Cognitive Processing Therapist

Cognitive Processing Therapy
Veteran/Military Version:
THERAPIST’S MANUAL
Patricia A. Resick, Ph.D., and Candice M. Monson, Ph.D.

National Center for PTSD, Women’s Health Sciences Division
VA Boston Healthcare System and Boston University
&
Kathleen M. Chard, Ph.D.
Cincinnati VA Medical Center and University of Cincinnati
August 2008
Correspondence should be addressed to:

Patricia Resick or Candice Monson, WHSD (116B-3), VA Boston Healthcare System,
150 South Huntington Ave., Boston, MA 02130
[email protected] or [email protected]
When referencing this manual, please use the following citation:

Resick, P.A., Monson, C.M., & Chard, K.M. (2008). Cognitive processing therapy:
Veteran/military version. Washington, DC: Department of Veterans’ Affairs.
How to Use This Manual
Parts I, II, and III
The veteran/military version of the therapist’s manual for Cognitive Processing Therapy
(CPT) has been organized to maximize the ease with which therapists prepare for and
conduct CPT.
Part I includes background information on CPT and other common issues related to
PTSD that may arise during the therapy. We recommend that therapists read the entire
manual before meeting with patients.
Part II includes instructions on each of the 12 sessions. Each session opens with a
summary that briefly outlines the format of the session and gives recommended times
for each segment of the session. Each segment is then reviewed in detail, with goals,
rationale, and sample dialogue. Call-outs are located throughout this section in the right
margins of the text to allow therapists to quickly locate specific topics. Sample session
progress notes follow the close of each session to facilitate tracking of therapist/patient
progress. Relevant patient handouts also follow each session; please refer to the
Materials Manual for additional information on handouts.
Part III offers information on alternatives to conducting CPT, including variations of CPT
and adaptations of CPT for group administration.
Table of Contents
| Part 1: | Introduction to Cognitive Processing Therapy (CPT) ............ 1
Theory Behind CPT ........................................................................................ 1

PTSD as Disorder of Non-Recovery ............................................................... 3
Pre-Therapy Issues......................................................................................... 3
1. Who Is Appropriate for CPT? ......................................................... 3
2. When Should the CPT Protocol Begin?......................................... .4
3. Treatment Contracting for CPT....................................................... 5
Overview of CPT Sessions ............................................................................. 6
Socratic Questioning Within CPT.................................................................... 7
1. Clarification .....................................................................................8
2. Probing Assumptions ......................................................................9
3. Probing Reasons and Evidence ......................................................9
4. Questioning Viewpoints and Perspectives .................................... 10
5. Analyzing Implications and Consequences ................................... 10
6. Questions About the Question ...................................................... 10
Issues in Conducting CPT ............................................................................ 11
1. Comorbidity .................................................................................. 11
2. Avoidance..................................................................................... 16
3. Needs of Returning OIF/OEF Veterans ........................................ 16
4. PTSD-Related Disability Status .................................................... 17
5. Religion and Morality .................................................................... 18
6. Military Sexual Trauma (MST) ...................................................... 21
7. Ongoing Symptom Assessments Using PTSD and Depression
Scales........................................................................................... 23
8. A Note on Session 2a—Bereavement .......................................... 23
| Part 2: | CPT: Session by Session........................................................ 25

Session 1: Introduction and Education ...................................................... 28
Session 2: The Meaning of the Event ........................................................ 58
Session 2a: Traumatic Bereavement (Optional Session) ............................ 44
Session 3: Identification of Thoughts and Feelings.................................... 73
Session 4: Remembering the Traumatic Event.......................................... 84
Session 5: Second Trauma Account.......................................................... 98
Session 6: Challenging Questions ........................................................... 108
Session 7: Patterns of Problematic Thinking ........................................... 118
Session 8: Safety Issues ......................................................................... 134
Session 9: Trust Issues ........................................................................... 146
Session 10: Power/Control Issues ............................................................. 158
Session 11: Esteem Issues ....................................................................... 172
Session 12: Intimacy Issues and Meaning of the Event............................. 184
| Part 3: | Alternatives and Considerations in Conducting CPT……..195
CPT Without the Trauma Account (CPT-C) ................................................ 195
Group CPT Administration .......................................................................... 198
| Appendix A: | Glossary of CPT Terms……..…….…….…….…….…A1
| Appendix B: | Literature on CPT……………..…….…….…….…….…B1

| Part 1: | Introduction to Cognitive Processing
Therapy (CPT)
Cognitive Processing Therapy (CPT) is a 12-session therapy that has been

found effective for posttraumatic stress disorder (PTSD) and other corollary
symptoms following traumatic events (Monson et al., 2006; Resick et al.,
2002; Resick & Schnicke, 1992, 1993 1 ). Although the research on CPT
focused on rape victims originally, we have used the therapy successfully
with a range of other traumatic events, including military-related traumas.
This revision of the manual is in response to requests for a treatment
manual that focuses exclusively on military trauma. The manual has been
updated to reflect changes in the therapy over time, particularly with an
increase in the amount of practice that is assigned and with some of the
handouts. It also includes suggestions from almost two decades of clinical
experience with the therapy.
Theory Behind CPT
CPT is based on a social cognitive theory of PTSD that focuses on how the • Theory
traumatic event is construed and coped with by a person who is trying to regain a behind CPT
sense of mastery and control in his or her life. The other major theory explaining
PTSD is Lang’s 2 (1977) information processing theory, which was extended to
PTSD by Foa, Steketee, and Rothbaum 3 (1989) in their emotional processing
theory of PTSD. In this theory, PTSD is believed to emerge due to the • Emotional
development of a fear network in memory that elicits escape and avoidance processing
theory of
behavior. Mental fear structures include stimuli, responses, and meaning PTSD
elements. Anything associated with the trauma may elicit the fear structure or
schema and subsequent avoidance behavior. The fear network in people with
PTSD is thought to be stable and broadly generalized so that it is easily accessed.
When the fear network is activated by reminders of the trauma, the information in
the network enters consciousness (intrusive symptoms). Attempts to avoid this
1
Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P.
(2006). Cognitive processing therapy for veterans with military-related posttraumatic stress
disorder. Journal of Consulting and Clinical Psychology, 74, 898–907; Resick, P. A., Nishith, P.,
Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive processing
therapy, prolonged exposure and a waiting condition for the treatment of posttraumatic stress
disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70, 867–879;
Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims.
Journal of Consulting and Clinical Psychology, 60(5), 748–756; Resick, P. A., & Schnicke, M. K.
(1993). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park, CA:
Sage Publications.
2
Lang, P. J. (1977). Imagery in therapy: An information processing analysis of fear. Behavior
Therapy, 8, 862–886.
3
Foa, E. B., Steketee, G. S., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations
of posttraumatic stress disorder. Behavior Therapy, 20, 155–176.
THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 1

activation result in the avoidance symptoms of PTSD. According to emotional
processing theory, repetitive exposure to the traumatic memory in a safe
environment will result in habituation of the fear and subsequent change in the
fear structure. As emotion decreases, patients with PTSD will begin to modify
their meaning elements spontaneously and will change their self-statements and
reduce their generalization. Repeated exposures to the traumatic memory are
thought to result in habituation or a change in the information about the event, and
subsequently, the fear structure.
Although social cognitive theories are not incompatible with • Social

information/emotional processing theories, these theories focus beyond the cognitive
development of a fear network to other pertinent affective responses such as theories
horror, anger, sadness, humiliation, or guilt. Some emotions such as fear, anger,
or sadness may emanate directly from the trauma (primary emotions) because the
event is interpreted as dangerous, abusive, and/or resulting in losses. It is possible
that secondary, or manufactured, emotions can also result from faulty
interpretations made by the patient. For example, if someone is intentionally
attacked by another person, the danger of the situation would lead to a fight-
flight-freeze response, and the attending emotions might be anger or fear
(primary). However, if in the aftermath, the person blamed himself 4 for the attack,
the person might experience shame. These manufactured emotions would have
resulted from thoughts and interpretations about the event rather than the event
itself. As long as the individual keeps saying that the event was his fault, he will
keep producing shame (hence, manufactured).
Social-cognitive theories focus more on the content of cognitions and the effect
that distorted cognitions have on emotional responses and behavior. In order to
reconcile information about the traumatic event with prior schemas, people tend
to do one or more of three things: assimilate, accommodate, or over-
accommodate. Assimilation is altering the incoming information to match prior
beliefs (“Because a bad thing happened to me, I must have been punished for
something I did”). Accommodation is altering beliefs enough to incorporate the
new information (“Although I didn’t use good judgment in that situation, most of
the time I make good decisions”). Over-accommodation is altering one’s beliefs
about oneself and the world to the extreme in order to feel safer and more in
control (“I can’t ever trust my judgment again”). Obviously, therapists are
working toward accommodation, a balance in beliefs that takes into account the
reality of the traumatic event without going overboard.
In a social-cognitive model, affective expression is needed, not for habituation,

but in order for the affective elements of the stored trauma memory to be
changed. It is assumed that the natural affect, once accessed, will dissipate rather
quickly and will no longer be stored with the trauma memory. Also, the work of
4
Throughout this manual, we will refer to a single patient using the pronouns “he” and “she”
alternately, rather than saying “she/he” or “him/her.” The term “service member” will also be used
as a generic term rather than marine, sailor, airman, etc., and will be used interchangeably with
veteran.

accommodating the memory and beliefs can begin. Once faulty beliefs about the
event (self-blame, guilt) and over-generalized beliefs about oneself and the world
(e.g., safety, trust, control, esteem, intimacy) are challenged, then the secondary
emotions will also decrease along with the intrusive reminders. The explanation
that CPT therapists give to patients about this process is described in Session 1
along with a handout in the patient materials section.
PTSD as Disorder of Non-Recovery
Because we know that PTSD symptoms are nearly universal immediately • PTSD
following very serious traumatic stressors and that recovery takes a few months symptoms
under normal circumstances, it may be best to think about diagnosable PTSD as a
disruption or stalling out of a normal recovery process, rather than the
development of a unique psychopathology. The therapist needs to determine what
has interfered with normal recovery. In one case, it may be that the patient
believes that he will be overwhelmed by the amount of affect that will emerge if
he stops avoiding and numbing himself. Perhaps he was taught as a child that
emotions are bad, that “real men” don’t have feelings, and that he should “just get
over it.” In another case, a patient may have refused to talk about what happened
with anyone because she blames herself for “letting” the event happen and she is
so shamed and humiliated that she is convinced that others will blame her, too. In
a third case, a patient may have seen something so horrifying that every time he
falls asleep and dreams about it, he wakes up in a cold sweat. In order to sleep, he
drinks heavily. Another patient is so convinced that she will be victimized again
that she refuses to go out any more and has greatly restricted her activities and
relationships. In still another case, in which other people were killed, a patient
experiences survivor guilt and obsesses over why he was spared when others were
killed. He feels unworthy and experiences guilt whenever he laughs or finds
himself enjoying something. In all these cases, thoughts or avoidance behaviors
are interfering with emotional processing and cognitive restructuring. There are as
many individual examples of things that can block a smooth recovery as there are
individuals with PTSD.
Pre-Therapy Issues
1. Who Is Appropriate for CPT?
CPT was developed and tested with people with a wide range of comorbid • Who is
disorders and extensive trauma histories. In research settings, we have appropriate
implemented the protocol with people who were from 3 months to 60 years post- for CPT?
trauma (worst trauma), although we have used it clinically for more recent
traumas. We have implemented the protocol successfully with people who had no
more than a fourth-grade education and as little as an IQ of 75 (although in both
cases, we needed to modify the worksheets somewhat). In research protocols,
people have met full criteria for a PTSD diagnosis, but there is no reason that it
could not be implemented with someone who is subthreshold for diagnosis.
However, if the person does not have PTSD at all and has some other diagnosis

(e.g., depression only, anxiety disorder), one should implement treatment
protocols for those disorders (i.e., just because someone has experienced a
traumatic event does not mean that she has PTSD). Clinical considerations as to
whether CPT is appropriate can follow the exclusion criteria we have used for
clinical trials except for those that were for purely methodological reasons (e.g.,
stable psychopharmacological regimen). First and foremost, if someone is a
danger to self or others, treatment of PTSD is not the most immediate treatment
goal. Likewise, if someone is in imminent danger, such as those who are being
stalked or are in an actively abusive relationship, then the first order of business is
safety planning. In contrast, just because someone might be redeployed to a
combat zone does not mean that he could not be treated successfully before
redeployment. The potential for trauma in the future is something we all live with,
so the possibility of future violence or trauma should not stop treatment now. In
fact, successful treatment of PTSD may actually reduce risk for future PTSD.
If someone cannot engage in treatment for his PTSD because he is so dissociative

or has such severe panic attacks that he cannot discuss the trauma at all, then
other therapy may need to precede CPT (e.g., grounding techniques, panic control
treatment). Depression is the most common comorbidity and is not a rule-out
unless the person cannot engage in therapy at all due to the severity of the
depression. We have implemented the CPT protocol with those who are abusing
substances, but typically not in an outpatient setting if they are substance
dependent. However, once someone has stabilized after detoxification, he may be
able to engage in CPT. These decisions need to be made on a case-by-case basis
in consultation with the patient. The motivation of the patient to reduce her PTSD
symptoms may be the most important consideration in whether to proceed with
the protocol. Coping skills development is not a part of the protocol, but a
therapist may choose to train her patients in affect tolerance skills if she
determines that the patients’ skills in this area are so poor that they will act out
and engage in self-harm behavior when thinking or talking about the traumatic
event. In these cases, the therapist may also consider implementing the CPT-C
(without the written trauma account component) rather than CPT (discussed later
in Part III of this manual).
2. When Should the CPT Protocol Begin?
We are frequently asked if it is important to develop a relationship with the • When should
patient before beginning any trauma work. Our answer is no, this is not necessary. the CPT
In fact, if a therapist waits for weeks or months to begin trauma work in the protocol
begin?
absence of any of the contraindications listed above, the patient may receive the
message that the therapist thinks that she is not ready or able to handle trauma-
focused therapy. This reluctance on the part of the therapist may collude with the
patient’s natural desire to avoid this work (as part of her PTSD avoidance
coping). The therapeutic relationship develops quickly within the protocol when
the therapist is using a Socratic style of interacting, because the therapist is
demonstrating to the patient her deep interest in understanding exactly how the
patient thinks and feels through these questions. Also, if additional time is taken

that is not CPT-focused, there is a risk of developing a manner of interacting that
will have to be reshaped in order to deliver the manualized therapy (see below
regarding CPT with established patient).
New Patient. We recommend that with a new patient, the therapist begins the • Starting the
CPT protocol within one to three sessions of assessment and information CPT protocol
gathering. Once the therapist determines that the patient indeed has PTSD, is with a new
interested in treatment for these symptoms, and that other symptoms and life patient
events are not interfering with treatment, the therapist can introduce the protocol
and the contract for CPT (see the Therapist Materials section of the Materials
Manual).
Established Patient. It is somewhat more difficult to transition from another form • Starting the
of therapy with an established patient to CPT than it is to introduce the protocol to CPT protocol
a new patient. We believe that the best method of introducing CPT is to with an
transparently discuss the possibility of this change with the patient. If a therapist established
has been seeing a patient for months or years and there has been no significant patient
improvement in some time, this provides a good opportunity to reassess where the
patient is with regard to symptoms and to suggest a new approach. The therapist
can tell the patient that he has received new training on a protocol that has now
been found to be effective with veterans with PTSD. It is quite acceptable to tell
the patient that you have received new training. The patient should be happy that
you are staying current with the latest procedures (as you would with your
doctors). The therapist should explain how this therapy protocol is different in
both style and content from the therapy they have received up to this point. If the
therapist has not been using a cognitive-behavioral approach, using practice
assignments, following a specific agenda during sessions, or focusing on a
specific traumatic event, this change can be quite dramatic. However, in
conducting supervision with VA therapists who have transitioned their patients to
CPT, there has rarely been a problem as long as the therapist explains the
rationale for the change and how the therapy would differ. The onus is very much
on the therapist to establish and follow the new therapy process because, in our
experience, patients with PTSD are happy to revert to a non-trauma-focused
therapy.
If changing formats within the context of a long-term therapy relationship appears

too daunting, another approach is to switch patients with another therapist who is
also learning CPT. The therapists can explain to the patients that they recommend
this change to another format of therapy in order for the patient to obtain the most
recent advances in the treatment of PTSD and that a fresh start with another
therapist might prove to be easier for both parties. Honesty in this matter is the
best approach.
3. Treatment Contracting for CPT
Regardless of whether someone is a new or an established patient, before starting

the protocol, the therapist should explain what is expected of both patient and

therapist. This therapy protocol is typically conducted in 12 sessions, which could
be administered once or twice a week. The therapy will focus to begin with the
worst traumatic event, although it can move to other events after Session 5. The
patient will be expected to attend all sessions regularly (once a month is not
sufficient) and to complete the practice assignments. The therapist will agree to
adhere to the protocol and focus on the PTSD for this period of time. It is helpful
for the therapist to explain that her job will also be to recognize and discourage
the patient’s avoidance behaviors that have maintained the PTSD.
In the Therapist Materials section of the Materials Manual there is a patient

contract that can be used to demark the work that will be done and to engage the
patient in the process.
Overview of CPT Sessions
The contents of each session are described in Part 2 along with issues that • Overview of
therapists are likely to encounter. The therapy begins with an education CPT sessions
component about PTSD, and the patient is asked to write an Impact Statement in
order for the patient and therapist to begin to identify problem areas in thinking
about the event (i.e., “stuck points”). The patient is then taught to identify and
label thoughts and feelings and to recognize the relationship between them. The
next two sessions focus on generating a trauma account of the worst traumatic
incident, which is read to the therapist in session. During these first five sessions,
the therapist uses Socratic questioning to begin to challenge distorted cognitions,
particularly those associated with assimilation, such as self-blame, hindsight bias,
and other guilt cognitions. Thereafter, the sessions focus on teaching the patient
cognitive therapy skills and finally focus on specific topics that are likely to have
been disrupted by the traumatic event: safety, trust, power/control, esteem, and
intimacy.
After the individual CPT protocol is described in detail, there are subsequent
sections on using the protocol without the written trauma account component, a
section on delivering CPT in a group format, and a section on treatment issues
with comorbid disorders.
It is strongly recommended that the protocol be implemented in the order • Order of

presented here. The skills and exercises are designed to build on one another, and sessions
even the modules in the last five sessions follow in the hierarchical order in which
they are likely to emerge with patients. However, when implemented in individual
therapy, the last five sessions may be modified depending on the particular issues
that a patient reports. For example, if a patient has severe safety issues but no
issues with esteem or intimacy, then the therapist may want to skip the later two
modules and focus more time on safety. Conversely, if someone has no safety or
control issues but is primarily troubled with self-trust and self-esteem issues, then
the therapist may want to spend more time on those modules. However, even if a
patient has not mentioned an issue within a particular domain of functioning
(safety, trust, power/control, esteem, intimacy), it may be helpful for her to read

the module and complete worksheets on any stuck points that become apparent. It
is not unusual for the modules to reveal issues that had not been identified earlier
in therapy.
The usual format for sessions is to begin with review of the practice assignments • Format of
using the Practice Assignment Review, located in the Therapist Materials section each session
of the Materials Manual, followed by the content of each specific session. The
Practice Assignment Review helps facilitate the patient’s compliance with out-of-
session practice assignments because of the therapist specifically inquiring
about these assignments at the beginning of therapy sessions (starting with
Session 2). Review of this form at the beginning of the sessions also decreases the
likelihood of getting off protocol due to an immediate focus on the assignments.
During the last 5 or so minutes of the session, the assignment for the next week is
introduced and is accompanied by the necessary explanation, definition(s), and
handouts. It is not recommended that the therapist start a general discussion at the
beginning of the session but should begin immediately with the practice
assignment that was assigned. If the patient wishes to speak about other topics,
we either use the topic to teach the new skills we are introducing (e.g., put the
content on an A-B-C Worksheet) or we save time at the end for these other topics,
reinforcing the trauma work with discussion of the topic. If the therapist allows
the patient to direct the therapy away from the protocol, avoidance will be
reinforced, along with disruption in the flow of the therapy. In addition, placing
the practice assignments last in the session will send a message to the patient that
the practice assignments are not very important and may lead to less treatment
adherence on the part of the patient. Among the most difficult skills for the
therapist to master, especially if he or she has been trained in more nondirective
therapies, is how to be empathic but firm in maintaining the protocol. If a patient
does not bring in his practice assignment one session, it does not mean that the
therapy is delayed for a week. The therapist has the patient do the assignment
orally (or they complete a worksheet together) in the session and reassigns the
uncompleted assignment along with the next assignment.
Socratic Questioning Within CPT
There are several styles of cognitive therapy within the general class of cognitive • Socratic
therapies. CPT is designed to bring patients into their own awareness of the questioning
inconsistent and/or dysfunctional thoughts maintaining their PTSD. Accordingly,
a cornerstone part of the practice of CPT is Socratic questioning. Throughout the
course of treatment, therapists should be consistently using Socratic questioning
to induce change, with the goal of teaching patients to question their own
thoughts and beliefs. Because the method is so integral to CPT, we have included
more general information here about what Socratic questioning is, and types and
examples of Socratic questions that can be posed.
Socratic questioning originated from the early Greek philosopher/teacher

Socrates. He believed that humans had innate knowledge and that this knowledge
could be revealed by another person asking specific questions. He also contended

that humans who came into knowledge, versus being told, were more likely to
retain the information and build on that knowledge to acquire more knowledge.
Socratic questioning is routinely used in American law schools, in some forms of
cognitive therapy, and specifically in CPT.
Socrates was convinced that thoughtful questioning enabled the logical self-
examination of ideas and facilitated the determination of the validity of those
ideas. As described in the writings of Plato, a student of Socrates, the teacher
feigns ignorance (à la “Columbo” in the modern ages) about a given subject in
order to acquire another person’s fullest possible knowledge of the topic. With the
capacity to recognize contradictions, Socrates assumed that incomplete or
inaccurate ideas would be corrected during the process of disciplined questioning
and hence would lead to progressively greater truth and accuracy.
Applied to CPT, the purpose of Socratic questioning is to challenge the accuracy

of patients’ thinking in a way that will help alleviate their psychological distress.
As the therapy unfolds, the patient is taught how to use Socratic questioning on
himself. Socratic questioning involves subtle methods. Therapists who are
accustomed to delivering overtly directive psychotherapy may find it
disconcerting at first to ask more questions and make fewer interpretive
statements. Therapists who are accustomed to nondirective psychotherapy may
initially be concerned that they are being coercive or too directive with the
patient. Through Socratic questioning, the patient is empowered to take more
credit than the therapist for change that occurs. We have found that this strategy
fosters less dependence on the therapist and encourages patients to take more
responsibility for their treatment. Further, the goal of Socratic questioning is
never for the therapist to “win” an argument or to convince the patient to take the
therapist’s side. Instead, patients are allowed to fully explore their rationale for
their thoughts in a safe environment. Used alone and in conjunction with the
worksheets, Socratic questioning will help patients examine their problematic
thinking that has been created or reinforced as a result of the traumatic event(s).
Socratic questioning consists of six main categories: clarification, probing

assumptions, probing reasons and evidence, questioning viewpoints or
perspectives, probing implications and consequences, and questions about
questions (Paul, 2006). The categories build on one another, but it is also possible
to shift from one category to another throughout a therapy session. Below are
sample questions that can be used in sessions to help patients examine their
beliefs.
1. Clarification
Patients often accept their automatic thought about an event as the only option. • Clarification
Clarification questions help patients examine their beliefs or assumptions at a questions
deeper level, which can help to elicit more possible reactions from which to
choose. These questions often fall into the “tell me more” category and are
typified by the following:

- What do you mean when you say…?
- How do you understand this?
- Why do you say that?
- What exactly does this mean?
- What do we already know about this?
- Can you give me an example?
- Are you saying…or…?
- Can you say that another way?
2. Probing Assumptions
Probing questions challenge the patient’s presuppositions and unquestioned • Probing

beliefs on which her argument is founded. Often patients have never questioned assumptions
the “why” or “how” of their beliefs, and once the beliefs are held up to further
inspection, the patient can see the tenuous bedrock that the beliefs are built on.
- How did you come to this conclusion?

- What else could we assume?
- Is this thought based on certain assumptions?
- How did you choose those assumptions?
- How did you come up with these assumptions that…?
- How can you verify or disprove that assumption?
- What would happen if…?
- Do you agree or disagree with…?
- If this happened to a friend/sibling, would you have the same
thoughts about them?
3. Probing Reasons and Evidence
Probing reasons and evidence is a similar process to probing assumptions. When • Probing
reasons and
the therapist helps patients look at the actual evidence behind their beliefs, they evidence
often find that the rationale in support of their arguments is rudimentary at best.
- How do you know this?

- Show me…?
- Can you give me an example of that?
- What do you think causes…?
- Are these the only explanations?
- Are these reasons good enough?
- How might it be refuted in court?
- Would these reasons stand up in a reputable newspaper?
- Why is…happening?
- Why?
- What evidence is there to support what you are saying?
- Has anyone in your life expressed a different opinion?
- Would _________ stand up in a court of law as evidence?

4. Questioning Viewpoints and Perspectives
Often the patient has never considered other viewpoints but instead adopted a • Questioning
viewpoints
perspective that fits his needs for safety and control most readily. By questioning and
alternative viewpoints or perspectives, the therapist is in effect “challenging” the perspectives
position. This will help the patient see that that there are other, equally valid,
viewpoints that still allow the patient to feel appropriately safe and in control.
- What alternative ways of looking at this are there?

- What does it do for you to continue to think this way?
- Who benefits from this?
- What is the difference between…and…?
- Why is it better than…?
- What are the strengths and weaknesses of…?
- How are…and…similar?
- What would…say about it?
- What if you compared…and…?
- How could you look at this another way?
5. Analyzing Implications and Consequences
Often patients are not aware that the beliefs that they hold lead to predictable and • Analyzing
often unpleasant logical implications. By helping the patient examine the implications
and
potential outcomes to see if they make sense, or are even desirable, the patient consequences
may realize that their entrenched beliefs are creating a large part of their distress.
- Then what would happen?

- What are the consequences of that assumption?
- How could…be used to…?
- What are the implications of…?
- How does…affect…?
- How does…fit with what we learned in session before?
- Why is…important?
- What can we assume will happen?
- What would it mean if you gave up that belief?
6. Questions About the Question

• Questions
Often therapists become flustered when patients ask direct questions or make
about the
direct statements toward the therapist that may even appear to be “challenging the question
therapist” or an attempt to violate therapist-patient boundaries. For example,
“have you ever been to war?” or “have you ever been raped?” At these points in
therapy it can be very helpful to question the question. By putting the focus back
on the patient and his intentions, the dialogue is often de-escalated and this can
allow the patient to more thoroughly examine his motives for asking in the first
place.

- What is the point of asking that question?
- Why do you think you asked this question?
- What does that mean?
- What would getting an answer either way mean to you?
- Are you concerned that I don’t understand? Please tell me what
you think I am missing. I would like to understand what the
experience was like for you.
Issues in Conducting CPT
Many therapists were never trained to conduct manualized psychotherapies and • Therapist-
may feel uncomfortable with both the concept and the execution. It is important patient
that the patient and therapist agree on the goal for the therapy (trauma work for agreement on
therapy goals
PTSD and related symptoms) so that the goals do not drift or switch from session
to session. Without a firm commitment to the treatment goals, when the therapy is
“off track,” the therapist may not know whether to get back on the protocol or to
let it slide. As other topics arise, the therapist sometimes isn’t sure whether, or
how, to incorporate them into the sessions. A few words on these topics are
appropriate here. Once therapists have conducted protocol therapy a few times,
they usually find that they become more efficient and effective therapists. They
learn to guide the therapy without tangents or delays. They find they can develop
rapport with patients through the use of Socratic questions because the patients
are explaining to the therapist exactly how they feel and think and the therapist
expresses interest and understanding with these questions. There is usually
enough time in the session to cover the material for the session and still have time
for some other topics, such as things that came up that week or other current
issues related to their PTSD (childrearing, job concerns, marital issues, etc.).
However, if those are major issues, then the therapist will need to prioritize the
order. It is inadvisable to try to deal with several types of therapy for different
problems simultaneously.
1. Comorbidity
Although PTSD has very high rates of comorbidity (other disorders along with the • Comorbidity
PTSD), normally, comorbid depression, anxiety, and dissociation remit along
with PTSD. Therefore, we believe there is rarely a need to deal with other
symptoms independently of the PTSD protocol.
Major depressive disorder, which occurs in approximately half of people with

PTSD and substance abuse, the rates of which vary depending on the population
being studied, are both commonly comorbid with PTSD. Anxiety disorders and
personality disorders are also fairly common. Additionally, health problems are
associated with PTSD. Fortunately, except for patients with substance
dependence, CPT has been tested on patients with a range of disorders in addition
to PTSD. Thus far, we have found that those with major depressive disorder
improve as much as those without the disorder, although they may begin and end

with higher levels of depressive symptoms. Patient-reported health symptoms
improve significantly, and measures of anxiety and dissociation also improve
over the course of treatment. Other complex symptoms such as an impaired sense
of self and tension-reduction behaviors (e.g., self-harming behaviors and acting
out) improve markedly with treatment. Nevertheless, there are considerations that
should be mentioned with regard to comorbid disorders. Discussing all possible
comorbid disorders is beyond the scope of this manual, so we have picked a few
of the more common disorders for your consideration.
Substance dependence should be treated before addressing PTSD, but substance- • Substance
abusing patients may be treated with CPT if there is a specific contract for not use disorders
drinking abusively during the therapy, and if there is a specific focus on the
suspected role of abusive drinking as avoidance coping. Further, it may be
possible to implement CPT immediately following substance abuse treatment.
In fact, if the veteran is following an inpatient admission for detoxification with a
residential program, there may be a unique window of opportunity to treat PTSD.
It is not unusual for intrusive recollections of traumatic events, particularly
nightmares and flashbacks, to emerge after someone has stopped drinking or
using drugs. The substance use may have served as a method to avoid these
memories and to suppress unwanted emotions. So, after detoxification, these
PTSD symptoms may reassert themselves. If the patient is motivated to work on
his PTSD, or if the therapist can use the increase in symptoms as a motivator,
there may be an opportunity to improve those PTSD symptoms before the patient
can fall back into his usual coping method and relapse. At this point, based on
clinical experience rather than research, our best predictor of success with CPT
with this population is motivation to change. The therapist should ask in a very
straightforward fashion whether the patient wants to improve his PTSD
symptoms enough to refrain from alcohol or drugs for treatment to commence.
Some patients have been able to tolerate CPT, including the account writing,
fairly soon after stopping their substance abuse, while others announce that they
will relapse if they talk about the trauma even years after sobriety. We take these
patients at their word. If someone promises to relapse, we do not implement the
protocol, but let them know that it is available when they are ready. Those who
proceed with treatment need to understand how their substance abuse has served
as avoidance, and the therapist should check in frequently about urges to drink or
use. If such urges occur during treatment, they can, in fact, indicate particular
stuck points or important emotions that should be processed. CPT without the
trauma account (CPT-C, discussed later in this manual in Part III: Alternatives
and Considerations in Conducting CPT) can also be implemented if the therapist
and patient determine that the patient is, in fact, too fragile to handle writing
about the trauma memory (i.e., reluctance is not due to the more common stuck
points about emotions). Typically we have the patients focus on specific child,
family, and marital issues after completing the course of PTSD treatment.
Sometimes those problems remit when the patient no longer has PTSD interfering
with functioning.

