
especially Asians.
Low versus high probability?
C. Emotion(s)
Specify sad, angry, etc.,
and rate how strongly
you feel each emotion
from 0-100%
Fear 70%,
Anger 50%,
Frustration 50%
There is a low probability
that any Asian would try
to harm me.
Based on feelings or facts?
My feelings are derived
from my service in VN.
Are they relevant today?
They are not relevant
today.
Irrelevant factors?
Because of my time in VN,
I am drawing the
I have some
conclusion that all
understandable, but
Asian people are
irrelevant, feelings around
Jumping to conclusions
untrustworthy
and
Asian people. As a group,
Exaggerating
or minimizing
dangerous
to me.
they are not dangerous to
Disregarding important
me. 90%
aspects
Exaggerating or
minimizing
Disregarding important
aspects
Oversimplifying
G. Re-rate how much you now
believe the thought in Column B
from 0-100%
40%
Overgeneralizing
Mind reading
Emotional reasoning
Because I feel scared
around Asian people,
I am in danger around
them.
H. Emotion(s)
Now what do you feel? 0-100%
Fear 50%
Anger 20%
Frustration 30%
108
Session 7. Introduce Safety
• Beliefs related to Self
– Belief you can protect yourself from
harm and have some control over
events
– Associated symptoms include anxiety,
intrusive thoughts about danger,
irritability, startle responses, intense
fears about future dangers
109
Session 7. Introduce Safety
• Beliefs related to Others
– Belief abut dangerousness of other
people and expectancies about the
intent of others to cause harm, injury,
or loss
– Symptoms include avoidant or phobic
responses, social withdrawal
110
Session 7. Group Notes
• Check-in/Group time
• Have each person identify their most
problematic thinking patterns and talk
about how they affect one’s life.
• Do Challenging Beliefs Worksheet
together as a group on a common stuck
point such as “I must be on guard or
bad things will happen to me”
111
Session 7. Practice Assignment
“Use the Challenging Beliefs Worksheets to
analyze and confront at least one of your
stuck points each day. Please read over the
module on safety and think about how your
prior beliefs were affected by the [event]. If
you have safety issues related to yourself or
others, complete at least one worksheet to
confront those beliefs. Use the remaining
sheets for other stuck points or for distressing
events that have occurred recently.”
112
Session 8. CBW and Safety
• Patient and therapist review
worksheets.
• Patient and therapist discuss safety
issues.
• Therapist introduces Trust module.
113
Session 8. Introduce Trust
• Beliefs related to Self
– Belief you can trust or rely upon one’s
own perceptions or judgments.
Important part of self-concept and
serves important self-protection
function.
– Associated symptoms include
feelings of self-betrayal, anxiety,
confusion, overcautious, inability to
make decisions, self-doubt.
116
Session 8. Introduce Trust
• Beliefs related to Others
– Belief that the promises of other people
or groups with regard to future behavior
can be relied upon. A person needs to
learn a healthy balance of trust and
mistrust and when each is appropriate.
– Associated symptoms include
disillusionment, fear of betrayal, anger
and rage, suspiciousness, fleeing from
relationships.
117
Session 8. Group Notes
• Check-in/Group time
• Each member discusses their Challenging
Beliefs Worksheet.
• Encourage patients to help each other identify
dysfunctional thinking.
• Do a Challenging Beliefs Worksheet together as
a group if needed.
• What risks do you take in group and in your
daily life?
• If this were the last group what would you
regret not getting out of group?
118
Session 8. Practice Assignment
“Please read the Trust Module and think
about your beliefs prior to experiencing
[event] as well as how the event
changed or reinforced those beliefs. Use
the Challenging Beliefs Worksheets to
continue analyzing your stuck points.
Focus some attention on issues of self
or other-trust, as well as safety, if these
remain important stuck points for you.”
119
Session 9. Trust Issues
• Patient and therapist review practice on
trust issues and other completed
Challenging Beliefs Worksheets.
• Therapist introduces Power/Control
module.
120
Session 9. Introduce Power/Control
• Beliefs related to Self
– Belief you can solve problems and meet
challenges. Associated with capacity for selfgrowth.
• Belief one must be in control of oneself at all times
• Belief one is helpless to control anything
– Symptoms include numbing, avoidance of
emotions, passivity, hopelessness, depression,
self-destructive patterns, outrage when events
seem out of control.