Major depressive disorder (MDD) is the most common comorbid disorder with • MDD
PTSD. Being depressed is not a rule-out for PTSD treatment. In fact, PTSD
treatment should successfully address MDD that is often secondary to the PTSD.
All treatment outcome studies on PTSD have found substantial and lasting
improvement in depressive symptoms along with PTSD improvement. There are
only a few caveats to consider. Although medication instability is a typical
exclusion criterion for psychosocial treatment outcome studies for pragmatic
purposes (i.e., is change attributable to the intervention or the medication?),
medication changes can also complicate clinical practice. A clinician may be
tempted to throw every possible intervention at the patient at once, expecting to
achieve the quickest possible results. However, if a patient is beginning or
increasing a medication while starting psychotherapy, neither the patient nor the
clinician will know what was effective. Why does this matter? When the patient
begins to feel better, she may attribute the change to the medication, even if it is
not the case, and not attribute the change to her own efforts. She may even stop
complying with psychotherapy. Also, if the medication was the locus of the
change, the prescribing physician needs to know what the minimally effective
dose of the medication is without the confusion of the common occurrence of
increasing symptoms during the trauma account or decreasing symptoms after the
trauma accounts or cognitive therapy. The prescribing physician and therapist
need to coordinate their efforts to minimize this confusion.
We have occasionally seen patients who were so heavily and multiply medicated • Psychotherapy
that they were unable to engage in treatment or access appropriate emotions. We and medication
have also occasionally seen unmedicated patients whose depression was so severe
they could not muster the energy to attend treatment or comply with assignments.
Either extreme is a problem that must be rectified before appropriate
psychotherapy can be implemented. It is important to stress that we are not
suggesting that all patients with PTSD, with or without MDD, should be on
medications. Rather, we suggest that, if a patient can tolerate her distress for a
few more weeks while CPT begins, there may not be a need for medications at
all. In addition, many of the young returning service members may not want to
begin a regimen of psychotropic medications. There is very little research on the
combination or sequencing of medication and psychotherapy to guide us at this
point. Good communication between providers can assist with decision making
on the appropriateness and sequencing of medication.
As with depression and substance abuse, the concern with other anxiety disorders • Anxiety
is whether they are so disabling that they interfere with PTSD treatment. If disorders
obsessive-compulsive disorder (OCD), panic disorder, or agoraphobia is so severe
that the patient cannot engage in PTSD treatment, then the other disorder should
be treated first. If the other anxiety disorder appears to be trauma-related (i.e., the
onset, precipitants, and anxious content appear conceptually related to traumatic
events) and the person can attend treatment, then it is quite possible that
successful treatment of PTSD will improve the comorbid anxiety condition(s) as
well. Any therapist who works with PTSD patients in VA will have heard stories
of patients who secure their home perimeter every evening before bedtime,

sometimes for hours. These superstitious safety behaviors may rise to the level of
OCD. When we have treated patients with PTSD and OCD, we have started with • OCD
the PTSD to see if the OCD symptoms would improve. There is no reason at this
point to expect that PTSD symptoms will improve with successful OCD
treatment. These OCD types of behaviors can be considered right along with
safety issues in Sessions 7 and 8, with the goal of getting the patients to test out
their overestimated level of danger (P: “If I don’t secure the perimeter this
amount, my house will be attacked.” T: “Do your neighbors and the people on
the next block march with rifles? Have they been attacked? Has there ever been a
time when you couldn’t do it?”). Once the flashbacks, nightmares, and triggered
false alarms are reduced, it is easier to explain the principles of behavioral
exposure and response prevention along with the cognitive work. Later in the
protocol, the therapist could assign the patient to do an experiment to test his
assumptions. Although this is not a typical component of CPT, a behavioral
experiment might be very helpful with comorbid anxiety disorders. OCD
symptoms may also be addressed while working on issues of control. The person
with OCD has the temporary illusion of control when engaging in the ritual that is
intended to reduce his anxiety. Aside from the fact that the rituals (cleaning,
checking, etc.) soon come to control the person rather than the other way around,
the therapist can help the patient to accept that he can’t have control over future
events (see Session 10) and that the rituals don’t prevent future events from
occurring and may be totally irrelevant.
Panic disorder is commonly comorbid with PTSD, and more so under the DSM- • Panic
IV decision rules than under the previous DSM-III-R, which disallowed the disorders
diagnosis in the presence of other Axis I disorders. Our research with CPT
indicates an improvement in panic symptoms without any particular extra
intervention. However, there are some people who are so crippled by their panic
disorder that they cannot tolerate discussing the traumatic event without having
panic attacks. In this case, the therapist may want to consider treating the panic
disorder first with a cognitive-behavioral treatment such as panic control
treatment (Craske, Barlow, & Meadows, 2000 5 ) or simultaneously with CPT
(Falsetti et al., 2001 6 ). Falsetti and her colleagues developed a protocol that
combines CPT with panic control treatment.
The challenge with personality disorders in PTSD treatment is how to stay on • Personality
track with the protocol and not get derailed by side issues. In other words, the disorder
therapist does not attempt to treat the personality disorder but treats the PTSD in
spite of the personality disorder. The therapist needs to keep in mind that the
patient has been coping with his life circumstances for a long time, albeit
5
Craske, M. G., Barlow, D. H., & Meadows, E. A. (2000). Mastery of your anxiety and panic:
Therapist guide for anxiety, panic, and agoraphobia (MAP-3). San Antonio, TX:
Graywind/Psychological Corporation.
6
Falsetti, S. A., Resnick, H. S., Davis, J., & Gallagher, N. G. (2001). Treatment of posttraumatic
stress disorder with comorbid panic attacks: Combining cognitive processing therapy with panic
control treatment techniques. Group Dynamics, 5(4), 252–260.

ineffectively, and that getting pulled off onto the “crisis of the week” can serve as
an avoidance function to doing the trauma work. If one can conceptualize
personality disorders as over-generalized patterns of responding across a range of
situations, then it is quite easy to see how someone with a long history of trauma,
or coping with his trauma, might develop avoidant personality, dependent
personality, and so forth. These beliefs and behavioral patterns served a
functional purpose, at least at some point in the person’s life. It is now
dysfunctional because these patterns are so over-generalized (and probably
obsolete). Within the cognitive framework, these over-generalized assumptions
and beliefs become reified to the schema level and become automatic filters
through which all experiences pass. Any experiences that do not conform to the
over-riding schema are either distorted (assimilated) to fit the construct or
ignored. Those experiences that appear to confirm the over-riding schema are
used as proof and lead to further over-accommodation. It is difficult to challenge
a large schema such as “everyone will abandon me” or “I can’t take care of
myself,” so the therapist should continually bring these global ideas down to very
specific events, thoughts, and emotions and then challenge the evidence on those
specific events with Challenging Beliefs Worksheets. When the same
assumptions emerge across many worksheets, the therapist can say, “I am
detecting a theme here. Across these six worksheets it always comes back to the
thought that people are trying to harm you (or whatever the schema is). You have
said this to yourself so often and across so many situations that you have come to
believe it is carved in stone as TRUTH. And we are going to have to chip away at
that belief just like you would have to chip away at stone to get it to change—in
this case, one worksheet at a time. Now I see that each time you have done a
Challenging Beliefs Worksheet that you were able to challenge the thought that
someone was intentionally trying to harm you. How many experiences will you
need to have, how much evidence will you need to move to the thought that some
people are not trying to harm you? And how would that feel if you believed that?”
While dissociative disorders are relatively rare, dissociative responses are fairly • Dissociation
common in traumatized individuals. In fact, peritraumatic dissociation, and amnesia
dissociation during or immediately after the traumatic event, is one of the most
robust predictors of PTSD. Dissociation can become conditioned, just like the
fight-flight response, to previously neutral cues. If the patient dissociates
whenever she is reminded of the trauma, such dissociation may interfere with the
tasks required during therapy. There are several solutions to this problem. One is
that the therapist can work with the patient in advance to refrain from
dissociating, through grounding techniques (e.g., cueing to date, time, location,
safety; touching a predetermined object as a reminder). The therapist needs to
provide a rationale for the patient to learn not to dissociate when stressed. There
are two good rationales. One is that dissociation actually puts the veteran at
greater risk, in that if she were really in danger, she would have fewer options for
extricating herself from the situation. Another rationale for learning not to
dissociate is that dissociation is an emergency response, like the fight-flight
response, that shuts down immune and other normal functioning. Having this
emergency response occur frequently, dysregulates the person’s immune

functioning. PTSD has been associated with greater health problems, and people
who dissociate frequently are often observed to have higher rates of many
physical disorders and diseases.
Another option for problematic dissociation is to use the CPT-C protocol. A third
option is to use the CPT protocol but have the patient write the account using
techniques to minimize dissociation. One strategy that we have used successfully
is to have the patient set a kitchen timer for 5 minutes and start writing. The bell
serves to interrupt dissociation, orienting the patient back to the present. The
kitchen timer can then be set for 6 minutes, with the patient returning to reading
or writing the account. The timer can be set for progressively longer periods to
provide graded habituation and stronger grounding skills.
In summary, therapists should not be daunted by comorbid disorders

accompanying PTSD or assume that CPT cannot be implemented with patients
who have extensive trauma histories. CPT was developed and has been tested
with patients who almost all had complex trauma histories and various
comorbidities. The decision the clinician must make is whether the comorbid
disorder is so severe that it will preclude the patient’s participation in PTSD
treatment. In that case, the therapist may want to treat the comorbid disorder
before, or simultaneously, with CPT. There are evidence-based cognitive-
behavioral therapies for most comorbid conditions that clinicians will encounter.
For the most part, however, the treatment of PTSD will improve the comorbid
symptoms and may even eliminate the necessity of further treatment for those
symptoms.
2. Avoidance
Most veterans present for PTSD treatment many years after the traumatic event. • Discourage
patient
They are usually not in crisis and are able to handle their day-to-day lives (at
avoidance
whatever level they are functioning) without constant intervention. Much of the
disruption in the flow of therapy for PTSD comes from avoidance attempts on the
part of the patient. We point out avoidance whenever we see it (e.g., changing the
subject, showing up late for sessions) and remind the patient that avoidance
maintains PTSD symptoms. If the patient wants to discuss other issues, we save
time at the end of the session or attempt to incorporate her issues into the skills
that are being taught (i.e., A-B-C Worksheets, Challenging Questions
Worksheets, Patterns of Problematic Thinking Worksheets, Challenging Beliefs
Worksheets). If the patient does not bring in practice assignments, we do not
delay the session but conduct the work in session and then reassign the practice
assignment along with the next assignment.
3. Needs of Returning OIF/OEF Veterans
Returning Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) • OIF/OEF

veterans
military personnel and veterans may have different needs than veterans from other
wars/conflicts. They may prefer two sessions a week so that they can get therapy

finished quickly. They may request early morning or evening appointments to
accommodate their jobs. They may want their PTSD treatment augmented with
couples counseling. They may appear a bit more “raw” than the very chronic
Vietnam veterans that most VA clinicians are accustomed to working with. The
more accessible emotions are actually an advantage in processing the traumatic
events and in motivating change, but therapists who have worked with only very
chronic (and emotionally numb) veterans may become alarmed when they first
work with these patients. They may think that strong emotions or dissociation
should be stabilized or medicated first. However, CPT was developed and tested
first with rape victims who may also be very acute and very emotional. As long as
patients are willing to engage in therapy and can contract against self-harm and
acting out, there is no reason to assume that they need to wait for treatment.
4. PTSD-Related Disability Status
Therapists often express concern about the patient’s disability status and what • PTSD-related
will happen to her disability status and entitlements if the PTSD is effectively disability
status
treated. For OIF/OEF veterans, the goal is to have them return to gainful
employment and not be on disability for their PTSD. At the beginning of
treatment with these patients, they may not be able to conceptualize sleeping
through the night again, not being disrupted by flashbacks, or having the
concentration to hold down a job. The therapist needs to impart a clear message
that these symptoms can improve, to instill some hope in the patient. However,
specific career or job planning might be postponed until later in therapy to see
how much symptom remission has been achieved. If the veteran sustained head
injuries during his deployment, it may not be clear how much of the symptom
picture is due to PTSD and how much is due to brain injury until the PTSD
symptoms are resolved.
Older veterans (and their therapists) are sometimes reluctant to engage in an

efficacious treatment for fear of losing benefits and not being able to support
themselves. We highly encourage clinicians to seek out specific information from
their Veterans Benefits Administration (VBA) staff about the likelihood that
veterans will have their disability rating reevaluated. In our experience, there is
much lore around VBA taking away veterans’ benefits. In our discussion with
VBA staff, they have indicated that they are so burdened with claims that they do
not have time to review older cases unless the veteran is seeking an increase in his
disability or there is some concrete evidence that the veteran is making money
through employment and he is not supposed to be able to be employed. There
may be an infamous case in your VA in which entitlements were taken away or
decreased, but it is important to assess more accurately with the veteran the
probability of such a situation occurring.
PTSD-related disability seems to present as the biggest challenge if a patient is

actively seeking a disability rating or increase in her existing rating. We
encourage clinicians to be up-front with patients about the timing of CPT in
relation to their pursuit of service-connected benefits. If they are actively trying to

prove that they have symptoms of PTSD, it is logically not the time to engage in a
therapy that is shown to decrease symptoms. It is far better to prevent the veteran
from having a failed therapy experience by delaying a course of CPT than it is to
proceed with a course that was doomed from the outset. There are many disabled
and nondisabled veterans with PTSD who are not seeking a change in their rating
who are better positioned to take advantage of the benefits of CPT. Veterans in
the claims process may want to seek a supportive therapy or non-trauma-focused
intervention while awaiting the outcome of their claims.
If someone is rated with a permanent 100% service-connected PTSD disability,

the veteran has every right to benefit from symptom reduction to improve the
quality of her life. If the veteran is not considered permanently and 100%
disabled by her PTSD, then the therapist should ask the patient to consider the
costs and benefits of symptom reduction and quality of life if her PTSD
improved, and the probability that her service-connected entitlement would even
change as a result of an improvement in her PTSD. Therapists should remember
that there is the option of diagnosing with PTSD, In Partial Remission, in their
progress note documentation.
In some cases, disability status is actually a stuck point that needs to be

challenged because it has an alternative function (“If I am not a disabled veteran,
who am I?” “If I stop receiving the benefits, that means the government thinks
what happened to me was not important”).
5. Religion and Morality
There are several ways in which religion and morality more generally intersect • Issues of
religion and
with PTSD. It is not uncommon for there to be disruptions in religious beliefs morality
(“How could God let this happen?” “Is God punishing me?”) or stuck points that
are produced by the conflict between the traumatic event and prior religious
beliefs. This may be directly entangled in the “just world belief” (“Why me?”
“Why not me?” “Why did my friend/family die?”), which is taught directly by
some religions but could have been inferred by the patient and not actually part of
the religion. It could be in the context of a violation of one’s moral or ethical code
(“I murdered people while in Iraq”). It could also entail other people trying to get
the patient to forgive himself or forgive a perpetrator.
You should not avoid these topics, because they may prove to be at the heart of
your patient’s PTSD. Even if you have a different set of religious beliefs (or are
agnostic or atheist), it is not a good reason to avoid these topics. You need to
wade into cross-cultural beliefs as part of your work, and religion is an important
part of your patient’s culture. The just world belief is probably the most common
assumption that is taught, not just by religions but also by parents and teachers.
People like to believe that if they follow the rules that good things will happen
and that if someone breaks the rules that they will be punished. People fail to
learn this as a probability statement (“If I follow the rules, it decreases my risk of
something bad happening”), which would be more realistic. If people hold

strongly to the just world belief, then they may engage in backward reasoning.
This would lead them to the conclusion that if something bad happened to them,
they are being punished. However, if they can’t figure out what they did wrong,
they will end up railing at the unfairness of the situation or of God. No religion
guarantees that good behavior will always be rewarded and bad behavior
punished (here on earth), so if your patient says this, then he may have either
distorted his religion or was taught this by a mistaken parent or religious leader.
Like any profession, there is variability on how educated or adherent a religious
leader is to the tenets of the religion. Please make sure you differentiate the
religion itself from an individual practitioner when you discuss these issues. You
may be able to check with the tenets of the religion through a Web search or by
talking to clergy at your VA or your own place of worship.
When someone doesn’t understand how God could let an event happen that
involves another person (rape, assault, combat), the concept of free will may be
very helpful. Most Western religions adhere to the concept of free will, of choice
to behave or misbehave (or what are heaven and hell for?). If God gives an
individual free will to make choices, then it does not follow that He would take
away the free will of another person in order to punish the patient. That person
also had free will to fire the gun or rape, etc. Free will implies that God does not
step in and stop the behavior of others any more than He forces the patient to
behave or misbehave. Furthermore, even when there is not another person’s
behavior and choice involved, it does not take a great deal of inspection of the
world to find evidence that God is not using natural events, accidents, or illnesses
only to punish bad people. When we see these events happening to infants,
children, or people we know to be wonderful, caring individuals, the only thing
that we can fall back on at that point is that “God works in mysterious ways.”
However, it could also be the case that God does not intervene in day-to-day lives
and that the concept of God should be used for comfort, community, and moral
guidance.
If a patient believes that lives are predetermined and that he has no free will, then
you may wonder why he has PTSD. What is the conflict? Is he having trouble
accepting his fate? Or is it just a matter of not being able to process emotions?
You should ask the patient how he came to understand what happened to him, and
what images or thoughts he keeps coming back to.
The question that may logically follow “Why me?” is “Why not you?” If • “Why me?”
someone wonders why she was spared (language that implies intent) when others
were killed, the same line of questioning can proceed. Is there logic to war, to
who dies or who lives? Because someone is a good person, did that make her
more immune to being killed in war? Unfortunately, the military, as well as
religions, may reinforce the notion that if something bad happened, someone
made a mistake. In the military, after events transpire, service members may be
subject to debriefings to determine “what went wrong.” While it is
understandable that military leaders are attempting to reduce risk in the future,
they are also planting the message that someone made mistakes for the outcome

to be as it was (as opposed to the possibility that an ambush worked or that the
combatants were outmanned in a particular situation).
The concepts of self- or other-forgiveness are sometimes brought up in therapy. If • Self- or other-
these issues are comfortable concepts for a patient, she probably would not bring forgiveness
them up for discussion. Instead, they are typically mentioned because there is
some discomfort with or conflict over the subjects. As noted above, with regard to
self-forgiveness, it is very important for you to first challenge the specifics of the
event to see if your patient has anything to forgive herself for. Because it is
almost axiomatic that people will blame themselves for traumatic events, it does
not mean that they intended the outcome. Therefore, blame and guilt may be
misplaced. If someone is the victim of a crime, she is just that, a victim. There is
nothing she could have done that would justify what happened to her. Because a
woman feels dirty or violated does not mean that she did anything wrong that
needs forgiveness. This would be an example of emotional reasoning. Killing
someone in war is not the same as murdering someone. The person may have had
no other options than what occurred at the time, so the Socratic questioning needs
to establish intent, available options at the time, etc. One should only discuss self-
forgiveness when it has been established that the patient had intended harm
against an innocent person, that he had other available options at the time and
willfully chose this course of action. Killing a civilian by accident (e.g., someone
caught in the crossfire) in a war is just that, an accident. Committing an atrocity
(raping women or children, torturing people) is clearly intended harm. Guilt is an
appropriate response to committing an atrocity or a crime. A patient may well
need to accept what he has done, be repentant, and seek out self-forgiveness, or if
religious, forgiveness within the church or other place of worship. Even then you
should work with your patient to contextualize who he was then with what his
values are now to help him realize that he is not the same as when the event
occurred. Once all this has been thoroughly processed and digested, some form of
restitution or community service may assist the patient in moving beyond his
permanent, self-inflicted sentence.
Forgiving others is sometimes brought into the session when the concept is
premature or forced by others. If a patient has just accepted that the event was not
her fault (e.g., sexual abuse or assault), she may be just recognizing that the other
person intended the harm and is to blame for the event. To foreclose on the
righteous anger before letting it run its course may bring comfort to a family, but
it is the same type of PTSD symptom that has been occurring already, avoiding
affect. You can ask the patient if the perpetrator has asked for forgiveness. Most
churches or other places of worship do not confer forgiveness on the unrepentant.
If the perpetrator has not asked for forgiveness, there is no need for the patient to
forgive. Even if the perpetrator of the traumatic event has asked for forgiveness,
the patient is not obligated to give it. Understanding why someone did something
is not the same as excusing him. The patient could refer the perpetrator to the
church, or other places of worship, to ask forgiveness of God. The purpose of the
patient granting forgiveness should not be for someone else to pretend that all is

well, but only for giving the patient some peace of mind. If forgiveness is being
forced by others, it will only bring frustration and guilt.
6. Military Sexual Trauma (MST)
Although there are many different types of traumatic experiences, each unique in • Military sexual
its own way, experiences of sexual trauma often raise special issues for patients trauma (MST)
and clinicians. This is particularly true when the trauma is what the VA terms
“military sexual trauma”; that is, sexual assault or repeated, threatening acts of
sexual harassment that occurred while the veteran was in the military. Sexual
assault is any sort of sexual activity between at least two people in which
someone is involved against his or her will. Physical force may or may not be
used. The sexual activity involved can include many different experiences such as
unwanted touching, grabbing, oral sex, anal sex, sexual penetration with an
object, and/or sexual intercourse. Sexual harassment that falls into the category of
MST involves repeated, unsolicited, and threatening verbal or physical contact of
a sexual nature. Examples of this include threats of retaliation for not being
sexually cooperative or implied faster promotions or better treatment in exchange
for being sexually cooperative.
A number of studies have shown that MST experiences are extremely prevalent
among veterans; rates are typically even higher among veterans using VA
healthcare. Although sexual trauma occurs more frequently among women than
among men, the disproportionate ratio of men to women in the military means
that as a clinician working with veterans, you are about equally likely to
encounter men with experiences of MST as you are to encounter women with
experiences of MST. In general, rape is the trauma most likely to be associated
with PTSD, meaning that you may treat sexual trauma quite frequently in your
CPT work.
While there is little empirical data comparing experiences of military sexual

trauma with experiences of sexual harassment and assault that occur outside of
military service, there are aspects of MST that may make these experiences
qualitatively different for victims. For example, because sexual trauma associated
with military service most often occurs in a setting where the victim lives and
works, many victims must continue to interact and work closely with their
perpetrators on an ongoing basis after the trauma. This often increases their sense
of helplessness and powerlessness and may leave them at risk for additional
victimization. Given the “total” nature of the military environment, this
victimization may take a variety of forms. Victims may need to rely on their
perpetrators (or associates of their perpetrator) to authorize medical and
psychological care or provide for other basic needs. There may also be career-
related consequences for victims in that perpetrators are frequently peers or
supervisors with the power to influence work evaluations and decisions about
promotions. Even if this is not the case, victims may face the difficult choice of
either continuing military careers in which they are forced to have frequent

contact with their perpetrators or sacrificing career goals in order to protect
themselves from future victimization or retraumatization.
Most military groups are characterized by high unit cohesion, particularly during
combat. Although this level of solidarity is typically a positive aspect of military
service, the dynamic it creates may amplify the difficulties of responding to
sexual harassment and assault in this environment. For example, the high value
placed on organizational cohesion may make it taboo to divulge any negative
information about a fellow soldier. As a result, many victims are reluctant to
report sexual trauma and may struggle to identify even to themselves that what
occurred was an assault. Those who choose to report to those in authority often
feel that they are not believed or, even worse, find themselves blamed for what
happened. They may be encouraged to keep silent and their reports may be
ignored. Having this type of invalidating experience often has a significant
negative impact on the victim’s posttrauma adjustment.
• MST and
How might these factors impact your CPT work with veterans? First, trust (both
CPT
of oneself and others) may be a particularly potent issue given that perpetrators
are most often someone the victim knows and may have been someone with
whom the victim was quite close. Because of this relationship, victims may have
stuck points related to the idea that the sexual assault or harassment was
consensual, or at least condoned on their part; it will be important for you to
remind them of the coercive aspects of the context surrounding the trauma. As
with sexual trauma occurring outside the military, the stigma associated with
sexual trauma may mean that you encounter a great number of stuck points
related to self-blame and esteem. Men in particular may express concerns about
their sexuality, sexual identity, or their masculinity. It may be hard for them to
reconcile what happened with societal beliefs about men being strong and
powerful—acknowledging their vulnerability is at odds with how they have been
taught to think about themselves as men. In addition, individuals who have been
sexually traumatized are at particularly high risk of experiencing subsequent
sexual victimization. When this happens, victims may find themselves stuck on
issues related to agency (power and control) and self-worth.
Another issue to consider is that because sexual arousal typically occurs in • Sexual
arousal
pleasurable settings, most people assume that sexual arousal equates with during MST
enjoyment. Victims of sexual assault may erroneously conclude that, because
they may have experienced arousal or even orgasm, that they must have enjoyed
the experience, that they are perverted, or that their bodies betrayed them. All
these conclusions are incorrect. It is quite possible to be stimulated and
experience fear, horror, or anger instead of pleasure. Soldiers have reported
experiencing erections or even orgasm in combat. That doesn’t mean that they
were experiencing enjoyment or found the experience to be sensual. It does mean
that they experienced a cascade of hormones throughout their bodies that
happened to include those that stimulate sexual arousal.

Patients are often reluctant to bring up this topic in therapy. They may feel deep
shame that they experienced sexual arousal in a situation in which they believe it
to be inappropriate and may view it as some type of personal failing. The
therapist can help alleviate this guilt and shame through education and should
bring up the topic in a low-key and routine way if the patient does not broach the
topic. One of the simplest ways to help the patient to think differently about it is
to remind the patient that sexual arousal is not a voluntary response any more
than being tickled is. In fact, tickling is a good analogy to use. Someone can be
tickled against his will, be laughing, and hate it at the same time. When nerve
endings are stimulated, there is no conscious choice about whether those nerve • Example
• worksheets
Example
endings should react. If the patient is helped to see that his or her reactions were worksheets
the normal outcome of stimulation and not some moral choice, he or she should on MST
on MSTin
located
experience relief and the lessening of guilt or shame. Please refer to the Patient located in
Materials
Workbook for examples of an A-B-C Worksheet, Challenging Questions Appendix B
Manual
Worksheet, and Challenging Beliefs Worksheet on MST.
7. Ongoing Symptom Assessment Using PTSD and Depression Scales
It is recommended that the patient be assessed, not just before and after treatment • Using PTSD
but during treatment as well. We typically give patients a brief PTSD scale and a & depression
depression scale, such as the Beck Depression Inventory 7 (if comorbid depression scales
is a problem), once a week. The PCL-S monthly version is administered once
before the first session and evaluates the patient’s symptoms during the past
month. Subsequent administrations of the PCL-S evaluate the patient’s symptoms
during the prior week and are administered weekly. We recommend that the
weekly versions of the PCL-S be given to the patient while he is waiting for the
start of the session. Most often there is a large drop in symptoms when the
assimilation about the trauma is resolving. Typically this occurs around the fifth
or sixth session with the trauma account and cognitive therapy focusing on the
traumatic event itself. Occasionally this takes longer, but with frequent
assessment, the therapist can monitor the progress and see when the shift occurs.
Both the monthly and weekly versions of the PCL-S are located in the Therapist
Materials section of the Materials Manual.
8. A Note on Session 2a—Bereavement
Included in this manual is a module for traumatic bereavement (Session 2a). This • Optional
bereavement
module is not included as 1 of the 12 sessions but could be added to the therapy. session
If the additional bereavement session is added, the protocol becomes 13 sessions;
session 2a does not replace any of the other sessions. We recommend that the
session be added early in therapy, perhaps as the third session. Although we
expect PTSD to remit as a result of treatment, we do not necessarily expect
bereavement to remit. Grief is a normal reaction to loss and is not a disorder.
Bereavement may have a long and varied course. The goal of dealing with grief
7
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for
measuring depression. Archives of General Psychiatry, 141, 1311.

issues within CPT is not to shorten the natural course of adjustment but to remove
blocks and barriers (distorted cognitions, assumptions, expectations) that are
interfering with normal bereavement. Therefore, the focus is on normal grief,
myths about bereavement, and stuck points that therapists may need to focus on in
this domain. If the bereavement session is added to CPT, one possibility is to have
the patients write two Impact Statements if they have both lost a loved one and
have PTSD related to something that happened to them directly. One statement
would be about what it means that the traumatic event happened to them. The
other statement would be about what it means that the loved one has died.

| Part 2: | CPT: Session by Session
It is presumed that the therapist will have conducted some form of

assessment of the patient’s traumatic event and persistent symptoms and
specifically contracted to do a course of CPT before undertaking the first
session. At least a brief assessment of PTSD and depressive symptoms
should be conducted. There are several brief PTSD checklists and
depression scales that can be used to assess pretreatment symptoms and to
conduct repeated assessments during therapy to monitor progress across
treatment. The PCL-S is included in this manual.
The contents of the following pages contain summaries, guided explanations of

the session, sample session notes, and accompanying handouts for the therapist’s
reference. Reproducible copies of the patient handouts can be found in the CPT
Materials Manual.
The individual sessions are:
Session 1: Introduction and Education

Session 2: The Meaning of the Event
Session 2a: Traumatic Bereavement (Optional session)
Session 3: Identification of Thoughts and Feelings
Session 4: Remembering the Traumatic Event
Session 5: Identification of Stuck Points
Session 6: Challenging Questions
Session 7: Patterns of Problematic Thinking
Session 8: Safety Issues
Session 9: Trust Issues
Session 10: Power/Control Issues
Session 11: Esteem Issues
Session 12: Intimacy Issues and Meaning of the Event
THERAPIST’S MANUAL – Cognitive Processing Therapy: Veteran/Military Version Page 25

Session 1: Introduction and Education
Summary of Session 1 – Introduction and Education Phase
Administer the PCL-S (monthly version) before the start of this session, collect, and
store.
1. Set agenda (5 minutes)
2. Therapist explanations to patient (10 minutes)
¾ PTSD Symptoms: 3 Clusters (Handout)
- Reexperiencing: thoughts, dreams, flashbacks, psych, physio
- Arousal: sleep, irritability/anger, concentration, hypervigilance, startle
- Avoidance: thoughts, places/activities/people, facts, no interest, detached,
no feelings, no future. Many other forms of avoidance: alcohol, staying as
busy as possible, physical symptoms, avoiding therapy or practice
assignments.
¾ Trauma Recovery and Fight-Flight Response
- Fight/flight, freeze
- Paired with cues: sight, sound, smell, etc.
¾ Cognitive Theory
- Belief structure: categories—just world, good things to good people, etc.
- Change memories to fit beliefs (assimilation)
- Change beliefs about the world (accommodation/over-accommodation)
¾ Types of Emotions
- Two types of emotions that follow trauma: natural and manufactured
3. Brief review of most traumatic event (5 minutes)
4. Therapy rationale—stuck points (10 minutes)
¾ Goals of Treatment
- To recognize and modify old thoughts and feelings that may be unhelpful
- To accept the reality of the event
- To change beliefs enough to accept it without going overboard
- To feel your emotions about the event
¾ Review Stuck Point Handout
5. Anticipating avoidance and increasing compliance (5 minutes)
6. Overview of treatment—structured (5 minutes)
¾ 12 Sessions, 50 mins.–1 hour each:
1- Introduction 7- Problematic Thinking
2- Meaning of the Event 8- Safety
3- Identifying Thoughts and Feelings 9- Trust
4- Remembering the Event 10- Power and Control
5- Identifying “Stuck Points” 11- Esteem
6- Challenging Questions 12- Intimacy and Meaning
¾ Note importance of compliance with attendance and practice assignments
7. Assign practice and problem solve re: completion (5 minutes)
¾ First Impact Statement
8. Check-in re: patient’s reactions to session (5 minutes)

Session 1: Introduction and Education Phase
The goals of Session 1 are:
• Session 1
1. To build rapport with the patient. goals
2. To educate the patient about symptoms of PTSD and depression.
3. To provide a rationale for treatment based on a cognitive conceptualization
of PTSD.
4. To lay out the course of treatment.
5. To elicit treatment compliance.
It is necessary to address treatment compliance early in the course of therapy • Compliance &
because avoidance behavior (half the symptoms of PTSD) can interfere with avoidance
successful outcomes. We are concerned with two forms of compliance:
attendance and completion of out-of-session practice assignments. It is strongly
recommended that patients attend all sessions and complete all assignments in
order to benefit fully from therapy. We set the expectation that therapy benefit is
dependent on the amount of effort patients invest through practice assignment
compliance and practice with new skills. It may be helpful to remind the patient
that what he has been doing has not been working and that it will be important to
tackle issues head-on rather than continue to avoid. Avoidance of affective
experience and expression should also be addressed.
In this session, patients are also given the opportunity to ask any questions they
may have about the therapy. Sometimes patients’ stuck points become evident in
the questions and concerns they express during this first session. And finally, as
with all therapies, rapport building is crucial for effective therapy. The patient
needs to feel understood and listened to, otherwise she may not return.
Patients sometimes arrive with a pressing need to speak about their trauma. • Trauma
However, the therapist should prevent the patient from engaging in an extended disclosure
exposure session at the first session. Intense affect and graphic details of an event,
disclosed before any type of rapport or trust has been established, may well lead
to premature termination from therapy. The patient is likely to assume that the
therapist holds the same opinions about his guilt, shame, or worthlessness that he,
the patient, holds, and may be afraid to return to therapy after such a disclosure.
Other patients will be very reluctant to discuss the traumatic event and will be
quite relieved that they do not have to describe it in detail during the first session.
In these cases, the therapist may have to draw out even a brief description of the
event. Dissociation when attempting to think about or talk about the event is
common. An initial assessment session grants the patient and therapist the
opportunity to get acquainted before the therapy begins and allows the therapist to
provide the patient with a description of what the therapy will entail. In this first
session, it is important that the therapist remind the patient that CPT is a very
structured form of therapy and that the first session is a bit different from the

others because the therapist will do more talking. The therapist begins with a
description of the symptoms of PTSD and a cognitive formulation of them.
Therapist Explanations to Patient
1. PTSD Symptoms
“In going over the results of your testing, we found that you are • PTSD
suffering from posttraumatic stress disorder. The symptoms of PTSD symptoms–
fall into three clusters. The first cluster is the reexperiencing of the criterion B
event in some way. This includes nightmares about the event or other
scary dreams; flashbacks, when you act or feel as if the incident is
recurring; intrusive memories that suddenly pop into your mind. You
might have the intrusive memories when there is something in the
environment to remind you of the event (including anniversaries of
the event) or even when there is nothing there to remind you of it.
Common times to have these memories are when you are falling
asleep, when you relax, or when you are bored. These symptoms are
all normal following such a traumatic event. You are not going
crazy. Can you give me examples of these experiences in your own
life since the event?
“A second set of symptoms concern arousal. 8 As might be expected, • PTSD

when reminded of the event, you are likely to experience very strong symptoms–
criterion D
emotions. Along with these feelings are physical reactions.
Indicators of arousal symptoms include problems falling or staying
asleep, irritability or outbursts of anger, difficulty concentrating,
startle reactions like jumping at noises or if someone walks up
behind you, always feeling on guard or looking over your shoulder
even when there is no reason to. Which of these do you experience?
“The third cluster of symptoms is avoidance of reminders of the • PTSD

event. A natural reaction to intrusive memories and strong emotional symptoms–
reactions is the urge to push these thoughts and feelings away. You criterion C
might avoid places or people who remind you of the event. Some
people avoid watching certain television programs or turn off the
TV. Some people avoid reading the newspaper or watching the news.
You might avoid thinking about the event and letting yourself feel
your feelings about the event. There might be certain sights, sounds,
or smells that you find yourself avoiding or escaping from because
they remind you of the event. Sometimes people have trouble
remembering all or part of the event. Sometimes people feel numb
and cut-off from the world around them. This feeling of detachment
8
Although avoidance is listed second in the DSM, it makes more sense to present the symptoms
to patients in their most likely order: intrusion, arousal, and avoidance. This way the explanation
for the symptoms follows logically from their description.

or numbness is another form of avoidance. Sometimes it is described
as feeling as though you are watching life from behind glass. Which
things or thoughts do you avoid or run away from? Have you felt
numb or shut off from your emotions? Have you found yourself
feeling disconnected from other people?”
2. Trauma Recovery and Fight-Flight-Freeze Response

• Trauma
“Many people are exposed to traumatic events. In the time recovery
immediately following a trauma, most people will have the symptoms
of PTSD that we just talked about. However, over time, for many
people, those symptoms naturally decrease, and they are not
diagnosed with PTSD. In other words, they naturally recover from
the traumatic event. There are some people who do not recover and
are later diagnosed with PTSD. Based on that, it is helpful to think of
PTSD as a problem in recovery. Something got in the way of you
having that natural process of recovery, and our work together is to
determine what got in the way and to change it so that you can
recover from what happened. We will be working to get you
‘unstuck.’
“There are some different reasons why you may be having trouble • Fight-flight-
recovering. First, there is an automatic component during the event freeze reactions
that you should consider as you evaluate how you responded during
the time. When people face serious, possibly life-threatening events,
they are likely to experience a very strong physical reaction called
the fight-flight reaction. More recently we have learned that there is
a third possibility, the freeze response. In the fight-flight reaction,
your body is trying to get you ready to fight or flee danger. The goal
here is to get all the blood and oxygen out to your hands, feet, and
big muscle groups like your thighs and forearms so that you can run
or fight. In order to do that quickly, the blood leaves your stomach
or your head. You might feel like you have been kicked in the gut or
are going to faint. Your body stops fighting off diseases and
digesting food. You are not thinking about your philosophy of life
and may have trouble thinking at all. The same thing happens with
the freeze response, but in this case your body is trying to reduce
both physical and emotional pain. You may have stopped feeling
pain or had the sense that the event was happening to someone else
as if it were a movie. You might have been completely shut down
emotionally or even had shifts in perception like you are out of your
body or that time has slowed down.
“If you have been thinking now of other things that you could have
done then, you might need to consider what your state of mind was
during the event. Did you have all possible options available to you?

Did you know then what you know now? Do you have different skills
now than you did then?
• Classical
“Second, the fight-flight response that you were experiencing during
conditioning
the traumatic event can get quickly paired with cues, or things in the processes
environment, that didn’t have any particular meaning before. Then
later, when you encounter those cues, you are likely to have another
fight-flight reaction. Your nervous system senses the cue, which
could be a sight, a sound, smell, or even a time, and then your body
reacts as though you are in danger again. These reactions will fade
over time if you don’t avoid those cues. However, if you avoid
reminder cues, your body won’t learn that these are not, in fact,
good danger cues. They don’t tell you very accurately whether you
are actually in danger so you may have false alarms going off
frequently. After a while you won’t trust your own senses or
judgment about what is and isn’t dangerous, and too many situations
seem dangerous that are not.
“You may start to have thoughts about the dangerousness of the world,
particular places, or situations that are based on your reactions rather
than the actual realistic danger of those situations. This leads us to
examine how your thoughts may affect your reactions. Besides
thoughts about dangerousness, many different types of beliefs about
ourselves and the world can be affected by traumatic events.”
3. Cognitive Theory
“As you were growing up you learned about the world and • Cognitive
organized it into categories or beliefs. For example, when you were theory
small, you learned that a thing with a back, seat and four legs is a
chair. In the beginning you just called all of them ‘chair.’ You may
have even called a couch a chair or a stool a chair because they had
a back, seat, and four legs. Later, as you got older, through
experience, you learned more complex categories, so you may have
learned dining room chair, rocking chair, recliner, or folding chair.
We develop many categories of ideas and beliefs about others, the
world, and ourselves, as well as for objects.
“One common belief that many people learn while growing up is • Just world
that ‘good things happen to good people and bad things happen to belief
bad people.’ This is called the ‘just world belief.’ You may have
learned this through your religion, your parents, your teachers, or
you may have picked it up as a way to make the world seem safer
and more predictable. It makes more sense when you are young. For
example, parents wouldn’t want to say, ‘If you do something you’re
not supposed to, you may or may not get in trouble.’ However, as we
grow up, we realize that the world is more complex than that, just

like how we learn that there are all different types of chairs. If you
have ever had things go bad and you said ‘Why me?’ then you have
a just world belief. You also subscribe to the just world belief if you
wondered ‘‘Why not me?’ when others were hurt or killed.
“When an unexpected event occurs that doesn't fit your beliefs, there • Assimilation
are different ways that you may try to make it fit with your existing
beliefs. One way that you may have tried to make the event and your
beliefs fit is by changing your memories or interpretation of the
event to fit with your pre-existing beliefs (assimilation). Examples of
changing your interpretations/memories of the event are to blame
yourself for not preventing the event (or protecting loved ones), to
have trouble accepting that the event happened, to ‘forget’ that it
happened, or to forget the most horrifying parts. Changing the event
may seem easier than changing your entire set of beliefs about the
world, how people behave, or your beliefs about your safety.
“It is possible that instead of changing the event, you may change • Over-
your beliefs to accept what happened (accommodation). This is one accommo-
of our goals for therapy. Unfortunately, some people go overboard dation
and change their beliefs too much, which may result in a reluctance
to become intimate or develop trust, and increased fear (over-
accommodation). Examples that reflect an extreme change in beliefs
include thinking that no one can be trusted or that the world is
completely dangerous.
“For some people who have had previous negative experiences in

their life, traumatic events can seem to reinforce or confirm these
previously held beliefs. For example, prior to having experienced a
trauma you might have believed that others can’t be trusted or that
the world is generally unsafe. The traumatic event comes along and
seems to confirm those beliefs. Or, maybe you were told that
everything was your fault growing up, so when a bad thing happens,
it seems to confirm that once again, you are at fault.
“Our goals for therapy are: 1) to help you accept the reality of the
event, 2) to feel your emotions about it, and 3) to help you develop
balanced and realistic beliefs about the event, yourself, and others.”
4. Types of Emotions
“There are two kinds of emotions that follow traumatic events. The • Natural vs.
first type is the feelings that follow naturally from the event and that manufactured
would be universal: fear when in real danger, anger when being feelings
intentionally harmed, joy or happiness with positive events, or
sadness with losses. These natural emotions have a natural course.
They will not continue forever unless there is something that you do

to feed them. It is important to feel these emotions that you may not
have allowed yourself to experience about the event and let them run
their natural course.
“The second type of emotions, manufactured feelings, result not

directly in response to the event but based on how you interpret the
event. If you have thoughts such as ‘I should have rescued other
people’ or ‘I must be a failure that I can’t get over it,’ then you will
be feeling angry at yourself or shame. These emotions are not based
on the facts of the event but on your interpretations. The more that
you continue to think about the event in these ways, the more and
more of the manufactured feelings you are going to have. The upside
of the fact that you are producing these feelings is that if you change
your thoughts and interpretations, you will change your feelings.
Think of your emotions as a fire in a fireplace. The fire has energy
and heat to it, just like your emotions. However, it will burn out if it
is not continually fed. Self-blame or guilty thoughts can continue to
feed the emotional fire indefinitely. Take away the fuel of your
thoughts, and the fire burns out quickly.
“In order for you to recover from your traumatic event(s), we will be
working together for you to express and accept your natural
emotions and to adjust the manufactured feelings.”
Brief Review of Most Traumatic Event
In this first session, the therapist and patient work together to define the most • Honing in on
the traumatic
traumatic event that they will work on first. The patient then provides a brief
event
account of the traumatic event. It is important the therapist keep the patient
contained and not conduct an exposure to the traumatic material. Most veterans
have a “public version” of the incident that they can use that does not elicit much
affect. However, if the patient starts to become distressed or dissociates, the
therapist should ask questions and keep the patient grounded in the present. If
needed, the therapist can stop the patient’s description. The therapist only needs
enough of the details to begin to hypothesize what problematic interpretations and
cognitions might need to be explored.
We begin with the worst incident because there is more likely to be generalization
of new, more balanced cognitions from the worst event to less severe events than
the other way around. Also, if the patient begins with a less severe event because
she believes she cannot handle the worst event, she will still believe that after
working on the less distressing event. If the patient is resistant to writing an
account about the worst event, the therapist needs to do some cognitive therapy
during Session 2 and have the patient complete some A-B-C Worksheets on her
thoughts and feelings about working on the worst event (see Sessions 2 and 3).
It is helpful to provide an expectation that the patient provide a brief, less
affectively charged event by providing a time frame in the request.

“In order for me to have a clearer picture of what we will be working
on first, could you please give me a brief description, about five
minutes, of your most traumatic event…”
• Dealing with
If the patient responds that he has multiple traumatic events that disturb him, multiple
making it difficult or impossible to choose the “most” traumatic event, first traumatic
validate the fact that he may have multiple distressing events. Then, focus on events
ascertaining which one seems to be causing the most PTSD symptoms by
inquiring about the content of his reexperiencing symptoms. The therapist can
ask, “What do you think about or have flashbacks about the most?” It may also
be helpful to probe about his behavioral avoidance symptoms to determine the
event that should be addressed first. Remind the patient that work on the chosen
event will very likely impact the other events, and if not, there will be
opportunities to work on the other events.
Therapy Rationale—Stuck Points
“So, one goal of therapy will be to help you recognize and modify • Introducing
what you are saying to yourself—in other words, your thoughts and stuck points
interpretations about the event, which may have become automatic.
These distorted beliefs may become so automatic that you aren't
even aware that you have them. Even though you may not be aware
of what you are saying to yourself, your beliefs and self-statements
affect your mood and your behavior. Often, people aren't aware that
they are having thoughts about whatever they are experiencing. For
example, on the way here today, you were probably wondering what
this therapy would be like or what I would be asking you to talk
about. Do you remember what you were thinking about before the
session?
“I will be helping you to identify what your automatic thoughts are

and how they influence what you feel. I will also teach you ways to
challenge and change what you are saying to yourself and what you
believe about yourself and the event. Some of your beliefs about the
event will be more balanced than others. You’ll remember that we
discussed at the beginning of this session about how some people get
stuck in their recovery process. We will be focusing on changing the
• Give patient
beliefs that are interfering with your recovery or keeping you stuck.
Stuck Points
We call these problematic beliefs ‘stuck points.’ (The patient is Handout &
given the Stuck Points Handout and the Stuck Point Log.) We will Stuck Point
keep a Stuck Point Log in your folder so that as we identify Log
problematic ideas, we can write them down. Then when we move to
different worksheets you will have this list to draw on.”

Anticipating Avoidance and Increasing Compliance
The patient has been avoiding thinking about the event, thereby escaping and • Increasing
avoiding strong and unpleasant emotions. The therapist must develop a strong and patient
compelling rationale for therapy in order for the patient to be motivated to do compliance
something completely antithetical to what she has been doing. It is very important
that the patient understand what the therapy consists of and why it will work. She
should have ample opportunity to ask questions and express concerns. The
therapist needs to express confidence, warmth, and support.
“I cannot emphasize enough how important it is that you not avoid,

which is what you usually have done to try to cope since the event.
This will be your biggest (and probably scariest) hurdle. I cannot
help you feel your feelings, or challenge your thoughts if you don't
come to therapy or if you avoid completing your practice
assignments. If you find yourself wanting to avoid, remind yourself
that you are still struggling with the event because you have avoided
dealing with it head-on.”
Overview of Treatment
The therapist should describe the course of therapy (and the nature of the trauma
account in Sessions 4 and 5) and the importance of doing practice assignments.
“There are 168 hours in a week. We cannot expect you to change

your symptoms and the way you have been coping in one or two
hours of therapy a week if you are continuing to practice your old
ways of thinking the other 166 hours a week. It will be important for
you to take what you are learning and apply it to your everyday life.
Your therapy needs to be where your life and PTSD are, not just in
this little room.”
First Impact Statement
“For the next session, I want you to start working on how you think
about and explain the traumatic event. I also want you to pay
attention to how the traumatic event impacted on your views of
yourself, other people, and the world. I want you to write at least one
page on 1) why you think this event happened to you, and 2) how has
changed or strengthened your views about yourself, other people,
and the world in general?
“In order for this assignment to be most helpful to you, I strongly

suggest you try to start this assignment soon, so that you have
enough time to write thoughtfully. Pick a time and place where you
have as much privacy as possible, so you can feel any feelings that
arise as you complete the assignment.”

The patient is given a practice assignment sheet. If at all possible, the patient • Writing the
should handwrite the Impact Statement. Some patients will want to type on the Impact
computer. Research suggests that word processing can impede engagement with Statement
the assignment (e.g., too focused on grammar or spelling). Therefore, encourage
• Give patient
that this and other assignments be handwritten. It is often helpful to remind the practice
patient that you are not grading his work or interested in his grammar, etc. Rather, assignment
you’re interested in the content and feelings. If the patient has problems with sheet
literacy or physical disabilities that make it difficult or impossible to write, the
therapist might suggest that he record his thoughts on a tape recorder.
Practice Assignment
“Please write at least one page on why you think this traumatic • Assign
event occurred. You are not being asked to write specifics about the Session 1
traumatic event. Write about what you have been thinking about the practice
assignment
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.”
Check-in re: Patient’s Reactions to Session
Finish the session by asking about the patient’s reactions to the session and
whether he has any questions about the content or the practice assignment.
Remember to normalize any emotions and praise the patient for taking this
important step toward recovery.

Sample Session 1 Progress Note
Contact: 50-minute psychotherapy session
Content: The patient completed the first session of CPT for PTSD. An overview of PTSD
symptoms and a cognitive explanation of the development and maintenance of PTSD was
presented. A related rationale for treatment was provided, including the use of cognitive
restructuring to alleviate stuck points that prevent the patient from more fully emotionally
processing the traumatic event(s). The patient provided a brief description of his most
traumatic event.
The patient was given a practice assignment to write a one-page Impact Statement describing
the impact of his traumatic experiences on his thoughts and beliefs about himself, others, and
the world.
Plan: Continued CPT for PTSD

Posttrauma Reactions That Lead to PTSD
Intrusive Emotions
Reminders Angry
Flashbacks Scared
Nightmares Horrified
Images Shame
Sad
Thoughts
Beliefs
Assumptions
Escape/ Avoidance

Stuck Points—What Are They?
Throughout the rest of therapy we will be talking about stuck points and helping you to identify what yours are. Basically, stuck points are
conflicting beliefs or strong negative beliefs that create unpleasant emotions and problematic or unhealthy behavior. Stuck points can be
formed in a couple of different ways:
1. Stuck points may be conflicts between prior beliefs and beliefs after a traumatic experience.
STUCK
Traumatic
Event
Prior Belief Harmed During Military Service

I am able to protect myself in dangerous situations. I was harmed during my military service, and I am to blame.
Results
• If you cannot change your previous beliefs to accept what happened to you (i.e., it is possible that I cannot protect myself in all
situations), you may find yourself saying, “I deserved it because of my actions or inactions. I am responsible for what happened.”
• If you are questioning your role in the situation, you may be making sense of it by saying, “I misinterpreted what happened…I
didn't make myself clear…I acted inappropriately…I must be crazy, or I must have done something to have caused it…”
• If you are stuck here, it may take some time until you are able to get your feelings out about the trauma.
Goal
• To help you change the prior belief to “You may not be able to protect yourself in all situations.” When you are able to do this,
you are able to accept that it happened and move on from there.

2. Stuck points may also be formed if you have prior negative beliefs that seem to be confirmed or are
reinforced by the event.
CONFIRMED Traumatic
STUCKNESS Event
Prior Belief Harmed During Military Service

Authority is not to be trusted. I was harmed during my military service, and because of leadership.
Results
• If you see the trauma as further proof that authority (i.e., leadership) is not to be trusted, you believe this even more strongly.
• If you are stuck here, you may have strong emotional reactions that interfere with your ability to have successful relationships
with authority. It may feel “safe” for you to assume all authority is untrustworthy, but this belief may keep you distressed,
negatively impact your relationships, and possibly lead to legal, work, and social problems.
Goal
• To help you modify your beliefs so they are not so extreme. For example, “Some authority figures can be trusted in some ways and
to some extent.”

Stuck Point Log
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Summary of Session 2: The Meaning of the Event
1. Administer PCL-S (in waiting room if possible), collect, and store. Complete
Practice Assignment Review and set agenda. (5 minutes)
2. Have patient read Impact Statement—begin to look for stuck points (5 minutes)
¾ If practice not written, have patient describe meaning of event orally and reassign.
3. Discuss meaning of Impact Statement with patient (10 minutes)

¾ Begin to identify stuck points
¾ Review major issues to be focused on in treatment
¾ Identify Assimilation (changing memories to fit beliefs)
- Over-accommodation (going overboard on changing beliefs as a result of
memories)
- Accommodation (changing beliefs about the world and events…this is
desirable)
4. Review concepts (5 minutes)

¾ PTSD symptoms, info processing theory, treatment rationale, stuck points
5. Help identify and see connections among events, thoughts, and feelings (10 minutes)
¾ Six basic emotions: angry, disgusted, ashamed, sad, scared, happy
¾ Combined: jealous = mad + scared
¾ Varying intensity: irritated/angry/enraged
¾ Secondary emotions: guilt, shame.
¾ Patient examples of own feelings, including physical sensations
¾ Interpretation of events/self-talk affecting feelings (snubbed on street),
alternatives
¾ Go back to Impact Statement for personal application
6. *Introduce A-B-C Worksheets and fill one out together (5 minutes)
7. *Assign practice and problem solve re: completion (5 minutes)

¾ A-B-C Worksheets to become aware of connection among events, thoughts,
feelings, and behavior
¾ At least one A-B-C Worksheet each day (as soon after an event as possible)
¾ At least one worksheet directly about the worst traumatic event
*Note: If you decide to add the optional traumatic bereavement session (session 2a), instead
of introducing the A-B-C sheet (items 6 &7 in this outline), please discuss how the loss also
had an impact on the client’s thinking and emotions with a focus on meanings he has made
about safety, trust, power/control, esteem and intimacy. Introduce and assign the traumatic
bereavement impact statement instead of the A-B-C worksheet as the practice assignment for
the next session.

1. To begin to determine the patient’s stuck points and formulate why the patient • Session 2 goals
has not recovered naturally from the event (Impact Statement).
2. To review the cognitive-behavioral formulation of PTSD and depression.
3. To begin helping the patient to identify and see the connection among events,
thoughts, and emotions. The primary vehicle for understanding the patient’s
understanding of her own trauma and its effects is through the Impact
Statement. Review of the effects of the trauma on one’s life can also be used to
enhance motivation for change.
Patient Reading of the Impact Statement
The therapist should begin the session by asking how the practice assignment • Reviewing the
went and asking the patient to read it to the therapist. In listening to the Impact Impact
Statement, the therapist should be attuned to stuck points that are interfering with Statement
acceptance of the event (assimilation) and extreme, over-generalized beliefs
(over-accommodation). If the patient did not do her practice assignment, the
therapist should discuss the importance of completing practice assignments,
review the problem of avoidance in the maintenance of the symptoms, and then
ask the patient if she thought about the meaning of the event. We never reinforce
avoidance. If a patient does not do her practice assignment or “forgets to bring it
in,” we proceed with the assignment orally during the session. The patient should
read this and all other assignments out loud. If the therapist were to read it, the
patient could tune out. It is another attempt at avoidance. The assignment to write
the Impact Statement should be reassigned if it was not completed out of session,
but the therapist should proceed with the next assignment as well.
The purpose of the Impact Statement is to have the patient examine the effect that
the event has had on his life in several different areas. When reading the essays, it
will be important for the therapist to determine whether or not this goal has been
achieved. After listening to the Impact Statement, the therapist should praise the
patient and review with the patient the major issues that emerged that will be
focused on during treatment. The therapist should normalize the impact of the
event but also begin to instill the idea that there may be other ways to interpret the
event or begin to move beyond it.
Meaning of the Impact Statement
The therapist should use the framework of the Impact Statement to help the
patient begin to recognize which of her statements reflect assimilation and over- • Using the
Impact
accommodation. Please note that it is not necessary to use these terms. For Statement to
example, in response to a patient’s statement on thinking of ways she could have address
handled the traumatic situation differently, the therapist might say, “It sounds like assimilation
you wish that you could have had more options at the time. It’s hard to accept the and over-
accommo-
dation

outcome, isn’t it?” Engaging in hindsight bias, self-blame, and denial of various
sorts are all examples of assimilation or trying to alter the event to fit prior
beliefs. Examples of over-accommodation would be “We are in grave danger all
the time,” “I can’t trust my own judgment,” and “I can never feel close to anyone
again.” The therapist can mildly point out those extreme statements, while
intended to make the patient feel safer and more in control, have a heavy price
and ultimately do not work.
The following is an example of an Impact Statement written by a 34-year-old man

who had been sexually abused as a child and is the victim of several adult
assaults. Although he is clearly blaming himself for the events (assimilation), he
is intimidated by other people and has over-generalized danger in the world. His
problems with self-esteem are also evident.
“The overall feeling of what it means to have been assaulted is the • Example of
feeling that I must be bad or a bad person for something like this to Impact
Statement
have occurred. I feel it will or could happen again at any time. I feel
only safe at home. The world scares me and I think it unsafe. I feel
all people are more powerful than I, and am scared by most people. I
view myself as ugly and stupid. I can’t let people get real close to
me. I have a hard time communicating with people of authority, so
plainly I haven’t been able to work. My fiancée and I rarely have sex
and sometimes just a hug revolts me and scares me. I feel if I spend
too much time out in the world an event like my past will take place.
I feel hatred and anger towards myself for letting these things
happen. I feel guilty that I’ve caused problems with my family
(parents divorced). I feel dirty most of the time and believe that’s
how others view me. I don’t trust others when they make promises. I
find it hard to accept that these events have happened to me.”
Along with helping to begin identifying stuck points, problematic thoughts,

beliefs, assumptions, and conflicts that will need to be attended to in therapy, the
initial Impact Statement can also be used to help increase the patient’s motivation
to change. In the process of examining all the ways that the traumatic event has
affected the patient’s beliefs about self and others, it may be possible for the
therapist to help the patient see that the cost of avoiding is very high and that it is
worth it to risk remembering the trauma and feeling the painful emotions. After
the therapist and patient have discussed the Impact Statement, the therapist begins
to help the patient to identify and label thoughts and emotions; to learn to see the • Give patient
Identifying
connection among events, thoughts, and feelings; and to be introduced to the idea
Emotions
that changing thoughts can change the level and type of emotion experienced. The Handout
therapist first gives the patient the Identifying Emotions Handout as they discuss
types and intensity of emotions.
“Today we are going to work on identifying what different feelings

are, and we will be looking at the connection between your thoughts
and feelings. Let's start with some basic emotions—angry, disgusted,

ashamed, sad, scared, or happy. These basic emotions can be
combined to create other emotions like jealousy (mad + scared) or
can vary in intensity (for example, irritated, angry, or enraged). Can
you give me an example of something that makes you mad? When do
you feel sad? How about happy? What frightens you? How do you
feel physically when you are feeling angry? How do you feel
physically when you are feeling scared? How are angry and scared
different for you? What does shame or embarrassment feel like?”
Connections Among Events, Thoughts, and Feelings
The therapist then describes how interpretations of events and self-statements can • Interpretation
affect feelings. The therapist can use as an example an acquaintance walking of events
down the street and not saying hello to the patient, or an alternative is if someone
says he will call and then doesn’t. The patient is then asked what she would feel
and next what she just said to herself (e.g., “I’m hurt. She must not like me” or “I
wonder if someone else might have different thoughts about her behavior?”). If
the patient is unable to generate alternative statements, the therapist should
present several other possible self-statements (“She must not have her glasses
on,” “I wonder if she is ill?” “She didn’t see me,” or “What a rude person!”).
Then the therapist can ask the patient what she would feel if she said any of the
other statements. It can then be pointed out how different self-statements elicit
different emotional reactions.
“Now, let’s go back to the Impact Statement you wrote. What kinds
of things did you write about when thinking about what it means to
you that _______ happened to you? What feelings did you have as
you wrote it?”
If the patient does not recognize his feelings or their connection to beliefs, help • Connection of
thoughts,
the patient tie his thoughts to his feelings and behavior. “How do these thoughts feelings, and
influence your mood? How do they affect your behavior?” The therapist should behavior
make sure the patient sees the connection among his thoughts, feelings, and
behaviors. Sometimes a simple “why” question can help elicit the patient’s
thinking.
T: Why were you angry?