122
Session 9. Introduce Power/Control
• Beliefs related to Others
– Belief that others have more control
than you do; that others have power
or attempt to control you.
– Associated symptoms include
passivity, submissiveness, lack of
assertiveness, or conversely, anger,
controlling behavior.
123
Session 9. Group Notes
• Check-in/Group time
• Each person shares at least one
Challenging Beliefs Worksheet
• Discuss cues that someone is trustworthy
• Identify trust beliefs by using the
thoughts they had of each other when
group first started compared to current
thoughts
124
Session 9. Practice Assignment
“Use the Challenging Beliefs Worksheets
to continue to address your stuck
points. After reading the Power/Control
Module and thinking about it, complete
worksheets on this topic.”
125
Session 10. Power and Control
• Patient and therapist review control/power
issues and other Challenging Beliefs
Worksheets
• Therapist introduces Esteem module.
126
Session 10. Introducing Esteem
• Beliefs related to Self
–Belief in your own worth. Being
understood, respected, and taken
seriously is basic to the
development of self-esteem.
–Symptoms include depression,
guilt, shame, self-destructive
behavior.
128
Session 10. Introducing Esteem
• Beliefs related to Others
– Beliefs about other people that match
the reality of the other person and are
revised as new information is received.
– Examples:
• People are uncaring, indifferent, selfish
• People are bad, evil, or malicious.
– Symptoms include anger, contempt,
bitterness, cynicism, isolation or
withdrawal, antisocial behavior.
129
Session 10. Group Notes
• Check-in/Group time
• Discuss ways of giving and taking power
negatively and positively.
• Have group members generate ways in
which they do all 4 of these, perhaps
even in the group.
130
Session 10. Practice Assignment
“After reading the Esteem Module, use
the worksheets to confront stuck points
regarding self- and other-esteem. In
addition to the worksheets, practice
giving and receiving compliments
during the week and do at least one
nice thing for yourself each day
(without having to earn it). Write down
on this sheet what you did for yourself
and who you complimented.”
131
Session 11. Esteem Issues
• Patient and therapist review esteem
issues and other Challenging Beliefs
Worksheets.
• Patient and therapist review other
practice.
• Therapist introduces Intimacy module.
132
Session 11. Introducing Intimacy
• Beliefs related to Self
– Self-intimacy is ability to soothe and calm
oneself. Reflected in the ability to be
alone without feeling lonely or empty.
– Associated symptoms include inability to
comfort or soothe self, fear of being
alone, feeling of inner emptiness or
deadness, use of external sources of
comfort, needy or demanding
relationships.
134
Session 11. Introducing Intimacy
• Beliefs related to Others
– Need for intimacy, connection, and
closeness is a basic human need. This
can be damaged through insensitive,
hurtful, or non-empathic responses
from others.
– Associated symptoms include
loneliness, emptiness or isolation,
inability to connect with others.
135
Session 11. Group Notes
• Check-in/Group time
• Discuss pressure group members may
be putting on themselves to be further
along in treatment or comparing
themselves to each other
• Discuss worry they may have about
aftercare
136
Session 11. Practice Assignment
“Use the Intimacy Module and Challenging
Beliefs Worksheets to confront stuck points
regarding self- and other-intimacy. Continue
completing worksheets on previous topics
that are still problematic. Please write at least
one page on what you think now about why
this traumatic event(s) occurred. Also,
consider what you believe now about
yourself, others, and the world in the
following areas: safety, trust, power/control,
esteem, and intimacy.”
137
Session 12. Intimacy and Final Impact
• Patient and therapist review Challenging
Beliefs Worksheets on intimacy
• Patient reads new Impact Statement
• Patient and therapist review course of
therapy and skills learned
• Patient and therapist identify future
goals and issues which still need
attention
138
Session 12. Group Notes
• Check-in/Group time
• Patients read new Impact Statements
• Ask group members to identify changes
they have seen occur in each other
• Discuss ways of staying in touch after
the group ends
142
Recommended Readings for Learning
Cognitive Therapy Approach
• Beck, J. (1995). Cognitive therapy:
Basics and beyond. New York: Guilford
Press.
• Wright, J., Basco, M., & Thase, M.
(2006). Learning cognitive-behavior
therapy: An Illustrated guide. New York:
American Psychiatric Press.
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