P: Because I should have known better.
T: So your thought was, “I should have known that this was going
to happen”?
P: Yes.
T: And your anger was directed toward yourself? (Always
remember to ask about the direction of anger.)
This exchange also allows the therapist to begin some gentle Socratic challenges
to assess how flexible the patient’s thinking is, and whether the patient has made

some simple blind assumptions (“I just should have known”) or whether she has
developed complex and convoluted thought patterns.
T: I don’t understand; how could you have known that this was
going to happen?
P: I had a strange feeling that morning, like something was going to
happen.
T: Have you ever had those kinds of feelings when nothing
happened?
P: Yes, but it was very strong. I should have done something.
T: Did your feeling tell you what was going to happen or when it
was going to happen?
P: No.
T: Then what could you have done?
P: I don’t know. I just should have done something.
T: Were you certain about your feeling? You said that sometimes
you have had feelings and then nothing happened.
P: No, I wasn’t positive.
T: So, you didn’t quite trust those feelings and wouldn’t have known
what to do even if you were sure?
P: No, but I still feel guilty that I should have done something.
T: Let’s pretend for a second that you had a clear vision of exactly
what was going to happen and exactly when it was going to
happen, and knew exactly who to call to warn. What do you think
their reaction would have been?
P: They wouldn’t have believed me. They would have thought I was
just some crank.
T: And then how would you feel?
P: Well, I wouldn’t feel guilty or angry at myself; I would be angry
at them and frustrated at not being able to do anything.
T: Yes, it’s frustrating not being able to do anything to stop an event
that is out of your control, isn’t it?
P: Yes, I hate it.
T: It is very difficult to accept that some events can be out of our
control. But it is not really your fault that it happened, is it?
P: No, I suppose not.
If the patient begins to argue with the therapist or dig in her heels over her beliefs, • Dealing with
the therapist should back off immediately and just say something like, “Well, I an
argumenta-
can see that this is an important topic that we will need to work on later in tive patient
therapy,” or just “We’ll get back to this topic later.”
Although some patients will have very convoluted thinking that justifies their
problematic cognitions, often a therapist will find almost no answers in response
to Socratic questions. For example, in response to questioning the statement “I let
it happen” with “How did you let it happen?” the patient may just say, “I don’t
know; I didn’t prevent it.” The therapist then would ask, “How could you have

prevented it?” and the patient may respond, “I don’t know, I just should have.” In
these cases, the patient has just made a blind assumption. He drew a conclusion
that he should have prevented it, believed it without question, and never examined
it any further. The patient then responds as if the statement were true, just because
he said so. If the patient becomes uncomfortable because he doesn’t have answers
to the questions, the therapist can gently reassure him that they will work on this
later in therapy.
Introduction to A-B-C Worksheets
Several A-B-C Worksheets are given to the patient (enough for one each day until • Give patient
the next session). The therapist points out the different columns and how to fill blank and
them in. More than one event can be written on each worksheet. The patient and example
A-B-C
therapist should fill out one worksheet together during the session. As an Worksheets
example, an event the patient has already brought into therapy or some event that
occurred within the past few days should be used. Example A-B-C Worksheets
that have some relevance to the patient’s presentation should also be given to him.
“These practice worksheets will help you to see the connection • Introducing
between your thoughts and feelings following events. Anything that A-B-C
Worksheets
happens to you or you think about can be the event to look at. You
may be more aware of your feelings than your thoughts at first. If
that is the case, go ahead and fill out Column C first. Then go back
and decide what the event was (Column A). Then try to recognize
what you were saying to yourself (Column B). Try to fill out these
worksheets as soon after the events as possible. If you wait until the
end of the day (or week) you are less likely to remember what you
were saying to yourself. Also, the events you record don’t have to be
negative events. You also have thoughts and feelings about pleasant
and neutral events. However, I want you to do at least one A-B-C
Worksheet about the traumatic event.”
At the bottom of the A-B-C Worksheets are two questions that introduce the
notion of alternative interpretations of events. The primary focus of the A-B-C
Worksheets should be on the patient identifying the link between thoughts and
feelings before moving on to challenging cognitions. Thus, the therapist should
use her judgment about introducing these questions in this session to the patient
based on the patient’s grasp of the basic cognitive-behavioral process. If the
patient fills out the session spontaneously with an appraisal that the thought is not
realistic, this may be an indicator that he is already beginning to challenge his
own thoughts. If he insists that the extreme thought is realistic, then the therapist
also has important information about the patient’s rigidity. The two questions at
the bottom can also be used in addition to the rest of the form as an alternative to
the Challenging Beliefs Worksheet if that form proves to be too difficult for the
patient due to low intelligence or literacy issues (see Session 7).

Note. If you opt to use Session 2a, review the first impact statement and finish
any material that has not been finished in the previous sessions. Then introduce
the idea that grief and PTSD are somewhat different and can complicate the
recovery from the traumatic event. Grieving the loss of other people may entail
different stuck points than those involved with the PTSD that the patient
experienced directly. The patient may have trouble with the concept that they still
have a relationship with the person who has died (i.e., they relate to them in
making decisions and reacting to life’s events and they have to accept that the
person has died). Assign the second impact statement instead of the A-B-C
worksheets for the next session.
Practice Assignment for session 3
“Please complete the A-B-C Worksheets to become aware of the • Assign

Session 2
connection between events, your thoughts, feelings, and behavior. practice
Complete at least one worksheet each day. Remember to fill out the assignment
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.”
Practice Assignment for Session 2a* (if completing the optional

Traumatic Bereavement session)
*Instead of assigning A-B-C sheets, the assignment for Session 2a is as follows:
• Assign
Session 2a
“Please write at least a page on what it means to you that practice
___________ was killed. As in the last assignment, focus on assignment
meanings regarding safety, trust, power/control, esteem, and
intimacy. Also write about how the death has affected your memory
of _________, your relationship with ___________, and how you
perceive you are adjusting to the loss.”

Content: This was the second session of CPT for PTSD. The patient did (not) complete the
practice related to writing an Impact Statement describing the impact of his traumatic
experiences on his thoughts and beliefs about himself, others, and the world. We discussed
the assignment in session, with an emphasis on identifying stuck points in his thinking that
interfere with recovery. The relationships amongst thoughts, feelings, and behaviors were
reviewed, and an example from his discussion about the impact of his trauma on his life was
used to illustrate the cognitive model. The patient agreed to complete A-B-C Worksheets
daily to monitor his thoughts, feelings, and behaviors until the next session.

PCL-S: WEEKLY
Instructions:
1. Consider the most stressful experience you have experienced ________________________________.

(event)
2. Here is a list of problems and complaints that people sometimes have in response to stressful life
experiences. Please read each one carefully, and then indicate, using the numbers to the right, how
much you have been bothered by that problem in the past WEEK.
A
Not Quite
little Moderately Extremely
at all a bit
bit
1. Repeated, disturbing memories, thoughts, or images, of the
1 2 3 4 5
stressful experience?
2. Repeated, disturbing dreams of the stressful experience? 1 2 3 4 5
3. Suddenly acting or feeling as if the stressful experience was

1 2 3 4 5
happening again (as if you were reliving it)?
4. Feeling very upset when something reminded you of the
1 2 3 4 5
5. Having physical reactions (e.g., heart pounding, trouble
breathing, sweating) when something reminded you of the 1 2 3 4 5
6. Avoiding thinking about or talking about the stressful
1 2 3 4 5
experience or avoiding having feelings related to it?
7. Avoiding activities or situations because they reminded you
1 2 3 4 5
of the stressful experience?
8. Trouble remembering important parts of the stressful
1 2 3 4 5
experience?
9. Loss of interest in activities that you used to enjoy? 1 2 3 4 5
10. Feeling distant or cut off from other people? 1 2 3 4 5
11. Feeling emotionally numb or being unable to have loving

1 2 3 4 5
feelings for those close to you?
12. Feeling as if your future will somehow be cut short? 1 2 3 4 5
13. Trouble falling or staying asleep? 1 2 3 4 5
14. Feeling irritable or having angry outbursts? 1 2 3 4 5
15. Having difficulty concentrating? 1 2 3 4 5
16. Being “super-alert” or watchful or on guard? 1 2 3 4 5
17. Feeling jumpy or easily startled? 1 2 3 4 5
PCL-S for DSM-IV (11/1/94) Weathers, Litz, Huska, & Keane National Center for PTSD – Behavioral
Science Division.

Identifying Emotions Handout

A-B-C Worksheet
Date: ___________ Patient: ____________________________
ACTIVATING EVENT BELIEF CONSEQUENCE

A B C
“Something happens” “I tell myself something” “I feel something”
Are my thoughts above in “B” realistic?

________________________________________________________________________
What can you tell yourself on such occasions in the future?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
A-B-C Worksheet
Date: ___________ Patient: ____________________________

A B C
“I shot a Vietnamese woman while “I am a bad person because I killed “I feel guilty and angry with
in combat.” a helpless civilian.” myself.”
Are my thoughts above in “B” realistic? “No. One mistake does not make me a bad person. People make mistakes, and
high stress situations, like combat zones, increase the probability of such mistakes.”
What can you tell yourself on such occasions in the future? “I may have made mistakes in my life, but that does not make
me a bad person. I may have done things that I regret, but I have also done good things in my life.”

A-B-C Worksheet
Date: ___________ Patient: ____________________________

A B C
“My commanding officer making “People in authority cannot be “I feel fearful and distrusting. I
orders that got us into crossfire.” trusted. He put us in harm’s way to avoid people in authority, or argue
protect himself.” with them about their decisions
when I have to interact with them.”
Are my thoughts above in “B” realistic? “No. Not all authority figures are necessarily like my commanding officer.”
What can you tell yourself on such occasions in the future? “People in authority are individuals, and they do not all share
the same strengths and weaknesses.”

A-B-C Worksheet
Date: ___________ Patient: ____________________________

A B C
“I build a porch and the railing “I can never do anything right.” “I get angry and kick the railing. I
comes loose.” also feel down and sad because I
can’t do anything right.”
Are my thoughts above in “B” realistic? “No. It wouldn’t hold up in a court of law, because I do SOME things right.”
What can you tell yourself on such occasions in the future? “There are some things that I do all right. It is not true that I
‘never’ do anything right.”

Session 2a: Optional Traumatic Bereavement Session
Summary of Session 2a: Optional Traumatic Bereavement Session
1. Administer PCL-S (in waiting room if possible), collect, and store. Set agenda.
(5 minutes)
2. Patient reads the second impact statement on the meaning of the loved
one’s death. If the patient did not complete the first impact statement, that
one should be read and processed first. (5-10 minutes)
3. Identify and discuss any stuck points that have emerged from the
bereavement impact statement that are different from the first impact
statement. ( 5 minutes)
4. Provide education on normal bereavement by reviewing the Myths of Mourning

Handout which is given to patient in session (10 minutes)
¾ Look for stuck points that may not have emerged in impact statement
5. Help identify and see connections among events, thoughts, and feelings (10 minutes)
¾ Six basic emotions: angry, disgusted, ashamed, sad, scared, happy
¾ Combined: jealous = mad + scared
¾ Varying intensity: irritated/angry/enraged
¾ Secondary emotions: guilt, shame.
¾ Patient examples of own feelings, including physical sensations
¾ Interpretation of events/self-talk affecting feelings (snubbed on street),
alternatives
¾ Go back to Impact Statement for personal application
6. Introduce A-B-C Worksheets and fill one out together (5 minutes)

¾ A-B-C Worksheets to become aware of connection among events, thoughts,
feelings, and behavior
¾ At least one A-B-C Worksheet each day (as soon after an event as possible)
¾ At least one worksheet directly about the worst traumatic event

Session 2a: Optional Traumatic Bereavement Session
The goals for this session are:
1. To begin to normalize the grief process and differentiate it from PTSD • Session 2a goals
symptoms.
2. To identify stuck points that may interfere with the normal course of
bereavement.
3. To begin to assist the patient in viewing his relationship with the person who
died as altered but not finished.
If this session is added, the topic should have been introduced at the end of
session 2 instead of the A-B-C worksheets. However, if the patient did not
complete the first impact statement and it was reassigned, that one should be read
first. After reviewing the practice assignment to write a second impact statement,
the therapist will begin an education portion on the topic of normal bereavement
and will look for stuck points that may interfere with normal grief reactions. To
facilitate this process, some information is provided below to assist the therapist
to think about traumatic versus normal bereavement issues and to provide some
education to the patient about the course of bereavement as varying and
multidimensional. It is important for the therapist to refrain from pathologizing
the grief process and to begin to differentiate grief from PTSD or depression.
PTSD can interfere with the normal course of bereavement. It is also possible that
unresolved grief can further complicate recovery from PTSD. Although
witnessing or being injured during an event in which a loved one/friend was killed
is more obviously associated with PTSD, therapists need to consider a PTSD
diagnosis among those who were not present at the traumatic death of a loved
one. In civilian life, the sudden, unexpected, and perhaps violent death of a
significant other is so shocking, horrifying, and schema-discrepant that family and
friends of the victim may have trouble taking in the fact that the person has been
killed. During war, service members may accept the possibility, on an abstract
level, that they or others may be killed, but losing friends, seeing children die, or
having deaths occur in unexpected places (when one thought he was safe) can
also be shocking and hard to accept. Acceptance may be particularly difficult for
parents who lose children because of the expectation that their children will
survive them. And like other trauma survivors who actively avoid accepting the
reality of the situation, traumatic-death surviving family and friends may engage
in self-blame as an attempt to undo the event (e.g., “If only I hadn’t done X, he
wouldn’t have been there at the time”). Unlike other trauma victims, traumatic-
death survivors may believe that to accept the trauma and begin to move on with
their lives means they have betrayed the other person, that the other person isn’t
being properly honored.

Flashbacks, intrusive thoughts, and other intrusive reminders can recur even if • Flashbacks &
someone was not present at the death of her significant other. People may flash intrusive
back on or have strong emotional or physiological reactions when reminded of reminders
being informed of the death. For example, some people have strong reactions
when the telephone or doorbell rings. They immediately flash back to being told.
Some people have strong reactions to temporal cues such as a specific time of day
(e.g., dusk, a certain month, or other anniversaries of the death). They may react
to climatic cues such as temperature, humidity, smells, or other seasonal
reminders. Holidays or other personal days of celebration (birthdays,
anniversaries) can be particularly difficult and can trigger trauma cues (as well as
positive memories).
It is not unusual for people to have images of or ruminate about (with

accompanying affect and physiological responses) what they imagine happened to
their loved one/friend. Some people feel compelled to put themselves into the
shoes of the person who died in an attempt to be closer with them. They try to
imagine what the other person experienced, what they must have been feeling or
thinking, and wonder if they suffered or were in pain for a long time before they
died. These images can serve as intrusive reminders of PTSD (Criterion B).
Often with PTSD induced by traumatic bereavement, we do not see effortful

avoidance with regard to the person who died. To the contrary, some people
intentionally ruminate and are afraid to let go of the images, even very distressing
images, because to let go is, in their minds, to lose their loved one. Effortful
avoidance is more likely to be of the trauma cues listed above. Numbing is
common.
When some people are killed during a traumatic event, those who survive, • Survivor guilt
whether they are friends, family, or strangers, may well have survivor guilt. When
people experience traumatic events, they often ask the question, “Why me?”
because of their just world belief. A corollary of this belief is asking “Why not
me?” when surrounding others are killed. People with survivor guilt feel that they
do not have the right to go on when others cannot, or believe that they are less
deserving of happiness (or even of living) than the person or people who died.
They try to determine why they survived and cannot find an acceptable
explanation. Both types of thoughts reflect the just world belief.
An issue that may need to be addressed with military and veteran populations is • Service member’s
not just witnessing or hearing about the death of someone the patient cared about, guilt re: killing or
but also issues that arise from having killed others. Service members may find violence
themselves forced to engage in behavior that is against their personal moral code
or in conflict with the circumstances under which they believed that they would
be killing others. In our experience, situations in which civilians, and especially
children, are killed are particularly traumatic for veterans and service members
(e.g., children with backpack bombs, children put in front of transportation
convoys). Grieving and assumptions about one’s actions during war can be very
complicated because of the nature of war itself. Veterans and military personnel

may blame themselves, the combatants, the government that put them in the
position they found themselves, or the behavior and perceived failures of
command or fellow service members. The combination of anger and guilt can
complicate and prolong the grief response.
The goal of CPT for bereavement is to help patients determine and eliminate any
stuck points, problematic cognitions that are blocking their recovery, and to help
them eventually focus on the person’s life, not just the way in which he or she
died.
First the therapist can start with bereavement issues… • Addressing

bereavement
“Prior to this death, what has been your experience with the death of with patient
loved ones?”
If the patient has never experienced the death of a loved one, then ask…
“What were your expectations about death of loved ones? Had you
ever thought about it? Or was it a topic that you avoided thinking
about?”
Once the therapist understands what the patient understood about death and the
grief process before the traumatic death, the therapist can then ask…
“How is this situation different than what you had experienced

before (or imagined)?”
“What have other people been telling you about grief and
mourning?”
“What suggestions have people been making?”
Give the patient the Myths of Mourning Handout. Discuss each statement with the • Give patient
patient to determine which, if any, statements the patient has been subscribing to. Myths of
Mourning
Along with debunking some common myths, the therapist uses this session to Handout
help the patient understand the normal process of bereavement, to see how the
traumatic bereavement relates to symptoms of PTSD, and to begin to identify
distorted cognitions, conflicts between prior beliefs and the traumatic event.
Education on Normal Bereavement
Bereavement affects different aspects of one’s life. People have emotional, • Normal
bereavement
spiritual, and physical reactions. They also have to adjust their roles with regard
to other people, the community more generally, and with regard to tasks and
behaviors. While some grief reactions may feel like and share some
characteristics with other psychological reactions such as depression, it is
important for the therapist not to pathologize grief. Bereavement is not the result
of personality traits but is the normal and time-limited reaction to loss. Mourning
is not the same as depression and does not respond to antidepressants.

In the past it was possible to tell that someone was grieving for a period because • Normal
bereavement
of clothing indicative of mourning and institutionalized rules about mourning continued
such as wearing black for a year, wearing certain jewelry or armbands, limiting
social engagements, and so forth. These practices provided more community
support because the person who was grieving was clearly identifiable and there
was an expectation that bereavement should take an extended period. On the other
hand, the rigid rules about length of mourning were not flexible enough to
accommodate different patterns of grief. Some people may not have needed a
year in order to begin to reestablish their lives (some may have needed longer). In
modern times, there is no way to identify whether someone is in mourning, so the
community quickly returns to usual routines and expects the bereaved person to
do so as well. While community support is often very active initially, people often
return to their own lives after a few months, leaving the bereaved adrift to adjust
to his changes in roles and tasks. After a few months, grieving people may start
receiving comments by others that they should move on with their lives and to put
the traumatic event and the loved one behind them (people with PTSD hear this
even without a traumatic death). People may need assistance in tolerating the
predominant community standards that do not reflect the reality of the mourning
timeline for them.
In the early stages of bereavement, people need information and support in coping • Coping
emotionally. Later, if the person who died is a family member, they need to focus mechanisms
more on instrumental tasks. Some tasks, like dealing with insurance companies
and changing names on titles, are directly due to the death of the family member.
Other tasks represent a realignment of typical chores (e.g., now the patient needs
to pay bills or cook, when before the other partner took responsibility for those
tasks). Each instrumental adjustment, if successfully negotiated, will help the
bereaved person accept the reality of the situation and assist in a greater sense of
control. As the tasks and roles are realigned, then the person also moves to
reconnect with his community, to reestablish and adjust relationships with his
friends and relatives, and finally to rebuild his assumptive world. This latter task
includes adjusting his beliefs about himself and the world with regard to the loved
one’s death. As elsewhere in CPT, the therapist is looking for accommodation
rather than assimilation or over-accommodation, balance in beliefs rather than
extreme statements.
In a military setting, the death of a fellow service member or members may also • Veterans &
bereavement
be accompanied by tasks and changes. Roles and responsibilities may shift along
with the dynamics of the remaining members of the unit. Sometimes the
bereavement process for military personnel becomes more acute once they leave
the military. While in the military, other people in that environment may have
been able to provide support and understanding of the losses that a service
member experienced. Upon the veteran’s return to the civilian world, however,
people in the environment may not be able to understand or appreciate the loss of
comrades or may even be unsympathetic because of different viewpoints on the
war. Although our society appears to be doing a better job separating the war
from the warrior in the recent OIF/OEF conflict, this is not universally true, and

there are many Vietnam veterans who carry the scars of verbal abuse upon
returning to the United States after their tours of duty. They may not have been
given the opportunity to grieve the loss of their friends and fellow service
members or may be stuck in a cycle of grieving that has not remitted.
• Example of a
The following are excerpts from a bereavement Impact Statement. The statement
bereavement
was four handwritten pages. It illustrates the effects the murder of a impact
granddaughter had on a patient. statement
(assimilation
“I think at first I needed to be strong for my son. As long as I could through non-
acceptance
do that, I did not have to face the finality of death. This is still so
and
hard for me to say. To think of ______ in the past tense still causes avoidance)
me to have a panicky feeling. I cannot describe how much I love her
or how much I miss her.
“I thought I would always be the same me. But now I realize I will
never be the same. At first I kept trying to be the same self—tried so
hard that I would get these panic attacks, so I just tried not to think
about it.
“I feel like this big cloud has settled over me and sometimes it
suffocates me. I would like to just pull the covers over my head and
not take them off for a long time. But I know I can’t, especially for
my son. He says he would like to go into a closet and not come out.
“I talked today with my pastor about my feelings, how I feel so

frozen inside, that I cannot pray and do not feel spiritual at all. It
makes me feel so empty. I miss the fellowship I had with my God. I
do want to have that again.
“Some people say I need to try to forgive—I can’t and I don’t want
to—at least not now… I really don’t want to be angry—this is not
me. But right now I’m so angry.”
While the example above illustrates assimilation through nonacceptance and • Example of a
avoidance, the next excerpt is from a different patient whose friend was killed, bereavement
impact statement
and illustrates both assimilation and over-accommodation. (assimilation and
over-
“I always believed that I could protect ______ from anything or accommodation)
anyone. I feel like a failure. I failed him. I should have been
watching his back, then no one would have been able to shoot him in
his back. I could have administered CPR and helped to breathe in
him the breath of life. He would have calmed down and fought
harder if I had been there. Who knew? But I failed him and I don’t
have any other chance to make it up to him.

“This world is a cruel world where no one seems to care about
anyone outside of their own family… I trust no one outside of the
family and I really am no longer close to my family. I no longer use
the word “friend” because it no longer serves a purpose in my life. I
feel abandoned by certain people in my family. They are already
ready for me to move on. Isn’t that crazy?!”
It may be helpful for a patient to realize that his relationship with the deceased has • Change, not
changed rather than ended. The patient can still have a relationship with the end of
deceased even though the relationship is not reciprocal. As part of the Impact relationship
Statement on the death of the significant other, the patient is asked “How has the
event affected your relationship with the deceased?”
One of the problems that can occur early in the grieving process, and stall out in • Over-
some cases, is the tendency to over-idealize the person who has died. It is difficult idealization of
for the bereaved person to move on, reestablish connections with others, and alter the deceased
her relationship with the deceased if the person who died is not the person who
lived before. Loved ones may experience more survivor guilt or hindsight bias if
they believe that the person who died was perfect or that it is bad or wrong to
remember any flaws or foibles. The therapist needs to tread lightly on this topic,
perhaps pursuing it later in therapy, although it can be broached gently at this
time. The therapist, in hearing an over-idealized description of the deceased can
say:
“He sounds like an angel. I’d like to have a better picture of the
whole man that you knew. Tell me a little about his eccentricities or
habits.”
The goal here is to help the patient to grieve for the person who really lived with
an integrated and balanced view.
In some cases, over-idealization may be a particular problem because the • Idealization of

the deceased
idealized image of the deceased is embraced by a whole community. In the
aftermath of the 2001 World Trade Center attack, firefighters, police, and other
rescue workers who died have been rightly hailed as heroes. Heroes are people
who risk themselves to help others in spite of their fear or flaws, not because they
were fearless and flawless. It may be particularly difficult for family members if
their memories of the person clash with the public image. If a couple was having
marital problems, or the partner was having an extramarital affair, was abusive, or
was alcoholic, the surviving partner would not know how to reconcile this
information with the accolades and images of the partner as a saint. Even to
remember small flaws would seem like a betrayal of the person who died. And
yet, the surviving partner and family members have these memories as well and
struggle to deal with them. Some people attempt to suppress or ignore
inconsistent information. If they are successful in avoiding, there is a greater
likelihood of more prolonged bereavement than for those who can put the
person’s life into an accurate perspective.

Pertinent to situations like the attack on September 11, 2001, and war, e.g.,
veterans from Vietnam, is the issue in which the body of the deceased is never
found. It may be more difficult in these cases for the surviving family and friends
to accept that the person is actually dead. When there is no concrete proof that the
person died, assimilation and denial are more likely. The survivors may have
continuing fantasies that there has been some mistake, that the loved one has been
wandering around with amnesia or was injured and unable to contact them. They
may have extended periods during which acceptance of the reality of the situation
is postponed.
Finally, when a group of people experience the same event and then support each
other in the aftermath, they can help each other progress through the various
stages of grief. However, there are two risks. One is that the members of the
group will be recovering at different rates, leading to misunderstandings or some
people being held back from their natural rate. A worse outcome is that the group
becomes stuck together and stops recovering altogether. They develop an us-
against-them mentality in which they come to believe that no one can understand
what they have experienced and that they can never recover. If someone who
seeks therapy is enrolled in a long-term support group (either formally or
informally) in which this has occurred, it will be somewhat more difficult for the
therapist to intervene with over-generalized beliefs because they are held by a
group of people, lending credence to them. The therapist will need to remind the
patients during cognitive therapy that other people saying things does not
constitute evidence for a belief.
The following is a list of possible stuck points that the therapist may encounter • Possible
while working on bereavement issues. This list is, of course, not exhaustive, but stuck points
during
merely suggestive. traumatic
bereavement
1. “I have no right to feel happiness when ____ has died and can no
longer be happy” (Survivor guilt).
2. “I could have prevented this, if only _____” (Distorted sense of

power).
3. “If only I had ___________, this would not (might not) have
happened” (Distorted sense of responsibility- hindsight bias).
4. “This can't be happening. He/she will show up at some time”

(Denial in many of its forms).
5. “This can't be happening to me” (Personal non-acceptance).
6. “Others may eventually pull out of this grief, but not me. My
relationships are of a different quality” (Uniqueness).

7. “I can never be happy with someone else ever again” (Distorted • Give patient
consequences). blank and
8. “My life is over.” example A-B-C
Worksheets
Once the impact statement has been processed and the education on grief
and bereavement has been introduced, please return to the second half of • Introducing
session two material to introduce identification of thoughts and emotions A-B-C
and the A-B-C worksheet assignment for the 4th session (labeled session Worksheets
3).

Sample Session 2a Progress Note
Content: This was the third session of CPT for PTSD. The patient did (not) complete the
impact statement about his/her traumatic loss. The client read the second impact statement
and we discussed the assignment in session. Myths of mourning and psychoeducation about
normal bereavement were discussed in this session. The relationships among thoughts,
feelings, and behaviors were reviewed, and an example from his discussion about the impact
of his trauma on his life was used to illustrate the cognitive model. The patient agreed to
complete A-B-C Worksheets daily to monitor his thoughts, feelings, and behaviors until the
next session.

Initial of Patient Last Name: _____________ Last 4 digits of SSN: ___________________
Therapist Initials: ______________________ Date: ____________ Session: ___________
Format of CPT: Individual Group CPT-C CPT
PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

Myths of Mourning Handout
¾ Grief and mourning decline in a steadily decreasing fashion over time.
¾ All losses prompt the same type of mourning.
¾ Bereaved individuals need only express their feelings in order to resolve their
mourning.
¾ To be healthy after the death of a loved one, the mourner must put that person out of
mind.
¾ Grief will affect the mourner psychologically but will not interfere in other ways.
¾ Intensity and length of mourning are a testimony to love for the deceased.
¾ When one mourns a death, one mourns only the loss of that person and nothing else.
¾ Losing someone to a sudden, unexpected death is the same as losing someone to an

anticipated death.
¾ Mourning is over in a year.
¾ Time heals all wounds.
From Therese A. Rando, Treatment of Complicated Mourning (1993), Research Press,

Champaign, IL, p. 27–28.

Summary of Session 3: Identification of Thoughts and Feelings
Session 3 Practice Assignment Review and set agenda. (5 minutes)
*Note: If using optional session 2a (traumatic bereavement session), review the

bereavement impact statement in session 3 before moving to the introduction of the
ABC worksheet. This session would then be picked up as session 4 instead of session 3
and the protocol proceeds the same after this point. If using the traumatic bereavement
optional session, the protocol is lengthened to 13 sessions; session 2a does not replace
any sessions.
2. Review A-B-C Worksheets, further differentiating between thoughts and feelings

(15 minutes)
¾ Label thoughts vs. emotions
¾ Recognize changing thoughts can change intensity of type of feelings
- Begin challenging self-blame and guilt
¾ Point out mismatches:
- Dominant emotion(s)? - Emotions follow thoughts?
- Dominant thought(s)? - Thoughts and emotional intensity match?
¾ Look for stuck points and use Socratic questioning to help patient identify
alternative hypotheses
3. Discuss the A-B-C Worksheet related to trauma (10 minutes)

¾ Review orally if patient did not complete
¾ Challenge the stuck point of self-blame using Socratic questioning
4. Introduce the Trauma Account (10 minutes)

¾ How to write the Trauma Account
¾ Cognitive therapy for any concerns about the Trauma Account

¾ Full Trauma Account with sensory details
¾ Daily reading of the full Trauma Account
¾ Daily completion of A-B-C Worksheets
¾ Problem-solving re: practice completion is very important. Refer to rationale if
necessary.

1. To assist the patient in labeling thoughts and emotions in response to events. • Session 3
2. To introduce the idea that changing thoughts can change the intensity or type of goals
emotions that are experienced.
3. To begin challenging the patient’s self-blame and guilt with regard to the
traumatic event through Socratic questions.
4. To assign the patient to write a detailed account of the traumatic incident.
(NOTE: If the therapist is using the CPT protocol without the trauma accounts,
then the assignment will be to do the A-B-C Worksheets again until the next
session.)
Review of A-B-C Worksheets
Homework Noncompliance—If the patient did not write the initial Impact
Statement for the last session, this session should begin with having the patient
read the Impact Statement and noticing any changes or additions since the last
session. If the patient fails to bring in the Impact Statement again or the A-B-C
Worksheets, the therapist should have a serious discussion about the patient’s
motivation for treatment at this time. If the patient continues to be noncompliant
with the assignments, therapy should not proceed without a commitment from the
patient. The therapist should consider whether some other form of treatment is
needed first (e.g., Dialectical Behavior Therapy (DBT), skills, substance abuse
treatment, panic disorder treatment) before PTSD treatment can commence. It is
preferable to ask the patient to return to treatment when he can devote himself to
the work than to have him fail to recover due to noncompliance. If the latter is the
case, it will be more difficult to implement the protocol at a later time (“That
therapy didn’t work; I’m a failure”). Remind the patient that avoidance behavior
is a symptom, not an effective method of coping. If the patient recommits to
treatment, have him bring in both the Impact Statement and A-B-C- Worksheets,
but hold off on the trauma account assignment to determine if he is going to
follow through. The therapist should begin by going over the A-B-C Worksheets
completed for practice. In looking over the worksheets that the patient has
completed since the previous session, the therapist should look for several
patterns first. Is there a particular dominant emotion that repeatedly occurs (e.g.,
anger at self)? Is there a particular thought that recurs across situations that might
indicate a greater schema distortion (“I can’t do anything right”—
incompetence)? Do the emotions follow logically from the thoughts that are
expressed? Is there a match between the thoughts and the degree of the emotions
(small event, disproportionately large feelings)?
After looking over the entries generally, the therapist assists the patient in sorting • Mismatch
through the individual items that were problematic for the patient. Frequently between
mismatches occur between thoughts and either type or degree of emotion because thoughts and
emotions

the thought that was listed was not actually the last thought in a chain of thoughts
and emotions. The therapist can point out the discrepancy mildly and ask what
thought goes with the level or type of emotion that was expressed. There may, in
fact, have been a series of thoughts and incremental emotions that lead to the final
stronger emotion. Tracking through the sequence can be helpful for patients to see
how increasingly extreme statements result in depression, terror, or other
desperate emotions.
Frequently, patients label thoughts as feelings. For example, one patient brought • Thoughts vs.
in an A-B-C Worksheet that said “Get yelled at before I even have my coffee” at feelings
“A,” “I try so hard but never get rewarded” at “B,” and “I feel like I’m fighting
an unsuccessful battle” at “C.” The therapist again labeled the basic emotions for
the patient and asked her which of the feelings fit the statement best. She said,
“sad and angry.” The therapist pointed out that what she had listed at “C” was
actually another thought that could be listed at “B.” The patient was able to
understand the distinction between thoughts and feelings. The therapist also
pointed out that just using the words “I feel...” in front of a thought does not
make that thought a feeling. Patients are encouraged to use the words “I think
that ...” or “I believe…” for thoughts and to reserve “I feel…” for emotions.
(NOTE: This misuse of the word “feel” is so common that the therapist may also
catch himself. It is quite acceptable, and in fact better, for the therapist to correct
himself during the session if it occurs, thus normalizing how our spoken language
can be misapplied.)
It is important for the therapist to praise the efforts of the patient and help with
corrections in a low-key manner, particularly if the patient has lots of issues with
negative self-evaluation (e.g., “O.K., let’s move this thought over to the “B”
column. Now what feeling goes with that thought? Just one word”).
Review of A-B-C Worksheet Related to Trauma
When going over the worksheet about the traumatic event, the therapist again has
an opportunity to begin cognitive challenges with Socratic questions. Consider
the following bereavement issue:
P: In the “A” column, I wrote “I didn’t think about Jack all day • Example of
when I was at work.” My thoughts were “How could I betray Socratic
him like this? I am worthless.” In the “C” column I wrote questioning
“shame, angry, and I cancelled my plans for the evening.”
T: Who were you angry at?
P: Myself.
T: I’m not sure I understand. How is that a betrayal of Jack?
P: I don’t know - it just is.
T: (Therapist waits silently)
P: Well, it just doesn’t seem fair for me to go on with my life, when
he can’t go on with his.

T: But how is that a betrayal? The word “betrayal” makes it sound
like you are saying that you were being disloyal or treacherous.
Is that what you mean?
P: Well, not treacherous, but yes, disloyal.
T: Before he died, did you ever have a workday when you didn’t
think about him all day?
P: Sure. Lots of times.
T: Were you being disloyal then? Were you betraying him by being
busy at work and concentrating on what you were being paid to
do?
P: Well, no, but that was different. He was alive then. I assumed that
I would see him again at the end of the day.
T: You said that it wasn’t fair for you to go on when he couldn’t. If
you go on with your work and life and don’t think about him all
the time, how will you have been disloyal? Why is it different
now?
P: (Tearfully) I’m afraid that if I am not thinking about him, that it
means that I am forgetting him.
T: (After a long pause to allow the patient to cry) When he was alive
and you didn’t think about him all day, did you forget him?
Could you have thought about him if you wanted to?
P: Of course.
T: And even though you know you are not going to see him at the
end of the day, you could decide to think about him? You can
remember him if you want to?
P: I suppose so. I’m just afraid to let go. It’s almost like if I don’t
think about him all the time, he really is gone.
T: So, you are saying that it is still very difficult to accept that he
has died.
P: Yes.
(Another pause)
T: Since he died, have you learned anything new about Jack? Did
anyone tell you any stories that you haven’t heard before?
P: Yes, lots of his relatives told me stories about when Jack was a
child, and people at work have told me about things he did for
people there that he never told me.
T: So, in some ways, even though he is gone, you are still learning
about him and who he was.
P: That’s true.
T: And have your feelings for Jack continued?
P: Yes, in some ways, they have increased. I heard so many nice
things that people said he had said and done. He was very
unselfish and never even mentioned these things to me. I’m very
proud of him.
T: So, rather than forgetting him, your relationship with him has
continued and your positive feelings have increased. That
doesn’t sound like you are betraying him. Also, being an

unselfish person, Jack would not expect you to stop living your
life because he had died, would he?
P: No, he wouldn’t. It just didn’t feel right to me. I just don’t know
how I am supposed to think or be.
T: There isn’t a right way or wrong way to grieve. In spite of some
stereotypes, people deal with the death of a loved one all sorts of
different ways with all sorts of different feelings over different
periods of time. You won’t be very fair to yourself if you hold up
some standard and decide that you are doing this wrong
somehow.
Introduction to the Trauma Account
The out-of-session practice assignment for the next week is to write a detailed • Writing the
account of the chosen index trauma. The patient is asked to write down exactly Trauma
Account
what happened with as many details as possible. He should be encouraged to
include sensory detail (sights, sounds, smells, etc.) and his thoughts and feelings
during the event. To encourage a more in-depth account, set the expectation that
the average handwritten trauma account is about eight pages long. If the patient is
unable to complete the assignment, he should be encouraged to write as much of
it as he can. He may need to write on several occasions to complete the
assignment. If he is unable to complete the assignment in one sitting or becomes
emotional and needs to stop for a few minutes, he should draw a line at the point
he stopped. The therapist may be able to determine some of the stuck points by
examining the points at which he quit writing. The patient should be instructed to
read the account to himself every day until the next session. (Once the account is
written, reading the account should only take a few minutes a day.) Encourage the
patient to pick a time when he has privacy and can cry and feel other emotions
without being interrupted or embarrassed. Be direct about discouraging
completing practice assignments at work, during lunch, or in a public place. For
those with substance abuse issues, directly indicate that they should not write the
account while using substances. Identify this as avoidance behavior. Also, the
account should be handwritten and not typed. As mentioned previously, there is
evidence that writing the account is more evocative. Typing the account lends
more objectivity and tends to focus on grammar rather than the emotional
engagement that is desired.
The therapist should add, “Don’t be surprised if you feel your reactions almost as
strongly as you did at the time of the incident. However, you need to remind
yourself that this is a memory and that you are not actually in danger as you
recall that event. Your feelings have been stored in your memory intact. If you
have not dealt with this event, your feelings and the details of the event are quite
vivid when you finally confront the memory in its entirety. People tend to
remember traumatic events in much greater detail than everyday events. Over
time, if you continue to allow yourself to feel your emotions about the event, your
feelings will become less intense and less overwhelming.”

There are two purposes for the writing assignments. First, writing about the event • Purposes of
in great detail assists in calling up the complete memory of the event, including writing the full
the natural emotions that have been encoded with the memory. Retrieving the Trauma
natural emotions allows them to be fully expressed and dissipated. The memory Account
can then be stored without such intense emotions encoded with it. (We have
found that the primary natural emotions dissipate quickly and do not need
extended exposure work, unlike theories that suggest the repeated prolonged
exposures are necessary for habituation.) The second purpose is for the therapist
and patient together to begin to search for stuck points.
Practice Assignment
• Assign
“Please begin this assignment as soon as possible. Write a full
Session 3
account of the traumatic event and include as many sensory details practice
(sights, sounds, smells, etc.) as possible. Also, include as many of assignment
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.”

Content: This was the third session of CPT for PTSD. He did (not) complete A-B-C
Worksheets daily, identifying his thoughts, feelings, and behaviors. These worksheets were
used to further illustrate the relationships among thoughts, feelings, and behaviors to daily
events. Some initial challenging of dysfunctional thoughts was introduced. The session
concluded with the assignment to write about the most traumatic event the patient has
experienced and to include as many sensory and emotional details as possible. Daily
monitoring of thoughts, feelings, and behaviors continues.
Plan: Continued CPT

PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

A-B-C Worksheet
Date: ___________ Patient: ____________________________

A B C

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Summary of Session 4: Remembering the Traumatic Event
2. Have patient read full Trauma Account aloud with affective expression (10 minutes)
¾ Goals of Written Trauma Account:
- Affective Expression—Holding back feelings? Why? (soda bottle analogy)
- Identify Stuck Points—Over-accommodation?
- Challenge Self-Blame—Assimilation?
¾ Remain quiet during reading (except to stop and ask to restart if no emotions are
expressed)
¾ Ask about feelings during writing and reading
¾ Ask about areas where it seemed something was avoided
¾ If Trauma Account was not written, discuss reasons and then have patient recount
the trauma during the session and reassign the writing
3. Identify stuck points (10 minutes)

¾ Use patient’s expression of affect or lack thereof to identify stuck points
¾ Ask to read again if initially read without affective expression or if clarification is
needed
¾ Listen for stuck points in the content
¾ Note the places the patient had to stop writing and ask about emotions, look for
stuck points
4. Challenge patient’s stuck points related to self-blame and other assimilation using
Socratic questioning (10 minutes)
¾ e.g., What else might you have done? And what might have happened then?
¾ Discuss hindsight bias
5. Explain difference between responsibility and blame (5 minutes)

¾ Rewriting of the full Trauma Account
¾ Daily reading of the full Trauma Account
¾ Daily completion of the A-B-C Worksheets
¾ Problem-solving re: practice completion (this is extremely important if practice
not completed this session)

1. To have the patient read his account, with affective expression. • Session 4
2. To identify the patient’s stuck points for the event. goals
3. To begin challenging self-blame and other assimilation with Socratic
questions.
4. To reassign the account with more details and anything that was left out.
Patient Reading of Full Trauma Account With Affective Expression
The therapist should begin the session by having the patient read the trauma • Patient
account. If the patient did not do the assignment, the therapist should first ask her reading of full
why she did not complete it. Discuss the problem of avoidance and how it trauma
prevents recovery. Then ask the patient to describe the event as if she had written account
it. Be sure to help the patient to identify her thoughts and feelings as she recounts
the event, but do not have the patient write it during session. If the patient has
brought the trauma account, having the patient, rather than the therapist, read the
account assists in engagement with the memory and reduces the likelihood of
dissociation or other emotional disengagement from the account. If the patient
• Therapist
expresses emotions, the therapist should remain still and not interfere with the
behavior
expression of affect. Comforting words or even handing the patient a tissue can during
actually interfere with expression of affect because the patient is brought back to reading
the present. Patients are usually trying so hard not to experience their emotions
that just about anything the therapist does can disrupt the process. Therapists who
are new to trauma therapy are often concerned that patients will experience an
overwhelming amount of affect. Patients are also frequently concerned about the
extent of emotions they have been avoiding. However, we have not found that to
be the case in the vast majority of cases and are usually very pleased with even a
small expression of affect. In those rare cases in which the therapist is concerned
about the extent of emotion that the patient is expressing, the therapist can begin
to do those very things mentioned above—talking to the patient, saying the
patient’s name, handing her a tissue, asking questions—to contain the affect.
It is important that the therapist allows and encourages the patient to express his • Therapist
emotions about the event and help him to identify both his thoughts and feelings. guidance
The patient should be encouraged to discuss his feelings and thoughts while doing during
the assignment, as well as during the incident. “What was the most frightening reading
part for you?” “Is there some aspect of the incident that you shy away from
recalling?” This exercise may help the patient and therapist to identify his stuck
points. The therapist should notice the points at which the patient stopped writing
and ask if these were particularly difficult points of his memory, and why. “What
were you feeling at the time that you quit writing?” Often these points are
particularly anxiety-provoking because they were the most life-threatening to the
patient or the moment at which he perceived a loss of control over the situation.

Depending on the length and complexity of the event, the average trauma account • Length and
content of
is about eight handwritten pages. However, some particularly short events may Trauma
not require as many. Others are so long and complex that several writing sessions Account
may be needed to complete the account. Some patients will write extensively
about irrelevant details and then gloss over the most crucial and traumatic
elements. The therapist needs to listen carefully, not just to what the patient reads
but also to what he leaves out. If the therapist realizes or suspects that an
important aspect of the account has been avoided, the patient should be asked for
more detail about that portion of the experience after he has finished reading the
whole account.
If the patient reads or recounts the event without any emotion, the therapist
should stop the patient early in the account and ask him if he is holding back his
feelings, and why. The therapist may need to discuss the issue of loss of control
and the patient’s fear of being overwhelmed by his emotions (“I will go crazy,
forever”). The analogy we typically use is one of a bottle of soda that has been • Soda bottle
shaken. When the cap comes off, there is a rush, but it is temporary and analogy of
emotions
eventually the soda flattens. If the patient were to quickly put the cap back on, the
soda would retain its fizz. The soda, under pressure, had energy to it but can’t
keep producing that energy when the cap is left off. Natural emotions can be
viewed the same way. The patient feels the strength of the emotions but keeps the
lid on them, thinking that they will continue indefinitely. At this point, the
therapist can ask the patient to recall times when he has experienced feelings such
as sadness or anger and what happened after he allowed himself to feel his
emotions. It can also be helpful for the therapist to remind him that the actual • Let the
event is over and that he is no longer in imminent danger. The strong feelings are patient feel
of a memory. After addressing this issue, the therapist should resume with the full emotions
account and ask the patient what he was feeling at the time. Again, when a patient
begins to experience emotions, it is important that the therapist sits quietly and
does not disrupt the emotions, minimize them, or interfere in any way.
Sometimes, the patient is not avoiding affect but is experiencing the emotions just
as they were experienced at the time. If the patient dissociated, she may dissociate
again as she recalls her memories of the event. If patients were nauseated, they
may feel the same way as they recall the event in detail the first time. Typically
the emotions change after the first account and the patient begins to experience
more current emotions, not just those that were encoded at the time of the event.
Identification of Stuck Points
Finally, the therapist should ask the patient about stuck points that may not be in • Stuck points
her trauma account (i.e., what she thought she should have done). Often, patients from Trauma
have regrets afterward because they believe they should have prevented an event, Account
did not fight hard enough, or did or didn’t do something that affected others.
Sometimes stuck points emerge because other people respond to hearing about
the event by second-guessing the veteran’s behavior. The therapist may have to
discuss 20/20 hindsight (hindsight bias) and how easy it is to say how you should

have behaved after something occurs. This can be a particularly difficult stuck
point if the other person’s comment mirrors what the patient previously believed
about how she would act in such a situation. No one knows how she will respond
in a particular situation. Sometimes patients jump to the faulty conclusion that if
they had acted differently in some way, the event would have turned out
differently. Of course, people’s fantasies usually result in a good outcome. They
don’t consider more negative outcomes. In this vein, Socratic questioning about
the range of possible outcomes with alternative courses of action is very helpful.
Stuck Points Specifically Related to Self-Blame and Other

Assimilation Using Socratic Questioning
Self-blame is often encountered early in therapy as the patient recalls the event. • Self-blame
This form of assimilation occurs because the patient is looking for ways in which
he could have prevented or stopped the particular outcome that occurred. Even
following disasters that are clearly outside of a patient’s control, self-blame and
guilt are common. People imagine ways they could have changed personal
outcomes; they have regrets about not saving others; they feel guilty about things
they did or did not do, and about feelings they did or did not feel during or after
the event. This “if only” type thinking serves as assimilation in that it is an
attempt to undo the event in retrospect. It usually never occurs to the patient that
the “if only” might not have worked. Some people get caught up in assumptions
about how one should react or how long it should take to recover, and then feel
guilty that they are not doing it right. Some people even feel guilty because they
are coping well when others around them are not.
It is important for the therapist to help the patient contextualize the traumatic • Contextualiza-
event. For example, if a veteran blames himself for killing someone in Vietnam tion of traumatic
and has flashbacks of seeing that person’s face, he may not be fully appreciating event
the context of the situation. Going through the account will help the patient see
that he was in a war, that the other person was shooting at him, and that he had no
other good option at the time (or perhaps a worse option). Part of the context
would also include the age of the person (and developmental level) at the time of
the event and his beliefs about war and the military at the time. He may also have
been sleep-deprived or hungry, or terrorized and dissociative at the time. It is
important for the patient to understand that actions he thinks of later, but not at
the time of the event, were not options. The therapist’s job is to guide the patient,
through the use of Socratic questions, to realize that events can occur in spite of
one’s best efforts. The best-made plans do not always result in positive outcomes.
The following is an example of Socratic questioning early in therapy about the
context of killing.
T: Earlier you mentioned that you were feeling angry about the • Example of
reports from Abu Ghraib. Can you tell me what makes you Socratic
angry? questioning
P: I can’t believe that they would do that to those prisoners.
T: What specifically upsets you about Abu Ghraib?

P: Haven’t you heard the reports? I can’t believe that they would
humiliate and hurt them like that. Once again, the U.S. military’s
use of force is unacceptable.
T: Do you think your use of force as a member of the U.S. military
was unacceptable?
P: Yes. I murdered innocent civilians. I am no different than those
military people at Abu Ghraib. In fact, I’m worse because I
murdered them.
T: Murder. That’s a strong word.
P: Yah?
T: From what you’ve told me, it seems like you killed some people
who may or may not have been “innocent.” Your shooting
occurred in a very specific place and time, and under certain
circumstances.
P: Yes, they died at my hands.
T: Yes, they died, and it seems because of your shooting. Does that
make you a murderer?
P: Innocent people died and I pulled the trigger. I murdered them.
That’s worse than what happened at Abu Ghraib.
T: (Quietly) Really, you think it is worse?
P: Yes. In one case, people died, and in another they didn’t. Both
are bad, and both were caused by soldiers, but I killed people
and they didn’t.
T: The outcomes are different. I’m curious if how it happened
matters?
P: Huh?
T: Does it matter what the soldiers’ intentions were in those
situations?
P: No. I don’t get what you’re saying. The bottom line is killing
versus no killing.
T: (Realizing that there was minimal flexibility in the patient’s
thinking at this point) I agree that there is no changing the fact
that people died, and that your shooting had something to do
with that. However, I think we might disagree on the use of the
term “murder.” It is clear that their deaths have been a very
difficult thing for you to accept, and that you are trying to make
sense of that. The sense that you appear to have made of their
deaths is that you are a “murderer.” I think this is a good
example of one of those stuck points that has prevented you from
recovering from this traumatic event. We’ll definitely be
spending more time together on understanding your role in their
deaths. I’m not sure “murder” is the right word to describe what
happened.
In addition to testing the patient’s cognitive flexibility, the therapist also wanted
to plant the seeds of a different interpretation of the event. She was careful not to
push too far, and she retreated when it was clear that he was not amenable to an

alternative interpretation. He was already defensive and somewhat angry, and she
did not want to exacerbate his defensiveness or possibly contribute to dropout
from the therapy.
If the patient’s index event was child physical or sexual abuse, he may be • Child physical
particularly confused by the concept of punishment. He may assume that the or sexual
event occurred as some form of punishment, an idea that may have been abuse
reinforced by the abuser. Later traumas are then also assumed to be some form of
punishment. Because the patients cannot figure out what they did wrong or what
they could have done that deserved such severe punishment, they may have
concluded that it must have been because they were bad people to begin with. The
ultimate goal for the therapist is to help the patient to see that abuse has nothing
to do with him as a person, but is only about the abuser and his or her choices.
Because rape is a very personal event, patients who have experienced it may also • Rape
believe that it means something about them as people. Again, the therapist will
need to guide the patient to see that she was the occasion for the assault (she was
convenient or had higher risk factors such as small size or alcohol use) but not the
cause of the event. The perpetrator is entirely responsible and to blame for the
event, and no risk factor can force someone to commit an assault. In fact, some
risk factors would result in protective behavior in good people (e.g., intoxication,
small size). Blame and fault are words that should only be used when intent was
present (i.e., when the patient says she is to blame for the event, the therapist can
ask if the patient intended for this to happen. When she says no, the therapist can
explain that blame and fault only apply to intentional acts.)
P: It is my fault that the sergeant raped me. I should have been able
to stop it.
T: How could you have stopped it?
P: I was trained in close combat.
T: When did you recognize that you were in danger?
P: We were talking and then he closed the door, walked over and
pushed me down.
T: And is this the type of situation you had been trained to handle?
P: No. They were training us for situations with strangers, with the
enemy. I never expected to be assaulted by my sergeant.
T: So you were surprised by him. Were you confused as to what was
going on?
P: Yes, very.
T: So there was a period of time that you didn’t know what was
going on and what to do?
P: Yes. I just froze for a minute. I said “no” several times but he
didn’t stop. I remember pushing at him but I remember thinking,
“If I fight him, he could kill me.”
T: Was he bigger than you? Stronger than you?
P: Yes. And when he was on top of me, I couldn’t move. I couldn’t
breathe.

T: So how could you have stopped it?
P: I guess I couldn’t have. But, I just keep thinking I should have.
T: But that thought doesn’t get you anywhere does it? He had
surprise on his side, your training didn’t include fighting off
someone you knew, who was your superior, was bigger, stronger,
and had the power to ruin your career. You know, I wonder if
you are confusing “I should have” with “I wish I could have.”
P: I do wish I could have stopped it.
T: I wish it hadn’t happened either. You didn’t deserve to have it
happen. And from everything you have told me, I am not hearing
any way you could have stopped it. How does it feel to say “I
wish I could have stopped it” instead of “I should have stopped
it”?
P: You know, it does feel different. When I say “I should have,” I feel
guilty. When I say, “I wish,” I just feel a little sad.
Difference Between Responsibility and Blame
In this stage of CPT focused on addressing assimilation, it is important for the

• Responsibility
therapist to educate the patient about the distinction between blame and vs. blame
responsibility. Responsibility relates to one’s actions in a situation that
contributes to a certain outcome. A combination of responsibility and
intentionality is what determines blame. If there is no intention to do harm, then
blame is not appropriate. People are capable of making distinctions in levels of
blame and responsibility. An example of that is the distinction that people can
make among an accident (no responsibility, no intentionality), negligent
manslaughter (responsibility, but no intentionality), and murder (responsibility
and intention to kill).
The following is Socratic questioning about intentionality and responsibility as it

relates to the prior example of killing in a combat situation.
T: I think it is worthwhile for us to discuss the differences between

blame and responsibility. Let’s start with responsibility. From
your account, it sounds like you were responsible for the
shooting. It sounds like there were other people who may have
been responsible, too, given that you were not the only person
who shot at that time. The bottom line is that responsibility is
about your behavior causing a certain outcome. Blame has to do
with your intentionality. It has to do with your motivations at the
time. In this case, did you go into the situation motivated and
intending to kill?
P: No, but the outcome was that they were murdered.
T: Some died. From what you’ve shared, if you put yourself back
into the situation at the time, it was not your intention at all for
them to die. Your, and others’, intentions were to get the people
out of the area. To secure and protect the area. Your intention at

the time did not seem to be to kill people. In fact, wasn’t your
intention quite the opposite?
P: Yes. (Begins to cry)
T: (Pause until his crying subsides somewhat) Your intention was
not to kill civilians at all. Thus, the word blame is not
appropriate. Your intention was not at all to have to shoot them.
P: But why do I feel like I am to blame?
T: That’s a good question. What’s your best guess about why that
is?
P: (Still crying) If someone dies, someone should take
responsibility.
T: Do you think it is possible to take responsibility without being to
blame? What would be a better word for a situation that you had
a part in, but you didn’t intend for it to happen? If someone shot
someone but didn’t intend to do that, what would we call that?
P: An accident, I guess.
T: That’s right. In fact, what would we call shooting someone when
you were trying to protect something or someone?
P: Self-defense.
T: Yes—very good. Weren’t you responsible for securing the area?
P: Yah.
T: So, if you were responsible for guarding and securing that area,
and they didn’t heed your warnings, wouldn’t that have put the
area at risk?
P: Yes, but they were civilians… not insurgents.
T: How do you know that?
P: (Pause) I don’t.
T: We actually don’t know what their intention was, do we? They
didn’t heed the several warnings, right?
P: Yes. (Pause)
T: We don’t know, and won’t know, bottom line. However, what we
do know is what you knew at the time. What you knew at the time
is that they had not heeded the warnings, that you were
responsible for securing the area, and that you took action when
you needed to take action to protect the area. Thinking about
those facts of what happened and what you knew at the time, how
do you feel?
P: Hmm… I guess I’d feel less guilty.
T: You’d feel less guilty, or you feel less guilty?
P: When I think through it, I do feel less guilty.
T: There may be points when you start feeling guiltier again. It will
be important for you to hold onto the facts of what happened,
versus going to your automatic interpretation that you’ve had for
a while now. Is there any part of it that makes you proud?
P: Proud?
T: Yes. It seems like you did exactly what you were supposed to do
in a stressful situation. Didn’t you show courage under fire?

P: It’s hard for me to consider my killing to be courageous.
T: Sure. You haven’t been thinking about it in this way before. It is
something to consider.
The therapist’s Socratic questioning was designed to help the patient consider
the entire context in which he was operating when he killed civilians, or
possibly insurgents. She also began to plant seeds that he not only did nothing
wrong, but did what he was supposed to do to protect the area. Whenever
possible, point out acts of heroism or courage as powerful interventions with
patients.
A Comment on Perpetration
Aside from acts of war and killing in that context, it is possible that a patient will • Perpetration
describe an event in which she did commit what might be considered murder (in
war, the intentional killing of an unarmed and nonthreatening person) or a sexual
assault. The therapist first needs to ask questions to determine if a patient’s self-
blame is a form of assimilation described earlier. If it was indeed intended and
unprovoked harm against an innocent person, the therapist should ascertain if this
is behavior that has continued since the person left the military or if it only
occurred in the context of war. If the former, then the therapy needs to shift focus
to assess whether someone is currently in danger (and possible Tarasoff • Safety of
warnings), and more generally to cease the behavior. In this case, it may be others
necessary to stop the CPT protocol to focus on the more basic safety of others. If
it is the latter case, that the behavior occurred during the combat and not since,
the therapist may need to help the patient to contextualize and differentiate who
she was then from who she is now. Too often people fall prey to the fundamental
attribution error and do not fully appreciate the contextual factors that determine
behavior. They make characterological attributions that may not be accurate
based on a review of their behavior.
Ultimately, the therapist must make a clear statement that the patient was not to
blame for things he had no control over and did not cause, but does have
responsibility for intended acts. The therapist and patient can discuss what values
the patient has now and strive for self-forgiveness in those situations for which he
has responsibility. He may also want to engage in some type of remediation to
society if it is not possible to do something for the victim.
Vicarious Traumatization
As a side note, therapists reading or hearing graphic accounts may experience • Therapist
vicarious traumatization and may need to process their own reactions to hearing reactions to
these accounts (McCann & Pearlman, 9 1990a). If a therapist becomes trauma
9
McCann, I. L., & Pearlman, L. A. (1990a). Vicarious traumatization: A framework for
understanding the psychological effects of working with victims. Journal of Traumatic Stress,
3(l), 131–149.

uncomfortable listening to a patient’s account of the event, it is possible that the
therapist may send subtle signals (and in cases we have heard about, not so subtle
signals) to the patient that the therapist can’t handle the event either. For example,
immediately handing the patient a tissue tells the patient to pull herself together
(and dry up). Shutting the patient down is a fatal error on the part of the therapist.
In order for the patient to be able to accept and integrate the event and tolerate her
emotions, the therapist must also be able to do so. Therapists are particularly at
risk if they are doing a great deal of trauma work. In these circumstances, the
therapist should make sure to get supervision and support in order to continue the
work effectively and not suffer unduly. The therapist should also check her own • Supervision
assumptions and thoughts to make sure they are not becoming unbalanced. The
principles behind CPT apply to therapists as well as patients.
Practice Assignment
For the practice assignment, the therapist asks the patient to write the whole • Second
account again at least one more time. If the patient has been unable to complete Trauma
Account
the assignment the first time, he should be encouraged to write more than last
time. Often, the first version reads like a police report with nothing but the facts.
The patient should be encouraged to add more sensory details and more of his
thoughts and feelings during the incident. The therapist should add that this time,
the patient is also requested to write his current thoughts and feelings, what he is
thinking and feeling as he is writing the account, in parentheses (e.g., “I’m feeling
very angry”). Also, the trauma may encompass much more than the narrow
circumstance of the event. Police or military procedures, medical treatment,
funerals, or rejection from loved ones may compound the trauma and should be
considered part of the event, for all practical purposes. Memories of these events
and concomitant stuck points should be included in the writing assignments and
discussions. If the patient is experiencing different thoughts and feelings from
those in the first account, then he can write his current thoughts or feelings in the
margins or in parentheses, e.g., “At that moment I was absolutely terrified (now I
am feeling angry).”
The patient should be reminded to read over the new account every day until the
next session.
“Write the whole incident again as soon as possible. If you were • Assign
unable to complete the assignment the first time, please write more Session 4
practice
than last time. Add more sensory details, as well as your thoughts assignment
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.”

Content: This was the fourth session of CPT for PTSD. The patient completed his practice
assignments related to writing a detailed account of his most traumatic event and daily
monitoring of thoughts, feelings, and behaviors. The patient was distressed in this session
when discussing his thoughts and feelings about the traumatic event but was able to tolerate
these emotions. The goal of this intervention is to increase his access to and expression of
these feelings and to allow the natural resolution of them. The therapist used cognitive
therapy strategies to challenge the patient’s dysfunctional interpretations about the event. The
session concluded with practice to write again about the most traumatic event the patient has
experienced and to further elaborate on the sensory and emotional details. He agreed to
include his thoughts and feelings while writing the account and to read the account daily.
Plan: Continued CPT

PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

A-B-C Worksheet
Date: ___________ Patient: ____________________________

A B C

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Session 5: Second Trauma Account
Summary of Session 5: Second Trauma Account
2. Read second Trauma Account aloud; help to identify differences between the first
and second accounts (15 minutes)
¾ Goals: New Additions (or Deletions)?
- Progress of affective expression and self-blame/guilt?
- Continue cognitive therapy on stuck points
- Introduce Challenging Questions
¾ Discuss: Feelings of when it happened and now
- Differences and similarities: at time of event, now
- Feelings after writing it the second time vs. the first time—less
intense?
3. Engage patient in challenging assumptions and conclusions that the patient had made
after processing affect, with particular focus on self-blame (10 minutes)
¾ Use some of the challenging questions to help introduce the next worksheet, The
Challenging Beliefs Worksheet, to continue cognitive therapy on stuck points
regarding the worst traumatic event.
¾ Help patient reduce use of word blame, which implies intentionality
4. Introduce Challenging Questions Worksheet to help patient challenge stuck points

(10 minutes)
¾ Go through blank question worksheet
¾ Go through example worksheets
¾ Choose a stuck point of the patient’s to begin addressing with these questions (a
focus on assimilation is helpful at this point in the therapy)

¾ One stuck point a day, using the Challenging Questions Worksheet
¾ Continue to work on trauma account(s) if not finished, and read over daily

Session 5: Identification of Stuck Points
The goals of Session 5 are: • Session 5
goals
1. To have the patient read and discuss the newest version of the Trauma
Account.
2. To discuss the new additions (or deletions).
3. To check the progress of affective expression and self-blame/guilt and other
forms of assimilation.
4. To continue cognitive therapy on stuck points for the event.
5. To introduce the Challenging Questions Worksheets so that the patient will
begin to use Socratic questions himself.
6. To assign Challenging Questions Worksheets and an account for another
traumatic event if needed.
• Reading of
Patient Reading of the Second Trauma Account With a Focus on the the second
Differences Between the First and Second Accounts Trauma
Account
The therapist should begin the session by going over the new version of the
account. The patient is helped to analyze her feelings then and now. The patient
should discuss the differences and similarities between how she felt at the time of
the event and how she felt as she wrote about it. The patient should be asked how
she felt after writing and reading about the event a second time as compared to
the first time. It is likely that the intensity of emotions will be less the second time
if she allowed herself to feel her emotions the first time. The therapist should
point out the difference as an example of how the feelings will become less
intense over time (or temporarily increased if she managed to avoid her feelings
during the first writing assignment).
Challenging Assumptions and Conclusions With a Focus on

Self-Blame
The therapist should continue to use Socratic questions, particularly the questions • Examining
listed on the Challenging Questions Worksheet in order to continue to help the various forms
patient to examine assimilation, self-blame, and other forms of hindsight bias. By of
assimilation
including questions that the patient will be introduced to, he will begin to become
acquainted with the concepts. Hopefully, by the time the patient has completed
two accounts and has put the event back into context, much of the self-blame will
have diminished. As with Sessions 3 and 4, it is important for the therapist to
keep in mind that often the self-blame and assimilation occur because the patient
is not remembering how he was thinking, feeling, or coping during the event. The
patient may assume that he had or should have had skills or knowledge that he did
not have and then judge himself harshly for not behaving differently. Typically,
when the therapist can put the patient back in the full context of the situation, the
patient can then see that the event (or his component of the event) was not
preventable and hence, he is not to blame.

The therapist can help the patient reduce her use of the words “blame” or “fault”
by catching it whenever the patient uses the words. Once the therapist and patient
have established that the patient did not intend the outcome and could not prevent
the event from occurring, then it is important to change the language that is used
to describe the event. As discussed in Session 4, “blame” implies intentionality. If
the patient agrees that she did not intend the outcome, then the words blame or
fault are not appropriate or accurate.
Introduction to the Challenging Questions Worksheet
The list of challenging questions is introduced during this session. The list can be • Give patient
used to question and confront maladaptive self-statements and stuck points. In Challenging
order to help patients comprehend the assignment, we have created a handout of a Questions
sample that walks the patient through the assignment step by step with a stuck Worksheet
point. The therapist should reiterate that stuck points are conflicts between old
beliefs and the reality of the event, or negative beliefs that were seemingly
confirmed by the event. In either case, the beliefs don’t work because they lead to
self-blame, guilt, anger at self and others, etc. The therapist can choose a
statement the patient has made during the session and use the questions to begin
confronting the validity of the belief. At this stage of therapy, it is particularly
valuable to focus attention on stuck points indicating assimilation and self-blame.
Until the patient can accept that she was not to blame or accept the reality of the
outcomes, it will be difficult to work on other issues. If there is time in the
session, it is helpful for the patient and therapist to complete one sheet together. It
should be pointed out that not all questions will be relevant to every thought.
To increase out-of-session assignment compliance, it is also helpful to determine

several stuck points that the patient can address with the Challenging Questions
Worksheets.
Practice Assignment
“Please choose one stuck point each day and answer the questions • Assign
on the Challenging Questions Worksheet with regard to each of Session 5
practice
these stuck points. There are extra copies of the Challenging assignment
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.”

Content: This was the fifth session of CPT for PTSD. The patient completed his practice
assignment related to rewriting his traumatic event, including further elaboration and
inclusion of his current thoughts and feelings. He was able to experience the associated
emotions, and his distress related to them was decreased compared to the last session.
Cognitions about self-blame/guilt were specifically targeted for cognitive restructuring. In
addition, “challenging questions” were introduced to the patient to aid his own challenge of
dysfunction and erroneous beliefs. The notion of stuck points (i.e., conflicts between existing
beliefs and traumatic events, or beliefs that were confirmed as a result of the traumatic
events) was reviewed, and the patient agreed to identify one stuck point each day to
challenge with the aid of the Challenging Questions Worksheet.
Plan: Continued CPT

PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

Challenging Questions Worksheet
Below is 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?

FOR:
AGAINST:
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?
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 the situation 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 focused on irrelevant factors?

Belief: I let the accident happen.

FOR: I stood by and watched the accident happen.
AGAINST: 1. I wasn’t the one who was assigned the duty.
2. It wasn’t my watch.
3. Others were there too—they did nothing.
We are what we speak and since I’ve spoken it for 39 years, I take it as a fact. It’s hard to
change my belief after I have spoken it so long. It kind of molds into your soul. On the opposite
side, the fact is I stood there. But others did too.
I don’t think I’m distorting what happened. It’s just hard to get past it. It’s like a major
disappointment in myself. I’ve always picked up the slack, and this time I let it slide.

The fact that this happened and I could have prevented it is either black or white. I errored and
a person paid the ultimate price. It was either stop him or let him go. I knew it as no excuse and
letting go is very hard.
Yes; I can’t believe I let this tragedy happen! Disappointment, hurt, mental angst,
permanent, death, lost forever.
I guess I’m looking at the bad—totally. I’m taking full responsibility for it without any
thought given to the circumstance of others being there.

Witnessed it for myself.

It is a high probability because it happened. Even though I still need to let it go.

But, the facts are that I couldn’t change the accident.

The beliefs are based on facts.

Belief: I take antidepressants, so I must be screwed.

FOR: Other people’s opinions.
AGAINST: I feel better when I take them. It gives me time to make better decisions.

Habit—listen to press/others and it seems like the whole world is on Prozac.
I need the medications to feel better.

I tell myself if I don’t take it today then I’ll lose it.
I use words like “screwed up.”
N/A

Not—it’s my belief. Professionals feel I need it. Other people tell me it’s not worth a
shit.

Yes, I could get to a point where I didn’t need it.

Feeling is what others think.

Lots—it really helps me. The person putting the medication down probably needs medication,
too.

Belief: I am responsible for my mom’s death.

FOR: There is what I believe is circumstantial evidence.
AGAINST: There is no concrete evidence to this belief.

It has become a habit.
I blame myself and don’t give my mom the responsibility for the actions she took.

Of course it was all or none; I felt responsible, guilty to the core. But now, I am
processing the events, and it’s not all my fault.
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)
I am responsible. It’s all my fault. I should have handled that night differently.
6. Are you taking the situation out of context?

My mom died from her actions.

I still feel as though I had some part of it.

My mom was not an emotionally stable woman and at this point, neither am I.

Feelings.

Yes, I am focused more on me than her role.

Summary of Session 6: Challenging Questions
2. Review Challenging Questions Worksheet (10 minutes)

¾ Assist patient in answering questions they had difficulty answering
¾ Assist patient to analyze and confront stuck points (hindsight bias)
¾ Begin shifting focus to over-accommodation, as the self-blame resolves
¾ Re-read Trauma Account (this applies only if account needed to be reassigned and
it is clinically important to read it in session)
3. Continue cognitive therapy for stuck points (10 minutes)
4. Introduce Patterns of Problematic Thinking Worksheet (15 minutes)

¾ Go over blank handout
¾ Go over example
¾ Questions to consider or address:
- Does the patient have tendency toward particular patterns of problematic
thinking?
- Describe how these patterns become automatic, creating negative feelings
(use example) or causing people to engage in self-defeating behavior (use
example)
- What other events in your life has this kind of thinking affected?
- Over-accommodation?
¾ Help patient generate more possible examples of problematic thinking patterns,
trauma and non-trauma-related, using the Patterns of Problematic Thinking
Worksheet
¾ Shift to patient taking over Socratic questioning of self; be supportive/consultative

¾ Identify stuck points and find examples for each Patterns of Problematic Thinking
Worksheet. Notice and write down new examples experienced each day. Look for
patterns. Look for ways your reactions to events have been affected by your past
bad experiences and the habitual patterns that have developed after them.
¾ Continue reading Trauma Accounts if you still have strong emotions about them.
¾ If patient had difficulty with Challenging Questions Worksheets, assign another
one as well as the Patterns of Problematic Thinking.

1. To review the Challenging Questions Worksheets. • Session 6

goals
2. To assist the patient in answering questions he had difficulties answering.
3. To continue cognitive therapy for stuck points the patient is trying to challenge.
4. To introduce and assign the Patterns of Problematic Thinking Worksheet.
Unless the patient has a strong need for the therapist to hear a new account, the
writing and reading of other trauma accounts can be done outside the session.
However, the therapist will want to check on progress and ask the patient to
report on stuck points that need to be resolved.
If the patient’s scores on the PTSD scale being used have not dropped by this • Review of
point in treatment, this may indicate that the core conflict about the event has still PTSD
not been resolved. The therapist should continue to spend the bulk of the session symptom
working on the index trauma with the Challenging Questions Worksheets and outcomes
Socratic questioning. At this point, the therapist should go over the PTSD scale
used to assess outcomes to see which symptoms are still most problematic. If the
patient is still avoiding thinking about or feeling emotions about a portion of the
event, having him write a more detailed account of that portion or confirming that
he is reading the account outside of session on a regular basis is indicated. If the
patient reports continued nightmares or flashbacks, the therapist should check on
the content. The content might give clues as to the part of the event in which the
patient is still stuck. On the other hand, if there has been a significant drop in
PTSD scores, then the therapist may turn attention to over-accommodated beliefs
in the present and future.
Review of the Challenging Questions Worksheet
The session begins with the practice assignments and reviewing the patient’s • Using
Challenging
answers to the Challenging Questions Worksheet. The therapist assists the patient Questions to
to analyze and confront her stuck points. For the most part, patients do an confront stuck
excellent job answering the questions. The most common problem we encounter points
is that patients will try to use another thought as evidence supporting their
problematic belief. For example, in challenging the stuck point “I should have
behaved differently during the event,” a patient says the evidence for the
statement is “I should have prevented the event.” The second statement is not
evidence for the first. The therapist can help define evidence as actions that would
“hold up in court,” in other words, observable actions that reasonable people
could agree on. In this case, the only evidence that might support the statement
would have to be some proof of negligence or intentional harmful behavior.
Occasionally, a patient will lose sight of the fact that he is trying to answer one
question and will wander around using the Challenging Questions to challenge
completely different thoughts instead of one thought. Other times a patient may

pick a stuck point that is too vague and be unable to answer the questions. These
• Focusing on
problems can be avoided if example worksheets are given to the patient and if the one stuck
therapist and patient pick out several well-specified stuck points to work on. At point
this stage of therapy, the most likely stuck points revolve around self-blame and
hindsight bias as to how the event could have been handled differently. In the
case of traumas including deaths of others around the patient, survivor guilt is
also likely. The therapist should make sure that underlying attributions,
expectations, and other conflicting cognitions have been identified. The relevance
of some of the questions that the patient was unable to recognize should be
pointed out.
At this point in therapy there should also be a shift in the therapist’s behavior. Up
until now, the therapist has been asking the Socratic questions to guide the patient
to question her assumptions. With the introduction of the Challenging Questions,
patients begin to ask and answer those questions for themselves. The therapist
begins to take on a more consultative and supportive role. The interchange can be
more interactive and the therapist may be able to suggest other possible answers
to the questions. The therapist will only need to return to Socratic questions when
the patient is stuck.
The first five or six sessions of therapy focus on encouraging natural affect to run • Addressing
its course and to modify maladaptive cognitions about the event through the over-
therapist’s Socratic questioning. Once assimilation (evidenced by self-blame, if- accommodation
only statements, and denial or functional amnesia) has been resolved, attention
turns to over-accommodation. Because of the patient’s interpretation about the
causes of the event, he then draws conclusions about himself and the world in
order to feel safer and in more control, as if he could prevent other negative
events from happening. For example, people who have been assaulted by
someone they know are likely to experience disruptions in trust. They may also
develop over-generalized problems with trust if their loved ones let them down in
the aftermath of the event. If a patient decides he had poor judgment that allowed
the event to happen, he won’t trust his judgment in other situations. If someone
concludes that authorities were responsible for the event, he will have distrust and
disregard for authorities. Such over-generalized, over-accommodated beliefs are
an attempt to feel safer but result in disrupted relationships, fearful behavior, poor
self-esteem, or suspicion of others
Introduction to Patterns of Problematic Thinking
After discussing the questions, Patterns of Problematic Thinking are introduced. • Give patient
This worksheet is different from the Challenging Questions Worksheet in that it is Patterns of
focused on patterns of thinking and not a specific belief. Rather than focusing on Problematic
Thinking
a single thought or belief, the patient is asked to notice whether he has tendencies Worksheet
toward particular counterproductive thinking patterns. The therapist should
describe how these patterns become automatic, creating negative feelings and
causing people to engage in self-defeating behavior (e.g., avoiding relationships
because of the conclusion that no one can be trusted). The therapist should use

examples from prior sessions or attempt to have the patient give an example from
a recent event.
Practice Assignment
For the practice assignment, the patient should consider her stuck points and find
examples for each relevant thinking pattern. As she experiences events in the
following days, she should notice and record any patterns she identifies. She
should be asked to look for specific ways in which her reactions to the event may
have been affected by these habitual patterns. Some of these thinking patterns
may have predated the event, or they could have developed in response to it. In
order for patients to understand these problematic thinking patterns better, we
give them a worksheet with examples along with blank worksheets for them to
complete. If the patient had difficulty with the Challenging Questions Worksheet,
assign another one in addition to the Patterns of Problematic Thinking Worksheet.
“Consider the stuck points you have identified thus far and find • Assign
examples for each of the problematic thinking patterns listed on the Session 6
practice
worksheet in your day to day life (or over the course of the next
assignment
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.”

Content: This was the sixth session of CPT for PTSD. The patient completed his practice
assignment related to challenging stuck points daily with aid of the Challenging Questions
Worksheet. Stuck points related to self-blame and hindsight bias were particularly targeted.
Patterns of problematic thinking contributing to stuck points continue to be targeted for
restructuring. The patient has developed a greater ability to challenge his dysfunctional and
erroneous beliefs associated with his stuck points. Patterns of problematic thinking (e.g.,
minimization/exaggeration, all-or-none thinking) were introduced, and examples from the
patient’s thinking about his traumatic event and life in general were used to illustrate these
patterns. He agreed to identify examples of each problematic thinking pattern before the next
session.
Plan: Continued CPT

PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

Patterns of Problematic Thinking Worksheet
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 these
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 the evidence is lacking or even contradictory.
2. Exaggerating or minimizing a situation (blowing things way out of proportion or shrinking

their importance inappropriately).
3. Disregarding important aspects of a situation.
4. Oversimplifying things as good/bad or right/wrong.
5. Over-generalizing from a single incident (a negative event is seen as a never-ending pattern).
6. Mind reading (you assume people are thinking negatively of you when there is no definite
evidence for this).
7. Emotional reasoning (you have a feeling and assume there must be a reason).


(Sexual assault victim/combat veteran) If a man is alone with a child, then the man will hurt the
child.

I saw a dead body and riots but I didn’t get hurt and others saw worse so my reaction to the
situation was wrong. I was weak.

I keep forgetting the fact that the perpetrator had a knife, which is important information about
how much control I had.

It was wrong for me to run from the dead body or hide while in Cuba.

I was raped by my grandfather, so when I see old men that look like him, I think they must be
like him.
evidence for this).
My dad yells now, so I assume he must be angry. But it’s not true a lot of the times, as he yells
sometimes because he is deaf in one ear and going deaf in another. He yells because he doesn’t
know he is yelling.
I cried and felt guilty when dad yelled at me when I got hurt, so I must have done something
wrong.


(Combat veteran) I did a bad job. I didn’t save my friend and other people also got killed in the
battle. But, I did the best I could, and there was no way I could have saved everyone that’s not
realistic. I contributed to the fight and in doing so I may have saved some of my friends’ lives. I
saved myself too. I guess that’s not evidence for doing a “bad” job. I guess that’s evidence for
doing my job, doing a good job.

I used to say that if I had not been asleep the ambush would not have happened and no one
would have died. I would say now that I have minimized the severity and unpredictability of war.

I have always felt guilty because I killed people. I have felt bad about myself and have put
myself down for years. It didn’t occur to me to think about the reality of the situation; it was
war. I had to kill. That is the nature of war. I may not agree with the war now, or believe in war,
but the fact is that it was war and to survive I had to shoot. It was my duty to shoot back and
defend our regiment. In feeling guilty and assuming I was bad, I was disregarding an important
factor of the situation—I was disregarding the fact that it was a war.

Not everyone is good or bad. I may have done some things in my life that were not that good, but
that does not make me a bad person.

That ambush was just one event in the entire war, and one event in my life. Just because that
was an awful event doesn’t mean that I can’t handle things. It doesn’t mean I do everything
wrong.
evidence for this).
I have always assumed everyone thought I had let them down. I assumed they thought that I had
blown it and allowed the ambush to happen. But now I realize I only imagined that—I didn’t
really know what they were thinking. Since then I have written to some of the guys and none of
them ever thought it was my fault. Boy, I guess I was mind reading.
Since I have always felt guilty I assumed I was guilty. But feeling something is very different
from what is really true. I felt guilty because people got hurt, but that doesn’t mean it was my
fault they got hurt.

Summary of Session 7: Patterns of Problematic Thinking
2. Review Patterns of Problematic Thinking Worksheet to address trauma-related

stuck points (10 minutes)
¾ Questions to consider or address:
- Does patient have strong tendencies toward particular patterns?
- Discuss how these patterns may have affected his reactions to the trauma
- Replace with other, more adaptive, cognitions
3. Introduce Challenging Beliefs Worksheet with a trauma example (15 minutes)

¾ Point out that much of this is repeated from previous worksheets
- Rate strength of belief (0%–100%)
- Rate strength of emotion (0%–100%)
- Use Challenging Questions Worksheet
- Use Patterns of Problematic Thinking Worksheet
- Generate new, balanced, evidence-based statement
4. Introduce first of five problem areas: Safety issues related to self and others
(10 minutes)
¾ Five themes: safety, trust, power/control, esteem, intimacy
¾ Prior/after: How did trauma affect beliefs about _____ for self? For others?
¾ If stuck point Æ worksheet
¾ Need to recognize how beliefs influence behavior/avoidance
¾ Help the patient begin to introduce more moderate self-statements
¾ Practice Challenging Beliefs Worksheet by introducing one on a safety-related
stuck point (which may be completed for practice)

¾ Daily identification of stuck points—one relating to safety and confront them
using the Challenging Beliefs Worksheet. Look for specific ways that your
reactions to the traumatic event may have been affected by these habitual patterns.
Try to use this for a recent distressing event, too.
¾ Have the patient continue reading Trauma Accounts if he still has strong emotions
about them.

1. To review the Patterns of Problematic Thinking Worksheet. • Session 7

2. To help the patient determine if she has particularly strong tendencies toward goals
any counterproductive patterns.
3. To introduce the Challenging Beliefs Worksheet that will be used throughout
the remainder of therapy.
4. To introduce the Safety Module Handout.
(NOTE: If the therapist is using CPT without trauma accounts, this session will
be divided and the Safety Module will be introduced at the next session. This
session will introduce the Challenging Beliefs Worksheet, and the patient will
work from his stuck point log.)
Review of Patterns of Problematic Thinking to Address Trauma-

Related Stuck Points
The session should begin with review of the practice assignment on Patterns of • Reviewing
Problematic Thinking. The therapist helps the patient to confront the automatic Patterns of
self-statements and replace them with other more adaptive cognitions. The Problematic
therapist should discuss with the patient how these patterns may have affected his Thinking
reactions to the traumatic event(s). There are a number of problematic thinking
patterns that are seen frequently with this population. For example, a patient who
habitually jumps to the conclusion that negative outcomes are his fault may
increase the likelihood of self-blame after the event. Mind reading is very
common. The patient assumes that other people think and feel the same way she
does and reacts as if this were the case, resulting in alienation from others.
Emotional reasoning about safety and guilt are frequently observed. Because a
patient feels fear, she then assumes that she is in danger. If a person feels shame
or guilt, he may assume that means this is proof he must have done something
wrong.
Over-generalizing from a single incident and extreme black-and-white thinking • Minimizing

are also very common. Even if he does not believe it completely to begin with, over-
convincing a patient to modify his language use can have an immediate effect on generalization
the severity of secondary (manufactured) emotions. Once the therapist can get a
foot in the door with the fact that perhaps some people (even one person) can be
trusted in some way, then the therapist can continue to remind the patient that
“all” is not accurate. Once the patient starts to say, “Some people cannot be
trusted,” the accompanying emotions are less intense than to say “all.” (See
examples next two pages.)

Introduction to the Challenging Beliefs Worksheet with a Trauma
Example
At this point the therapist should introduce the Challenging Beliefs Worksheet • Give patient
(adapted from Beck & Emery 10 , 1985, p. 205). The introduction of this worksheet Challenging
is very important so the patient is not overwhelmed by the seeming complexity of Beliefs
it. The worksheet brings together all the skills taught in the worksheets used thus Worksheet
far in the therapy and introduces the notion of alternative thoughts and feelings.
The Challenging Beliefs Worksheet will be used throughout the rest of the
sessions. The A-B-C Worksheet is incorporated into the two columns on the left.
However, at this point the patient is asked to rate the extent to which she believes
her statements (0%–100%) and how strong her emotions are (0%–100%). In order
to challenge the belief, the patient begins by examining the challenging questions
and answering the most pertinent ones. Next, she looks over the Patterns of
Problematic Thinking Worksheet to see if she has been engaging in one of the
counterproductive thinking patterns. Then, for the first time, the patient is asked
to generate another statement that is more balanced and evidence-based.
It is important at this point to emphasize that the goal of therapy is not necessarily • Developing
to return people to their prior beliefs. If someone had extreme beliefs before the balanced
event, the goal would be to develop more balanced, adaptive beliefs. For example, beliefs
if someone used to believe that she could trust everyone, it would not be very
realistic and might be high risk to return to that belief. Or if someone believed
that it is always important to shut down one’s emotions, we would not want to
return him to that belief. People with a long history of trauma, particularly
beginning in childhood, are prone to extreme beliefs that can become very
entrenched.
The practice assignment will be to analyze stuck points or other trauma reactions
and to confront and change problematic cognitions with the Challenging Beliefs
Worksheet. As an example, a stuck point that was identified from the initial
Impact Statement assignment or from preceding sessions should be used. The
therapist and patient should fill out one worksheet together in session. The
therapist should help the patient choose at least one stuck point to work on every
day over the next week, but should also encourage him to use the worksheets as
events occur during the week for practice.
Introduction to Safety Issues Related to Self and Others

• Introducing
The therapist should then introduce the first of five specific topics that will be
safety
discussed over the next five sessions.
10
Beck, A. T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New
York: Basic Books, Inc.

“For the next five sessions we will begin considering specific themes
which may be areas of beliefs in your life that were affected by the
traumatic event. At each session I will be asking you to consider
what your beliefs were prior to the event and to consider how the
[index event] has affected them. If we decide together that any of
these themes represent stuck points for you, I will be asking you to
complete worksheets on them in order for you to begin changing
what you are saying to yourself. The five general themes are safety,
trust, power and control, esteem, and intimacy. Each of these themes
can be considered from two directions, how you view yourself and
how you view others.
“The first topic we will discuss is safety. If prior to the [event] you
thought you were quite safe (that others were not dangerous) and
that you could protect yourself, these beliefs are likely to have been
disrupted by the event. On the other hand, if you had prior
experiences that left you thinking others were dangerous or likely to
harm you, or believing that you were unable to protect yourself, then
the event would serve to confirm or strengthen those beliefs. When
you were growing up did you have any experiences that left you
believing you were unsafe or at risk? Were you sheltered? Did you
believe you were invulnerable to traumatic events?”
After the patient describes her prior beliefs, the therapist should help her to • Over-
generalized
determine whether her prior beliefs were disrupted or reinforced by the traumatic
fear & safety
event. The therapist and patient should determine whether she continues to have
negative beliefs about the relative safety of others or her ability to protect herself
from harm. They should discuss how negative beliefs can elicit anxiety reactions
(e.g., “Something bad will happen to me if I go out alone in my car”). The patient
will need to recognize how these beliefs and emotions affect her behavior
(avoidance). Over-generalized fears lead some patients to avoid entire groups of
people who were associated with a particular conflict. A Vietnam veteran
reported that he was always uncomfortable around Asian people, while an Iraq
veteran said he was always on guard when near someone who looks Middle
Eastern. In both cases, the patients declared that because you couldn’t tell friend
from foe during the war, they had learned to be leery of most people they
encountered who reminded them in any way of their experiences. In the
beginning of therapy, they saw no difference between low-probability and high-
probability events and believed that they were at equal risk in Iraq and their
hometown. Any possibility of harm was too much to tolerate. The therapist
challenged them by asking how many times they had been shot at since being
home. When the veteran announced that he was safe because he secured his
perimeter every night and patrolled much of the evening, the therapist asked how
often the neighbors and people on the next block were attacked in their own
homes and mildly wondered if the patient had any evidence that he was in danger
other than his own fear (emotional reasoning).

The therapist may need to help the patient to differentiate prudent safety practices
from fear-based avoidance either at the end of this session or during the next
session. The patient can reduce the probability of being a victim through
increased safety practices (e.g., locking doors, but not repeatedly checking them)
without feeling fearful and panicky or engaging in excessive avoidance behavior.
However, some events are so unpredictable and unavoidable that there is no way
to decrease risk (e.g., the World Trade Center attack). Generalized fear is not
going to prevent traumatic events and will only serve to prevent recovery. Along
these lines, some patients have focused so much attention on some factor
associated with the trauma that they focus all their safety planning on that factor • Removing
to the exclusion of other higher-risk sources of danger. For example, one patient generalized
was attacked in her own home. For years afterward she spent a great deal of time fear
and money on alarm systems and safety measures in her home. On the other hand,
she was going out to bars and getting drunk with friends on a regular basis. She
was even the victim of a “date-rape drug” slipped into one of her drinks. Still, she
focused only on the likelihood of being attacked in her home while ignoring
higher risks elsewhere.
The therapist should help the patient recognize his self-statements and begin to
introduce alternative, more moderate, less fear-producing self-statements (e.g.,
replace “I’m sure it’s going to happen again” with “It’s unlikely to happen
again”). Sometimes patients believe that if the event happens once, it will happen
again. The therapist may need to give the patient some probability statistics and
remind him that this event was not a daily, weekly, or even yearly event for him.
It is, in fact, a low-probability event. Although the therapist cannot promise that it
will not occur again, she can help the patient to see that he doesn’t have to behave
as if it were a high-frequency event. The therapist can also point out that the
patient is jumping to conclusions without supporting evidence.
Practice Assignment
The patient should be given the Safety Module to remind her of these issues. The • Give patient
modules on safety and other issues are based on the work of McCann & Safety
Pearlman 11 (1990a). If self-safety or other-safety issues are evident in the Module
patient’s statements or behavior, she should complete at least one worksheet on
safety before the next session. Otherwise, the patient should be encouraged to
complete worksheets on other identified stuck points and recent trauma-related
events that have been distressing.
“Use the Challenging Beliefs Worksheets to analyze and confront at • Assign

Session 7
least one of your stuck points each day. Please read over the module
practice
on safety and think about how your prior beliefs were affected by the assignment
[event]. If you have safety issues related to yourself or others,
11
McCann, I. L., & Pearlman, L. A. (1990b). Psychological trauma and the adult survivor:
Theory, therapy and transformation. Philadelphia: Brunner/Mazel.

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.”

Content: This was the seventh session of CPT for PTSD. The patient completed his practice
assignment related to identifying patterns of problematic thinking. The Challenging Beliefs
Worksheet was introduced as a method of self-guided cognitive restructuring. An example
stuck point was used to illustrate the use of the worksheet. He is increasingly able to
challenge his own maladaptive thinking. The five themes targeted in the remainder of the
treatment were introduced, with a focus on safety for exploration in the next session. The
patient agreed to complete a Challenging Beliefs Worksheet each day about stuck points
before the next session and to read the materials related to safety stuck points.
Plan: Continued CPT

PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

Challenging Beliefs Worksheet
A. Situation B. Thought(s) D. Challenging Thoughts E. Problematic Patterns F. Alternative Thought(s)
Describe the event, Write thought(s) related to Use Challenging Questions to Use the Patterns of Problematic What else can I say instead of
thought or belief leading Column A. examine your automatic thoughts from Thinking Worksheet to decide if this is Column B? How else can I interpret
to the unpleasant Rate belief in each thought Column B. one of your problematic patterns of the event instead of Column B?
emotion(s). below from 0-100% thinking.
(How much do you believe Is the thought balanced and factual or Rate belief in alternative thought(s)
this thought?) extreme? from 0-100%
Evidence For? Jumping to conclusions:
Evidence Against?
Exaggerating or minimizing:
Habit or fact?
Disregarding important aspects:

Interpretations not accurate?
All or none?
Oversimplifying:
Extreme or exaggerated?
C. Emotion(s) G. Re-rate Old Thought(s)
Specify sad, angry, etc., Out of context? Over-generalizing: Re-rate how much you now believe
and rate how strongly you the thought(s) in Column B from 0-
feel each emotion from 0- 100%
100% Source unreliable?
Mind reading:
Low versus high probability?
H. Emotion(s)
Based on feelings or facts? Now what do you feel? 0-100%
Emotional reasoning:
Irrelevant factors?


I have to ride on a Air travel is dangerous. – Evidence For? People have been Jumping to conclusions: The chances are very small that I will
plane. 75% killed. be killed or hurt while flying. – 95%
I could be killed. – 50% Even if the plane blew up, I could not
Evidence Against? Airport security has do anything about it. – 80%
been increased. Exaggerating or minimizing:
Habit or fact?

All or none?
Oversimplifying:
G. Re-rate Old Thought(s)
Out of context? Over-generalizing: Re-rate how much you now believe
the thought(s) in Column B from 0-
C. Emotion(s) 100%
Specify sad, angry, etc., Source unreliable?
and rate how strongly you 15%, 10%
feel each emotion from 0- Mind reading:
100% Low versus high probability?
Afraid – 100% H. Emotion(s)

Helpless – 75% Based on feelings or facts? I am letting Now what do you feel? 0-100%
Anxious – 75% myself believe this because I feel Emotional reasoning: I feel very small…
scared and not because it is realistic. that I will be hurt or killed flying – 95% Afraid – 40%
Irrelevant factors? Helpless – 5%
Anxious – 10%

I led my company into I should have seen it Evidence For? People were killed. Jumping to conclusions: There was no way to see it coming at
an ambush, and many coming. – 100% the time. – 85%
of my men were killed. Evidence Against? There was no way
I should have prevented it – to know that there was going to be an I did the best I could given the
it is my fault that people ambush—that’s the nature of an circumstances. – 90%
were killed. – 100% ambush. To think I should have known Exaggerating or minimizing:
it was coming is to ignore the fact that It’s not my fault that people were
it was an ambush. killed in the ambush. – 75%
Habit or fact?
Disregarding important aspects: I
haven’t been paying attention to the fact
Interpretations not accurate? that it was an ambush. There was no
way I could have known.
All or none? No one else would have Oversimplifying:

led their company into an ambush.
Extreme or exaggerated? G. Re-rate Old Thought(s)

Re-rate how much you now believe
Over-generalizing:
C. Emotion(s) Out of context?
100%
Specify sad, angry, etc.,
and rate how strongly you 15%, 10%
Source unreliable?
feel each emotion from 0-
Mind reading:
100%
Guilt – 100% H. Emotion(s)
Helpless – 100%
Anxious – 75% Now what do you feel? 0-100%
Based on feelings or facts? Emotional reasoning: Because I feel
guilty, I AM guilty. Guilt – 40%
Helpless – 80%
Irrelevant factors? Anxious – 40%

If I express anger, I’ll be Anger is not right, so it is Evidence For? Feeling my anger Jumping to conclusions: Anger is appropriate in some
out of control. wrong. – 50% chokes me because I don’t let it out. situations. – 100%
Angry people are scary. I Anger can be expressed without

don’t want to be that way. – Evidence Against? Even Jesus got aggression. – 60%
90% angry. I have never been really Exaggerating or minimizing: Anger is
destructive when I was angry. rage instead of what it is—unpleasant. Anger is an emotion like sadness. I
If I let myself go, I’ll be let myself feel that and it is not
destructive. – 85% Habit or fact? overwhelming. – 60%

All or none?
Oversimplifying:
Extreme or exaggerated? My phrases

and words to describe anger are G. Re-rate Old Thought(s)
exaggerated.
Re-rate how much you now believe
C. Emotion(s) Out of context? Over-generalizing:
Specify sad, angry, etc., 100%
and rate how strongly you Source unreliable?
feel each emotion from 0- 20%, 75%, 50%
100% Mind reading:
Angry – 50%
Fear – 95% H. Emotion(s)
Emotional reasoning: Because anger
feels bad, it is bad/wrong, so I must be, Angry – 50%
Irrelevant factors? too. Fear – 70%

A friend wants to set me I can’t get involved with Evidence For? One person I told about Jumping to conclusions: A date could tell me they don’t want
up for a date with anyone because since this the assault while we were dating was anything to do with me because I am
someone she knows. assault I am too afraid to let very supportive at the time, but dealing with having been assaulted. –
anyone close enough see became more and more distant after 60%
how restricted my life has that and finally stopped calling
become. – 75% altogether. Exaggerating or minimizing: Because 1
Evidence Against? date may have had problems, doesn’t
mean others will.
Habit or fact?
Disregarding important aspects: That
person was not healthy or secure.
All or none? Most healthy people

would not run from a relationship. Oversimplifying: If I tell someone who
can’t deal with it, it is not necessarily
C. Emotion(s) Extreme or exaggerated? bad because I could find something
important about the relationship. G. Re-rate Old Thought(s)
Specify sad, angry, etc.,
and rate how strongly you Re-rate how much you now believe
Out of context? Over-generalizing:
feel each emotion from 0- the thought(s) in Column B from 0-
100% 100%
Source unreliable? Coming from past
Fear – 50% 50%
negative experience and from an
Sadness – 80% unhealthy person. Mind reading:
Anger – 50% Low versus high probability?
H. Emotion(s)
Fear – 25%
Irrelevant factors? Sadness – 40%
Anger – 10%

Safety Issues Module
Beliefs Related to SELF: The belief that you can protect yourself from harm and have
some control over events.
Prior Experience
Negative Positive
If you are repeatedly exposed If you have positive prior
to dangerous and experiences, you may develop
uncontrollable life situations, the belief that you have
you may develop negative control over most events and
beliefs about your ability to can protect yourself from
protect yourself from harm. harm. The traumatic event
The traumatic event serves to causes disruption in this
confirm those beliefs. belief.
Symptoms Associated With Negative Self-Safety Beliefs

¾ Chronic and persistent anxiety
¾ Intrusive thoughts about themes of danger
¾ Irritability
¾ Startled responses or physical arousal
¾ Intense fears related to future victimization
Resolution
If you previously believed that… Possible self-statements may be…

“It can’t happen to me,” you will need to
“It is unlikely to happen again, but the
resolve the conflict between this belief and
possibility exists.”
the victimization experience.
“I can control what happens to me and can “I do not have control over everything that
protect myself from any harm,” you will need happens to me, but I can take precautions to
to resolve the conflict between prior beliefs reduce the possibility of future traumatic
and the victimization experience. events.”
You had no control over events and could not “I do have some control over events and I can
protect yourself, the traumatic event will take steps to protect myself from harm. I
confirm these beliefs. New beliefs must be cannot control the behavior of other people,
developed that mirror reality and serve to but I can take steps to reduce the possibility
increase your beliefs about your control and that I will be in a situation where my control
ability to protect yourself. is taken from me.”

Beliefs Related to OTHERS: The belief about the dangerousness of other people and
expectancies about the intent of others to cause harm, injury, or loss.
Prior Experience
Negative Positive
If you experienced people as
If you experienced people as safe in early life, you may
dangerous in early life or you expect others to keep you safe
believed it as a cultural norm, and not cause harm, injury, or
the traumatic event will seem loss. The traumatic event
to confirm these beliefs. causes a disruption in this
belief.
Symptoms Associated With Negative Others-Safety Beliefs
¾ Avoidant or phobic responses

¾ Social withdrawal
Resolution
“Others are out to harm me and can be

expected to cause harm, injury, or loss,” you
“There are some people out there who are
will need to adopt new beliefs in order to be
dangerous, but not everyone is out to harm
able to continue to feel comfortable with
me in some way.”
people you know and to be able to enter into
new relationships with others.
“I will not be hurt by others,” you will need “There may be some people who will harm
to resolve the conflict between this belief and others, but it is unrealistic to expect that
the victimization. everyone I meet will want to harm me.”

Summary of Session 8: Safety Issues
2. Review the Challenging Beliefs Worksheet to address safety stuck points (10 minutes)
¾ Help the patient to complete practice, if necessary
¾ Discuss success or problems in changing cognitions
¾ Help the patient confront problematic cognitions that he was unable to modify by
himself
3. Help patient confront problematic cognitions and generate alternative beliefs using
the Challenging Beliefs Worksheet (15 minutes)
¾ Review Safety Module; focus on patient’s self- or other- safety issues
¾ Probability: Low vs. high = reality vs. fear
¾ Calculate %’s
4. Introduce second of five problem areas: Trust issues related to self and others
(10 minutes)
¾ Self-trust = belief one can trust or rely on one’s own perceptions and judgment
¾ After trauma, many begin to second-guess own judgment about
- Being there in the first place: “Did I do something to ‘ask for it’?”
- Own behavior during event: “Why didn’t I ____ when it was happening?”
- Ability to judge character: “I should have known _____ about him.”
¾ Trust in others is also frequently disrupted after a trauma
- Betrayal if perpetrator was trusted
- Betrayal if others don’t give belief or support
- Rejection if others can’t tolerate what happened and withdraw
¾ Compare trust in self/others before/after
¾ Go over module

¾ Patient to challenge stuck points with the Challenging Beliefs Worksheet, with
one relating to trust and confront them using the Challenging Beliefs Worksheet
daily.
about them.

1. To go over the Challenging Beliefs Worksheets with the patient and assist the • Session 8
veteran as needed to complete the worksheets. goals
2. To review the Safety Module and focus on self- or other-safety issues for
which the patient should complete worksheets.
3. To introduce the Trust Module and the concepts of self- and other- trust.
Review of the Challenging Beliefs Worksheet to Address Safety

Stuck Points
The therapist should begin the session by going over the worksheets and • Review
discussing the patient’s success or problems in changing cognitions (and Challenging
subsequent emotions). The therapist and patient should use the Challenging Beliefs
Questions to help the patient confront problematic cognitions that he was unable Worksheets
to modify himself. As an example, one patient was in an elevator that fell 20
floors and then stopped just as it reached the bottom. Aside from having
nightmares and flashbacks, he found himself unable to get back into an elevator
again. His thought was “Elevators are unsafe” and “The next time I am going to
die.” On the worksheet, the patient stated that the evidence was correct that
elevators were unsafe and that he knew he would die the next time because he
survived this time. He did not see that he was exaggerating or drawing
conclusions when evidence is lacking, nor did he report engaging in emotional
reasoning. At the end of the worksheet, his ratings did not change.
Confronting Problematic Cognitions and Generating Alternative

Beliefs Using the Challenging Beliefs Worksheet
Unfortunately, the above example is sometimes typical of the forms filled out for • Probability
the first time by patients. The patients are sometimes so entrenched in their beliefs estimates
that they can't look at them any other way. For this patient (and for many with
safety issues) the therapist began to focus on the probability of being in an
elevator crash again. The therapist needs to remind the patient that, although most
people experience a serious traumatic event during their life, in day-to-day living,
traumatic events are very low probability. Yet, he continues to behave as if the
probability were extremely high. For example, in the case above, the therapist
asked the patient how often he rode in elevators before. The patient informed the
therapist that his apartment and work place both had elevators, and he estimated
that he had ridden in elevators six to eight times a day for the past 20 years. The
therapist asked him if he had been in an elevator crash before and when the
patient said “no”, he was asked if he knew anyone who had ever been in a crash
(also “no”).
At that point the therapist pulled out a calculator and said:

“That’s about 58,000 times over the last 20 years. For you, that
means that if everything stayed the same and these events occurred
at the same rate, and you began using elevators again, you might
have a 1 in 58,000 chance of being in a crash and a 57,999 out of
58,000 chance of not being in an elevator crash over the next 20
years. Does it make sense to you that you walk around being
terrified all of the time and avoid places where you might need to use
an elevator? Do you want those few terrifying moments to own the
rest of your life and to dictate what you can and cannot do?”
The therapist also pointed out that the patient probably had a greater chance of
being in a car accident, yet he didn’t avoid driving and was not in perpetual fear
of an accident. The patient agreed with the statements and began to rethink his
beliefs. The patient and therapist completed the worksheet a second time. Under
the column “Challenging Questions” they noted “Confusing a low probability for
a high probability event.” Under the “Patterns of Problematic Thinking” column
they circled “Jumping to conclusions, either/or thinking, and emotional
reasoning.” He then re-rated his fear as 40%. The next week he reported that he
had gone on an elevator for a few floors and was not as frightened. The idea that
the next time would result in death was also challenged successfully. Once a
patient has a worksheet that successfully challenges a stuck point, the patient
should be encouraged to re-read the worksheet regularly so that the reasoning
becomes comfortable.
Another patient, an Iraq veteran, who struggled with his first Challenging Beliefs • Example of
Worksheet, believed that, even though he had been back in the United States for an Iraq
6 months, he was at the same level of danger that he had been in Baghdad. He veteran
insisted that because there might be some people in the United States who could
plan another attack, he was in just as much danger. He could not see the
difference between the ideas “something could happen” and “something will
happen.” His high level of fear led him to emotional reasoning and to the
assumption that he was in danger. The therapist asked him how many times he
was shot at in Iraq, and he said “many.” Then the therapist asked him how many
times he had been shot at before going over there or since returning (“none”).
When the therapist asked him how he concluded he was in equal danger, his
response was “but it could happen.” The therapist agreed with that statement but
not the assumption that it will happen and had him notice how he felt when he
said it could happen versus that it will happen. The patient was able to
acknowledge that the two statements felt somewhat different and that could was
different from will in terms of probability (100% for the latter and something less
for the former). The therapist assigned him to work on this with more Challenging
Beliefs Worksheets.

Introduction to Trust Issues Related to Self and Others
• Introducing
During the remainder of the session the therapist should introduce and discuss the Trust
theme of trust (self-trust and trust of others):
“Self-trust is concerned with the belief that one can trust or rely
upon one’s own perceptions or judgments. After traumatic events,
many people begin to second-guess themselves and to question their
own judgment about being in the situation that led to the event, their
behaviors during the event, or about their ability to judge character
if, in the case of an assault, the perpetrator was an acquaintance.
Trust in others is also frequently disrupted following traumatic
events. Aside from the obvious sense of betrayal that occurs when a
trauma is caused intentionally by someone the patient thought he or
she could trust, sometimes patients feel betrayed by the people they
turned to for help or support during or after the event. For example,
if a patient thought that someone let him down during battle, he
might decide right then and there not to trust anybody. Sometimes
patients carry that belief for decades without actually knowing
whether the other person or group in fact betrayed them or whether
there might be an alternative explanation for their behavior.
“Sometimes people cannot cope with the patients’ emotions and they
withdraw or try to minimize the event or the impact. Such a
withdrawal may be viewed as a rejection by patients, and they come
to believe that the other person cannot be trusted to be supportive.
Sometimes when more than one member of a family is affected by a
traumatic event, such as the traumatic death of a loved one, family
members are out of sync with each other. One person wants to talk
and needs comfort just as another closes off because she has had all
of the emotions that she could handle for a while. Without clear
communication, the cycling of grief and withdrawal can be
misunderstood as lack of support and can result in problematic
interpretations of the situation.
“Prior to the event, how did you feel about your own judgment? Did
you trust other people? In what ways? How did your prior life
experiences affect your feelings of trust? How did the ________
affect your feelings of trust in yourself or others?”
The therapist and patient should briefly go over the Trust Module. For practice, • Give patient
the patient should analyze and confront themes of safety and trust using the Trust Module
worksheets.

Practice Assignment
“Please read the Trust Module and think about your beliefs prior to • Assign
experiencing [event] as well as how the event changed or reinforced Session 8
those beliefs. Use the Challenging Beliefs Worksheets to continue practice
analyzing your stuck points. Focus some attention on issues of self- assignment
or other-trust, as well as safety, if these remain important stuck
points for you.”

Content: This was the eighth session of CPT for PTSD. The patient completed his practice
assignment related to daily completion of the Challenging Beliefs Worksheet. Examples from
these worksheets were reviewed to offer further cognitive restructuring and to fine-tune
completion of the worksheets. Safety-related stuck points were specifically targeted. Stuck
points related to trust were introduced, and he agreed to read materials related to this theme.
The patient also agreed to complete a Challenging Beliefs Worksheet each day about stuck
points before the next session.
Plan: Continued CPT

PCL-S: WEEKLY
Instructions:

(event)
much you have been bothered by that problem in the past week.
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

Evidence Against?
Habit or fact?

All or none?
Oversimplifying:
Mind reading:
H. Emotion(s)
Irrelevant factors?

Trust Issues Module
Beliefs Related to SELF: The belief that one can trust or rely on one’s own perceptions or
judgments. This belief is an important part of self-concept and serves an important self-
protection function.
Prior Experience
Negative Positive
If you had prior experiences
where you were blamed for
negative events, you may If you had prior experiences
develop negative beliefs about that led you to believe that you
your ability to make decisions had great judgment, the
or judgments about situations traumatic event may disrupt
or people. The traumatic event this belief.
serves to confirm these
beliefs.
Symptoms Associated With Negative Self-Trust Beliefs

¾ Feelings of self-betrayal
¾ Anxiety
¾ Confusion
¾ Over-caution
¾ Inability to make decisions
¾ Self-doubt and excessive self-criticism
Resolution
If you previously believed that… A possible self-statement may be…

You could not rely on your own perceptions or
judgments, the traumatic event may have “I can still trust my good judgment even
reinforced your belief that “I cannot trust my though it’s not perfect.” “Even if I misjudged
judgment” or “I have bad judgment.” In order this person or situation, I realize that I cannot
to come to understand that the traumatic event always realistically predict what others will do
was not your fault and that your judgments did or whether a situation may turn out as I expect
not cause the traumatic event, you need to it to.”
adopt more adaptive beliefs.
… you had perfect judgment, the traumatic “No one has perfect judgment. I did the best I
event may shatter this belief. New beliefs need could in an unpredictable situation, and I can
to reflect the possibility that you can make still trust my ability to make decisions even
mistakes but still have good judgment. though it’s not perfect.”

Beliefs Related to OTHERS: Trust is the belief that the promises of other people or groups
can be relied on with regard to future behavior. One of the earliest tasks of childhood
development is trust versus mistrust. A person needs to learn a healthy balance of trust and
mistrust and when each is appropriate.
Prior Experience
Negative Positive
If you were betrayed in early
life, you may have developed If you had particularly good
the generalized belief that “no experiences growing up, you
one can be trusted.” The may have developed the belief
traumatic event serves to that “All people can be
confirm this belief, especially trusted.” The traumatic event
if you were hurt by an shatters this belief.
acquaintance.
Posttraumatic Event Experience
If the people you knew and trusted were blaming, distant, or

unsupportive after the traumatic event, your belief in their
trustworthiness may have been shattered.
Symptoms Associated With Negative Others-Trust Beliefs

¾ Pervasive sense of disillusionment and disappointment
in others
¾ Fear of betrayal or abandonment
¾ Anger and rage at betrayers
¾ If repeatedly betrayed, negative beliefs may become so
rigid that even people who are trustworthy may be
viewed with suspicion
¾ Fear of close relationships, particularly when trust is
beginning to develop, active anxiety and fear of being
betrayed
¾ Fleeing from relationships
Resolution

If you grew up believing that “no one can be “Although I may find some people to be
trusted,” which was confirmed by the traumatic untrustworthy, I cannot assume that everyone is
event, you need to adopt new beliefs that will that way.” “Trust is not an all-or-none concept.
allow you to enter into new relationships with Some may be more trustworthy than others.”

others instead of withdrawing because you “Trusting another involves some risk, but I can
believe others to be untrustworthy. protect myself by developing trust slowly and
including what I learn about that person as I get
to know him or her.”
“Everyone can be trusted,” the traumatic event

will shatter this belief. In order to avoid “I may not be able to trust everyone, but that
becoming suspicious of the trustworthiness of doesn’t mean I have to stop trusting the people
others, including those you used to trust, you I used to trust.”
will need to understand trust is not either/or.
If your beliefs about the trustworthiness of

your support system were shattered, it will be
necessary to address general issues before you
assume that you can no longer trust the support
system. Of central importance is to consider
their reaction and the reasons why they may
have reacted in an unsupportive fashion. Many
people simply do not know how to respond and
may be reacting out of ignorance. Some
respond out of fear or denial because what has
happened to you makes them feel vulnerable
and may shatter their own beliefs. Practicing
how to ask for what you need from them may
be a step in assessing their trustworthiness.
If your attempts to discuss the traumatic event

with them leaves you feeling unsupported, you
may use self-statements such as “There may be
some people I cannot trust talking with about
the traumatic event, but they can be trusted to
support me in other areas.” If that person
continues to blame you and make negative
judgments about you, you may decide that this
person is no longer trustworthy. It’s
unfortunate, but sometimes you find out that
some people you thought of as friends do not
turn out to be true friends after a trauma.
However, you may also be pleasantly surprised
to find that some people have better reactions
than you expected.

Summary of Session 9: Trust Issues
2. Review Challenging Beliefs Worksheet to challenge trauma-related trust stuck points

and generate alternative beliefs (10 minutes)
3. Discuss judgment issues that may arise from stuck points related to trust (15 minutes)
¾ Trust falls on a continuum, not “all or none”
¾ Different kinds of trust: with money vs. with a secret
¾ “Star” diagram
¾ Discuss patient’s social support systems (family and friends): may be protecting
themselves from emotions/helplessness/vulnerability, inadequacy/ignorance—not
rejection
4. Introduce third of five problem areas: Power/control issues related to self and others
(10 minutes)
¾ Self-power (self-efficacy)
¾ People naturally expect they can solve problems and meet new challenges
¾ Traumatized people often try to control everything–to stay safe
¾ Lack of TOTAL CONTROL may feel like NO CONTROL
¾ Power over others:
- Need to control may spill into relationships, ruining old ones and preventing
new ones

¾ Identify stuck points, one relating to Power/Control (and Safety or Trust as
needed), and confront them using the Challenging Beliefs Worksheet.
about them.

The goals of Session 9 are: • Session 9
goals
1. To review the worksheets on self- and other-trust.
2. To review other worksheets on patient stuck points.
3. To introduce the module and concepts about power and control.
Review of Challenging Beliefs Worksheet to Challenge Trauma-

Related Trust Stuck Points and Generate Alternative Beliefs
As with the other sessions, the therapist should begin by going over the practice
assignments and discussing the patient’s success or difficulties in changing
cognitions. Although trust is often an issue for patients with PTSD generally, it is
particularly an issue for those who were victimized by acquaintances (for
example, in military sexual trauma situations). They often think that they should
have been able to tell that this person might harm them and, as a result, they begin
to question their judgment in whom they can or cannot trust. Looking back at the
event, many people look for clues and indicators that may have indicated that this
event was going to happen. They judge themselves as having failed at preventing
what they determined to be a preventable event (or at least the outcome was
preventable for them, as in the case of a disaster).
Discussion of Judgment Issues Arising From Stuck Points Related

to Trust
Self-distrust may even generalize to other areas of functioning, and the patient • Explaining
trust
may have difficulty making everyday decisions. Rather than falling on a
continuum, trust becomes an either/or concept in which people tend not to be
trusted unless there is overwhelming evidence to the contrary. As a result, they
tend to avoid becoming involved in or withdraw from relationships.
The therapist needs to present the idea that trust falls on a continuum and is multi-
dimensional. Sometimes people decide that because someone can’t be trusted in
one way, they can’t be trusted in any other way.
T: Along with different levels of trust, there are also different kinds
of trust. Have you ever met anyone that you would trust to $20
but wouldn’t want to trust with a secret?
P: Yes.
T: I can imagine someone that I would trust with my life, but I
wouldn’t expect him to remember to return $20.
P: I know someone like that.
T: I know someone else that I would not trust with my opinion about
the weather. He’d figure out some way to insult me. However, it
takes time to determine in which ways you can and cannot trust
someone.

P: That’s why I think it is safer just to distrust everyone to begin
with.
T: The problem with that is that people are always trying to dig out
of a deep hole with you then. When is it enough? And weren’t
you saying that you were feeling very alone and wish you had
more friends?
P: Yeah, but if I started out by trusting everyone, then I might get
hurt.
T: True. I agree that starting out by assuming that everyone is
trustworthy would be risky. How about starting out somewhere
other than the two extremes?
P: What do you mean?
T: Well, what if we called the middle point between total trust and
total distrust “0”, meaning no information? And rather than a
single line with a middle point like a seesaw, we could think of it
as having lines coming out in many directions. (Therapist draws
lines on paper for the patient to see.)
So you could have a line for trusting with a secret, and another
line for trusting with money, and still another line for not using
your weaknesses to hurt you, and so forth. Then as you get
information about the person, they could move further out on the
lines. If they all head in the positive direction then this is
someone you can trust more in many ways. If some lines are
going one way and others are going the other, then perhaps you
just wouldn’t tell them your deepest secrets or loan them your
life savings, but you might be able to still have them in your life.
You would just know what their limitations are. Someone who
always scores on the negative side is someone you want to stay
away from.
P: That makes sense. But, it’s scary to think that I would be giving
someone a chance to hurt me.
T: Well, you don’t start with the big stuff. You start with small
things and see how they handle them. You also listen to what
other people say about the person and what their experiences
are. They can provide information too.
With regard to trusting family and friends, it may be helpful for the therapist to • Trust &
explain why other people sometimes react negatively to the patient—as a defense others’
reactions

against their own feelings of helplessness and vulnerability, or their own need to
retain the just-world belief. Sometimes other people react negatively or withdraw
because they just don’t know how to react or what to say, and the patient
interprets their reactions as rejection. Sometimes the patient cannot even
recognize that family members are also hurting and upset because of what
happened to him. It is not unusual for a patient to say, “But why would they be
upset? It happened to me.” The therapist can discuss with the patient how to ask
for the support he needs from others (e.g., “I don't need advice; I just need you to
listen and understand what I am going through”).
With regard to self-trust, it is important for the therapist to point out that it is • Self-trust
probable that other people would not have picked up on cues that the event was
going to occur either, and that no one can know for sure what the outcome of her
behaviors will be in the middle of an emergency (or what the outcome would
have been if she had done something else). In addition, while 20/20 hindsight
may be more accurate, no one has perfect judgment about how other people are
going to behave in the future. However, in being overly suspicious of everyone,
the patient may lose many people who are, in fact, trustworthy. In the end, she
will end up feeling isolated and alienated from people who could provide genuine
support and intimacy.
Introduction to Power/Control Issues Related to Self and Others
The theme of power and control is introduced next as the topic for the next
session. The patient is given the Power/Control Module to read and work with for
the next session. Self-power (self-efficacy) refers to a person’s expectations that
she can solve problems and meet new challenges. Because the event was out of
their control, traumatized people often attempt complete control over other
situations and their emotions. These people may adopt the unrealistic belief that • Give patient
they must control everything or they will be completely out of control. Again, Power/
Control
there is a tendency to engage in either/or thinking. Conversely, if someone over- Handout
generalizes and believes she has no control over anything, she may refuse to make
any decisions or be proactive with her life because she believes that nothing will
work out anyway. Like trust, control is also multidimensional, so it is appropriate
for the therapist to say, “Control with regard to what? Your emotions? Your
spending? Your nervous habits?” It is not uncommon for patients with PTSD to
believe that if they don’t clamp down on their emotions that they will go to the
other extreme and lose control completely.
Power with regard to others involves the belief that one can or cannot control
future outcomes in interpersonal relationships. People who have been the victim
of interpersonal violence, particularly by acquaintances, attempt to have complete
control in any new relationships they may develop after the trauma and have
difficulty allowing the other member to have any control. As a result, previously
existing relationships may become disrupted, or they may have great difficulty
establishing new relationships, and possibly avoid the situation all together. This

issue is usually closely tied to trust of others and should be explored for stuck
points.
The therapist should describe how prior experience affects these beliefs and how
traumatic events can confirm negative or disrupt positive beliefs. For practice, the
patient should continue using worksheets to analyze and confront these beliefs.
Practice Assignment
“Use the Challenging Beliefs Worksheets to continue to address • Assign

your stuck points. After reading the Power/Control Module and Session 9
thinking about it, complete worksheets on this topic.” practice
assignment

Content: This was the ninth session of CPT for PTSD. The patient completed his practice
completion of the worksheets. Trust-related stuck points were specifically targeted. Stuck
points related to power/control were introduced, and he agreed to read materials related to
this theme. The patient also agreed to complete a Challenging Beliefs Worksheet each day
about stuck points before the next session.
Plan: Continued CPT

PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

Evidence Against?
Habit or fact?

All or none?
Oversimplifying:
and rate how strongly you the thought(s) in Column B from
feel each emotion from 0- 0=100%
Mind reading:
H. Emotion(s)
Based on feelings or facts? Now what do you feel? 0=100%
Irrelevant factors?

Power/Control Issues Module
Beliefs Related to SELF: The belief/expectation that you can solve problems and meet
challenges. Power is associated with your capacity for self-growth.
Prior Experience
Negative Positive
If you grew up experiencing
inescapable, negative events,
If you grew up believing that
you may develop the belief
you had control over events
that you cannot control events
and could solve problems
or solve problems even if they
(possibly unrealistically
are controllable/solvable. This
positive beliefs), the traumatic
is called learned helplessness.
event may disrupt those
Later traumatic events may
beliefs.
seem to confirm prior beliefs
about helplessness.
Symptoms Associated With Negative

Self-Power/Control Beliefs
¾ Numbing of feelings
¾ Avoidance of emotions
¾ Chronic passivity
¾ Hopelessness and depression
¾ Self-destructive patterns
¾ Outrage when faced with events that are out of your
control or people who do not behave as you would like
Resolution

Over-control—It is important to understand
that no one can have complete control over his
emotions or behavior at all times. While you “I do not have total control over my reactions,
may be able to influence external events, it is other people, or events at all times. I am not
impossible to control all external events or the powerless, however, to have some control over
behavior of other people. Neither of these facts my reactions to events or to influence the
is a sign of weakness, but only an behavior of others or the outcome of some
understanding that you are human and can events.”
admit that you are not in control of everything
that happens to you or your reactions.

Helplessness or powerlessness—In order to
regain a sense of control and decrease the
accompanying symptoms of depression and “I cannot control all events outside of myself,
loss of self-esteem that often go along with but I do have some control over what happens
believing you are helpless, you will need to to me and my reactions to events.”
reconsider the ability to control events.
Beliefs Related to OTHERS: The belief that you can control future outcomes in interpersonal
relationships or that you have some power, even in relation to powerful others.
Prior Experience
Negative Positive
If you had prior positive
experiences in your
relationships with others and
with others that led you to
in relation to powerful others,
believe that you had no
you may have come to believe
control in your relationships
that you could influence
with others, or that you had no
others. The traumatic event
power in relation to powerful
may shatter this belief because
others, the traumatic event
you were unable to exert
will seem to confirm those
enough control, despite your
beliefs.
best efforts, to prevent the
event.

Others-Power/Control Beliefs
¾ Passivity
¾ Submissiveness
¾ Lack of assertiveness that can generalize to all
relationships
¾ Inability to maintain relationships because you do not
allow the person to exert any control in the relationships
(including becoming enraged if the other person tries to
exert even a minimal amount of control)

Resolution

Powerlessness—In order for you to avoid
“Even though I cannot always get everything I
being abused in relationships because you do
want in a relationship, I do have the ability to
not exert any control, you will need to learn
influence others by standing up for my rights to
adaptive, balanced beliefs about your influence
ask for what I want.”
on other people.
“Even though I may not get everything I want

Over-control—It is important to realize that or need out of a relationship, I can assert
healthy relationships involve sharing power myself and ask for it. A good relationship is
and control. Relationships in which one person one in which power is balanced between both
has all the power tend to be abusive (even if people. If I am not allowed any control, I can
you are the one with all the power). exert my control in this relationship by ending
it, if necessary.”

Summary of Session 10: Power/Control Issues
2. Discuss connection. Set agenda between power/control and self-blame, and help
challenge related problematic cognitions using the Challenging Beliefs Worksheet
(10 minutes)
¾ Help patient gain a balanced view of power/control
- No such thing as total control, but not completely helpless either
¾ Address anger issues:
- Over-arousal, lack of sleep, increased startled reactions
- “Stuffed” when unable to express at time of event
- Anger vs. aggression (not the same thing)—can come out on family
- Anger at self for “should have dones”
- Innocence/responsibility/intentionality
- Is described by others as a “control freak”
3. Review ways of giving and taking power using the handout (10 minutes)
4. Introduce fourth of five problem areas: Esteem issues related to self and others
(15 minutes)
¾ Review Esteem Module; self and others
¾ Explore patient’s self-esteem before event

¾ Identify stuck points daily, one relating to esteem issues, and confront them using
the Challenging Beliefs Worksheet
¾ Practice giving and receiving compliments daily
¾ Do at least one nice thing for self each day
about them.

1. To review the patient’s Challenging Beliefs Worksheets on control and power. • Session 10
goals
2. To introduce the Esteem Module for challenging self- and other-esteem issues.
3. To assign the patient to practice giving and receiving compliments.
4. To assign the patient to do at least one nice thing for herself every day
(pleasant events scheduling).
Connection Between Power/Control and Self-Blame
The session should begin with a discussion of the patient’s attempts to change • Helping the
cognitions about control/power. The therapist needs to help the patient regain a patient gain a
balanced view of power and control. Realistically, no one has complete control balanced view
over all events that occur to them, or the behavior of other people. On the other
hand, people are not completely helpless. They can influence the course of events,
and they can control their own reactions to those events. If a patient believes that
he has no control over his life, the therapist may walk the service member through
his day focusing on all the decisions he made, or assign him to monitor decisions
for an entire day. Usually, by the time the patient completes the assignment, he
realizes how many hundreds of decisions are made in a day, from what time to get
up, to what to wear and to eat, to what route to take to work, etc. Patients very
often blame some small everyday decision for putting them in the location and
circumstances of the traumatic event. The therapist can remind the patient that if
the traumatic event had not happened, he never would have remembered the
decisions that he made that day. Only because the outcome was so catastrophic do
people go back and try to question all the decisions they made that day, and
mentally try to undo those decisions.
For example, one patient had come to believe that she was helpless and
incompetent in many areas of her life because of her helplessness during the
traumatic event. As a result of feeling incompetent, she did not assert herself
when she had the opportunity. She believed that such efforts would be futile. She
was stuck in a job that was unsatisfying and felt helpless to influence her
employer’s unreasonable demands. When the therapist began to help her look at
her options, she began to see she wasn’t totally helpless. As she began to apply
and get interviews for other jobs, she felt more comfortable asserting herself with
her boss. Although she eventually left that job for a better one, her last months on
the first job were more satisfying, and she was able to see that she could effect
change in other people.
Another patient believed that he was completely in or completely out of control.

His automatic thought was “If I’m not in control, who is? I can’t decide anything
if I’m not in control, and I don’t have a choice in the matter if someone else is
controlling the situation.” Periodically, in reaction to the tight control over his
emotions and attempts to control everything and everyone else, he would totally

lose control by getting drunk to the point of unconsciousness. In this case, it was
necessary for the therapist to help the patient view control as falling on a
continuum. The patient’s alternative thought was “I don’t have to have total
control over everything to have control over most of my decisions.”
Control issues are evident in people who exhibit compulsive behavior such as • Addressing
checking and rechecking, compulsive neatness, binging and purging, etc. These control issues
patients need to understand how their behavior, an attempt to control their
emotions, serves as an escape or avoidance. In fact, as compulsions increase over
time, the patient is eventually controlled by them rather than the other way
around. Reframing the behavior as out of control may help the patient to shift his
thinking about the effectiveness of the compulsive behavior. Response prevention
of the behavior and tolerance of affect are the means of treatment, perhaps after
completing the CPT protocol if the behavior continues to be a significant
problem.
The topic of anger frequently emerges in treatment with veterans. Some anger is • Addressing
related to the hyperarousal symptoms of PTSD such as irritability from anger issues
physiological arousal, lack of sleep, and frequent startle reactions. It is important
to also remember that while fear is associated with the fight-flight response, so is
anger. Environmental cues may trigger anger associated with the fight response
that did not stop when the imminent danger stopped. In fact, military training
encourages the fight and anger response. Unfortunately, there is no equivalent
time in training to turn off the “battle mind” when the service member returns
home.
While some veterans and many crime victims report that they did not experience • Anger vs.
anger during the event, many people find feelings of anger emerge in the aggression
aftermath. However, because the person or persons who harmed them may not be
available for them to express their anger (or are too dangerous to express anger
toward), the anger is sometimes left without a target and is experienced as
helpless anger. Some victims turn their anger on those who are close by, family
and friends. Many people have never been taught to discriminate between anger
and aggression and believe that aggression is the appropriate outlet for anger.
Anger directed at self often emerges, as traumatized people dwell on all the things
they “should” have done to prevent the event or defend themselves. Many people
entering therapy are angry at themselves for this reason. Once they are able to see
that a change in their behavior may not have prevented the event, they may direct
their anger outward at anyone they perceive to have taken away their control and
created feelings of helplessness. Anger may also be directed at society, at
government, or at other individuals who may be held responsible for not
preventing the event in some way. As in the case of guilt, it may be necessary for
the therapist to help the patient discriminate innocence, responsibility, and
intentionality. Only the intentional perpetrator of events should be blamed. Others
may be responsible for setting the stage or inadvertently increasing the risk to the
service member, but they should not have an equal share of the blame and anger.

One patient in therapy expressed anger at himself because he felt he was not
competent to deal with the event. In this case, his stuck point was that he should
have been able to recover from this event quickly and by himself. He began to
question his competence in many areas of his life. In this case, the therapist
needed to remind the patient that most people have difficulties following severe
traumas and that some events in life are too big to be handled all alone.
Ways of Giving and Taking Power
Hand the patient the Ways of Giving and Taking Power Handout. • Ways of
giving and
“There are many ways people give and take their power. You can do taking power
this appropriately or inappropriately and this sheet gives us some
examples. For example, if you tell your partner you will not have sex
unless he/she does XYZ, you are taking power in a negative way. Or,
if you base your actions or behaviors solely on the reactions you
expect from others, you are giving your power away. If, on the other
hand, you do something (or do not do something) because you want
to and it makes you feel good, you are taking your power
appropriately.
“Can you give me an example of things that you do that fit in each of
the categories below? Are these behaviors that you would like to
change? What stuck points keep your from making the changes you
would like to make?”
Introduction to Esteem Issues Related to Self and Others
The remainder of the session should focus on the theme of esteem. The therapist • Introducing
briefly goes over the Esteem Module with the patient and describes how self- Esteem
esteem and esteem toward others can be disrupted by traumatic events. The
patient’s self-esteem before the event should be explored.
Practice Assignment
For practice, drawing from the Esteem Module, the patient completes Challenging • Give patient
Beliefs Worksheets on stuck points for self- and other-esteem. In addition, the Esteem
patient is assigned to practice giving and receiving compliments during the week handout
and to do at least one nice thing for herself each day without any conditions or
strings attached (e.g., exercise, read a magazine, call a friend to chat). These
assignments are given to help the patient become comfortable with the idea that
she is worthy of compliments and pleasant events without having to earn them or
disown them. The assignments are also intended to help the patient connect
socially with others because those with PTSD tend to isolate themselves. Pleasant
events scheduling can also be helpful for those with depression and may assist
with relapse prevention.

“After reading the Esteem Module, use the worksheets to confront • Assign
Session 10
stuck points regarding self- and other-esteem.
practice
assignment
“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.”

Content: This was the 10th session of CPT for PTSD. The patient completed his practice
completion of the worksheets. Power-/control-related stuck points were specifically targeted.
Stuck points related to esteem were introduced, and he agreed to read materials related to this
theme. The patient also agreed to complete a Challenging Beliefs Worksheet about stuck
points and give or receive a compliment each day before the next session. He also agreed to
do one nice thing for himself daily.
Plan: Continued CPT

PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

Evidence Against?
Habit or fact?

All or none?
Oversimplifying:
Mind reading:
H. Emotion(s)
Irrelevant factors?

Ways of Giving and Taking Power
GIVING POWER TAKING POWER

POSITIVE • Being altruistic (helping others without expecting • Being assertive
anything in return) • Setting limits and boundaries with others
• Helping others in need or crisis • Being honest with yourself and others
• Sharing yourself with another person as part of
the give and take in relationships
Example: You are on your way to the store when a Example: Telling someone you cannot help her now, but
friend asks for a ride to the doctor, and you decide to you schedule a time to meet later when it fits into your
take her. schedule.
NEGATIVE • Basing your actions or behaviors solely on the • Giving ultimatums

reactions you expect from others • Testing limits
• Always placing the needs of others above your • Intentionally upsetting others for personal gain
own • Behaving aggressively
• Allowing others to easily access your “buttons”
to get you emotionally upset
Example: Having a strong negative reaction to Example: Telling your partner you will not have sex with
someone who is clearly manipulating you to feel that him until he does what you want.
way.

Esteem Issues Module
Beliefs Related to SELF: Self-esteem is the belief in your own worth, which is a basic
human need. Being understood, respected, and taken seriously is basic to the development of
self-esteem.
Prior Experience
Negative Positive
that represented a violation of
your own sense of self, you
are likely to develop negative
beliefs about your self-worth.
The traumatic event may seem
to confirm these beliefs. Prior
life experiences that are
associated with negative If you had prior experiences
beliefs about the self are likely that served to enhance your
to be caused by: beliefs about your self-worth,
then the traumatic event may
- Believing other people’s disrupt those beliefs (your
negative attitude about you self-esteem).
- An absence of empathy and
responsiveness by others
- The experience of being
devalued, criticized, or
blamed by others
- The belief that you had
violated your own ideals or
values
Examples of Negative Self-Esteem (Self-Worth) Beliefs

¾ I am bad, destructive, or evil
¾ I am responsible for bad, destructive, or evil acts
¾ I am basically damaged or flawed
¾ I am worthless and deserving of unhappiness and
suffering
Symptoms Associated With Negative Self-Esteem

(Self-Worth) Beliefs
¾ Depression
¾ Guilt
¾ Shame
¾ Possible self-destructive behavior

Resolution

You were worthless (or any of the beliefs listed
above) because of prior experiences, the “Sometimes bad things happen to good people.
traumatic event may seem to confirm this Just because someone says something bad
belief. This can also occur if you received poor about me, that does not make it true. No one
social support after the event. In order to deserves this, and that includes me. Even if I
improve your self-esteem and reduce the have made mistakes in the past, that does not
symptoms that often go along with it, you will make me a bad person deserving of
need to reevaluate your beliefs about your self- unhappiness or suffering (including the
worth and be able to replace maladaptive traumatic event).”
beliefs with more realistic, positive ones.
If you had positive beliefs about your self-

worth before the traumatic event, you may
have believed that “nothing bad will happen to
me because I am a good person.” The event
may disrupt such beliefs, and you may think
you are a bad person because this event
happened, or look for reasons why it happened
or what you did to deserve it (i.e., “Maybe I “Sometimes bad things happen to good people.
was being punished for something I had done If something bad happens to me, it is not
or because I am a bad person.”) In order to necessarily because I did something to cause it
regain your prior positive beliefs about your or because I deserved it. Sometimes there is
self-worth, you will need to make some not a good explanation for why bad things
adjustments so that your sense of worth is not happen.”
disrupted every time something unexpected
and bad happens to you. When you can accept
that bad things might happen to you (as they
happen to everybody from time to time), you
let go of blaming yourself for events that you
did not cause.
Beliefs Related to OTHERS: These are beliefs about how much you value other people. In
addition, a realistic view of others is important to psychological health. In less psychologically
healthy people, these beliefs are stereotyped, rigid, and relatively unchanged by new information.
Prior Experience
Negative Positive
If you had many bad If your prior experiences with
experiences with people in the people had been positive, and
past or had difficulty taking in if negative events in the world
new information about people did not seem to apply to your

you knew (particularly life, the event was probably a
negative information), you belief-shattering event. Prior
may have found yourself beliefs in the basic goodness
surprised, hurt, and betrayed. of other people may be
You may have concluded that particularly disrupted if
other people are not good or people, who were assumed to
not to be respected. You may be supportive, were not there
have generalized this belief to for you after the event.
everyone (even those who are
basically good and to be
respected). The traumatic
event may seem to confirm
these beliefs about people.
Examples of Negative Others-Esteem Beliefs

¾ The belief that people are basically uncaring, indifferent,
and only out for themselves
¾ The belief that people are bad, evil, or malicious
¾ The belief that the entire human race is bad, evil, or
malicious

Others-Esteem Beliefs
¾ Chronic anger
¾ Contempt
¾ Bitterness
¾ Cynicism
¾ Disbelief when treated with genuine caring compassion
(“What do they really want?”)
¾ Isolation or withdrawal from others
¾ Antisocial behavior justified by the belief that people
are only out for themselves
Resolution
Possible self-statements may be…

It will be important for you to reconsider the
automatic assumption that people are no good,
and consider how that belief has affected your
behavior and social life in general.
When you first meet someone, it is important

that you do not form snap judgments because
these tend to be based on stereotypes, which
are not generally true for the majority of people

you will meet. It is all right to adopt a “wait
and see” attitude, which allows you flexibility
in developing your perceptions about the other
person and does not penalize the person whom
you are trying to get to know.
If, over time, this person makes you

uncomfortable, or does things that you do not
approve of, you are free to stop trying to
develop the relationship and end it. Be aware,
however, that all people make mistakes, and
consider your ground rules for friendships or
intimate relationships. If you confront the
person with something that makes you
uncomfortable, you can use that person’s
reaction to your request in making a decision “Although there are people I do not respect and
about what you want from that person in the do not wish to know, I cannot assume this
future (i.e., if the person is apologetic and about everyone I meet. I may come to this
makes a genuine effort to avoid making the conclusion later, but it will be after I have
same mistake, then you might want to continue learned more about this person.”
getting to know this person. If the person is
insensitive to your request or belittles you in
some other way, then you may want to get out
of this relationship.) The important point is,
like trust, you need time to get to know people
and form an opinion of them. It is important
that you adopt a view of others that is balanced
and allows for changes.
If those you expected support from let you “People sometimes make mistakes. I will try to
down, don’t drop these people altogether at find out whether they understand it was a
first. Talk to them about how you feel and mistake or whether it reflects a negative
what you want from them. Use their reactions characteristic of that person, which may end
to your request as a way of evaluating where the relationship for me if it is something I
you want these relationships to go. cannot accept.”

Summary of Session 11: Esteem Issues
2. Discuss patient’s reactions to giving and receiving compliments and engaging in a

pleasant activity (5 minutes)
¾ Reinforce—How did it go?
¾ Compliments/Pleasant Activities
- What happened? - Like it?
- Able to hear for self? - Feel you deserved it?
- Recipients pleased? - Feel guilty?
- Continue to talk? - Encourage more and enjoy!
3. Help patient identify esteem issues and assumptions, and challenge them using
Challenging Beliefs Worksheet (20 minutes)
¾ Does patient believe she is permanently damaged as a result of the trauma?
¾ Perfectionist? Does patient believe she made a mistake?
¾ Esteem for others—over-generalize disregard to whole groups?
4. Introduce fifth of five problem areas: Intimacy issues related to self and others
(10 minutes)
¾ How have relationships been affected by the trauma?
¾ Self-intimacy—ability to calm and soothe oneself?
¾ How were these both before and after?
¾ Any problems: e.g., food? alcohol? spending?

¾ Patient should identify stuck points, one of which relates to Intimacy issues, and
confront them using the Challenging Beliefs Worksheet
¾ Write Impact Statement (discuss the purpose of this)
¾ Continue to give and receive compliments
¾ Continue to do at least one nice thing for self each day
about them.

1. To review the compliments and nice things that the patient has done for • Session 11
goals
himself.
2. To review the Challenging Beliefs Worksheets on esteem and other topics.
3. To introduce the concepts of self- and other-intimacy.
4. To assign Challenging Beliefs Worksheets on intimacy.
5. To assign a new Impact Statement.
Giving and Receiving Compliments
The therapist should reinforce the patient’s efforts to give and receive • Giving and
compliments and to do nice things for herself. Was she able to hear the receiving
compliment without immediately rejecting it? (T: “Just say thank you and think compliments
about what they said.”) What happened when she gave compliments? Did the
recipients seemed pleased? Did they continue to talk with the patient? The patient
is asked how she felt when doing nice things for herself (e.g., did she feel that she
did not deserve it? or feel guilty?). She should be encouraged to continue to do
nice things for herself, practice giving and receiving compliments daily, and to
allow herself to enjoy them. The therapist can help the patient to generate some
self-esteem-enhancing self-statements if she tends to make disparaging comments
about herself.
Identifying Esteem Issues and Assumptions
The patient and therapist then discuss the Challenging Beliefs Worksheets on • Identifying
self-esteem
esteem. A very common stuck point on the topic of self-esteem is that the patient
issues &
is now damaged in some way because of the event. Because he has been suffering assumptions
from flashbacks, nightmares, startle reactions, etc., the patient may have
concluded that he is crazy or is permanently damaged. Perceiving oneself as
damaged, believing that one has poor judgment, or believing that others blame
him for things he did or did not do about the event all eat away at one’s global
perception of self-esteem. In the case of interpersonal crimes (such as military
sexual trauma) the victim may also conclude that there must have been something
wrong with him to begin with to have been targeted. If the patient makes global
negative comments about himself, the therapist can begin by pinning down what
the patient is being self-critical about. Like trust, esteem is a global construct that
is multidimensional.
It is sometimes helpful to address issues about perfectionism here. Patients often • Addressing
have poor opinions of themselves because they so harshly judge themselves perfectionism
whenever they make a mistake. This overgeneralization follows logically from
the patient’s belief that she made mistakes before, during, or after the traumatic
event. It may be helpful for the therapist to remind the patient about the basic
unfairness she is practicing with herself.

T: What would you think of a teacher who said, “If you don’t get
100% correct, you will earn an F in the course?”
P: I would say that is unfair.
T: Right. That way there would be two grades, A for perfect, F for
everything else. Normally an A, an outstanding grade, goes to
those people who score 90% or better. That gives people up to
10% mistakes and still be considered outstanding. 80% would be
above average and 70% would be average. So let’s grade
yesterday. You say it was a bad day and that you really screwed
up when you didn’t handle that phone call at work as well as you
would have liked. It sounds like you gave yourself an F.
P: I did.
T: So how many things did you do yesterday? How many decisions
did you make? What percentage correct did you have for the
day?
P: Well, when you put it that way… I guess I did fine. But lots of the
things I did yesterday don’t matter as much as the mistake I
made at work.
T: Sure. Not everything has equal importance. At school, some of
your projects earned more points than others, too. Was it the
most important activity of the day?
P: Yes, I think so.
T: Was it the most important event or activity of the week?
P: No. Two days before, I turned in a big report to my boss that I
had worked on for weeks. She was very pleased with what I had
done.
T: So, if you give yourself a grade only for the day, it would carry
more points, but if you gave yourself a grade for the entire week,
it would not be very important?
P: No, I would give myself an A for the week.
T: Thinking of it that way, do your emotions feel a bit less than
when you first said that you were a failure and couldn’t do
anything right?
P: (Laughs) Yeah. It is such a bad habit to make those extreme
statements.
T: And to believe them when you say them.
P: Yes, at the time, it feels right and true.
T: Sure. It feels right because it is what you have been practicing
for a long time. It is a habit rather than a fact. Just because it
feels right doesn’t make it true.
With regard to esteem for others, it is not uncommon for patients to

overgeneralize their disregard for the perpetrator of a traumatic event to an entire
group (e.g., Asians or Iraqis). In these cases when the patient maligns all
humanity or some subgroup of the population, it is important for the therapist to
help him move off of the extreme and down the continuum. The patient will need

to look for and acknowledge the exceptions to his over-generalized schema in
order to accommodate the schema more realistically.
Another way in which beliefs about the “goodness/badness” of humans is affected • Addressing
following traumatic events is through selective attention. For example, before selective
being criminally victimized, many people pay little attention to reports about attention
crime in the media. After being victimized, they begin to notice how often the
topic emerges on the news, programs on television, or in magazines. Because they
are now attending to crime, it appears to them that crime is everywhere and that
all people are bad. They forget that these events are being reported because they
are “news” and that most people are not victimizing or being victimized daily.
Like crime, other devastating events such as natural disasters, wars, plane crashes,
and terrorist activities may not elicit much attention until they strike near home.
Then these events suddenly become very real and very personal. And the victims
often over-generalize blame of others (as well as themselves) in order to regain a
sense of control. It is not at all unusual for patients with PTSD to over-generalize
to the entire population of the country that was at war and assume that everyone
in that country has identical attitudes about Americans and the war. The patient
may express great disdain for everyone from that country, even those people who
have lived in the United States for generations.
Another topic that emerges frequently with patients as an other-esteem issue is an • Addressing an
over-accommodated viewpoint of the “government.” Just like the words “trust” or over-
“control,” “government” is an overly general term. In fact, some patients with accommodated
PTSD use their outrage at the government as an avoidance strategy. Instead of viewpoint of the
focusing on specific traumatic events, some patients with PTSD will immediately government
try to move the focus to politics and the government (avoidance by rhetoric or
diatribe). It is important for the therapist early in therapy to bring the focus of the
discussion back to the index event and not allow the patient to dominate the
session with ranting. And just as the therapist may ask, “trust with regard to
what?” he or she can also ask, “What do you mean by government? Do you mean
the federal government? Which administration or which branch of government?
Do you mean state or local government? Are they all the same? When you say
that the government is no good, does that mean that when you call 911 no one
answers the phone?” As with other overly vague terms, it is important for the
patient to move off of the extreme and see the different types and categories that
he might in fact judge in a more graded fashion. Although this issue might
emerge early in therapy, it could reemerge with the topic of esteem and can be
challenged again.
Intimacy Issues Related to Self and Others
The topic of intimacy is introduced toward the end of the session, and the • Introducing
therapist and patient briefly discuss how relationships may have been affected by Intimacy
the event. Intimacy with others (or lack of intimacy) will be easier to identify than
self-intimacy. However, it is important that there is a focus on nonsexual intimacy
as well as sexual intimacy. Self-intimacy is the ability to soothe and calm oneself

and to be alone without feeling lonely or empty. Self-intimacy moves beyond • Give patient
Intimacy
self-esteem and includes a strong sense of self-efficacy and comfort with one’s handout
own company. The patient is encouraged to recognize how intimacy with self and
others was before the event and how it was affected by the event. The therapist
and patient should discuss any problems with inappropriate external attempts to
self-soothe (e.g., alcohol, food, spending, etc.) that were likely discussed earlier in
the therapy but should be reinforced here. Again, the patient should use the
Challenging Beliefs Worksheets to confront maladaptive self-statements and to
generate more comforting statements.
Practice Assignment
Finally, in order to assess how the patient's beliefs have changed since the start of
treatment, the patient is asked to write a new Impact Statement reflecting what it
now means to her that the event(s) happened, and what her current beliefs are in
relation to the five topics of safety, trust, power/control, esteem, and intimacy. It
is important to stress that the patient should write about her current thoughts and
not how she may have thought in the past.
“Use the Intimacy Module and Challenging Beliefs Worksheets to • Assign

Session 11
confront stuck points regarding self- and other-intimacy. Continue
practice
completing worksheets on previous topics that are still problematic. assignment
“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.”

Content: This was the 11th session of CPT for PTSD. The patient completed his practice
assignment related to completing the Challenging Beliefs Worksheet daily, giving/receiving
a compliment each day, and doing something nice for himself each day. Examples from the
worksheets were reviewed to offer further cognitive restructuring and to fine-tune completion
of the worksheets. Esteem-related stuck points were specifically targeted. Stuck points
related to intimacy were introduced, and he agreed to read materials related to this theme.
The patient also agreed to complete a Challenging Beliefs Worksheet about stuck points each
day and to write another Impact Statement describing his current thoughts and beliefs about
himself, others, and the world related to his traumatic experiences.
Plan: Conclusion of CPT at next session

PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

Evidence Against?
Habit or fact?

All or none?
Oversimplifying:
Mind reading:
H. Emotion(s)
Irrelevant factors?

Intimacy Issues Module
Beliefs Related to SELF: An important function for stability is the ability to soothe and
calm oneself. This self-intimacy is reflected in the ability to be alone without feeling lonely or
empty. When a trauma occurs, people react differently depending on their expectancy of how
well they will cope.
Prior Experience
Negative Positive
A person with stable and
If you had prior experiences positive self-intimacy may
(or poor role models) that led experience the traumatic event
you to believe that you are as less traumatic because of
unable to cope with negative the expectancy and ability of
life events, you may have drawing support from internal
reacted to the traumatic event resources. However, if the
with negative beliefs that you event is in conflict with earlier
were unable to soothe, self-intimacy beliefs, the
comfort, or nurture yourself. person may feel overwhelmed
or flooded by anxiety.
Symptoms Associated With Negative Self-Intimacy Beliefs

¾ Inability to comfort and soothe self
¾ Fear of being alone
¾ Experience of inner emptiness or deadness
¾ Periods of great anxiety or panic if reminded of trauma
when alone
¾ May look to external sources of comfort—food, drugs,
alcohol, medications, spending money, or sex
¾ Needy or demanding relationships
Resolution
New beliefs A possible self-statement may be…

Understanding the typical reactions to trauma “I will not suffer forever. I can soothe myself
may help you feel less panicky about what you and use the skills I have learned to cope with
are experiencing. Most people cannot recover these negative feelings. I may need help in
from such a major traumatic event without the dealing with my reactions, but that is normal.
support of others. External sources of comfort, Even though my feelings are quite strong and
such as alcohol or food, are just crutches that, unpleasant to experience, I know they are
instead of helping you to recover, may in fact temporary and will fade over time. The skills
prolong your reactions. They may comfort you and abilities I am developing now will help me
in the short run because you use them to avoid to cope better with other stressful situations in

and suppress your feelings. The feelings do not the future.”
go away, however, and you then have to deal
with the consequences of the excess food,
spending, alcohol, etc., which compound the
problem.
Beliefs Related to OTHERS: The longing for intimacy, connection, and closeness is one of
the most basic human needs. The capacity to be intimately connected with other people is fragile. It
can easily be damaged or destroyed through insensitive, hurtful, or unempathic responses from
others.
Prior Experience
Negative Positive
If you previously had
Negative beliefs may result satisfying intimate
from traumatic loss of intimate relationships with others, you
connections. The event may may find that the event
seem to confirm your belief in (especially if committed by an
your inability to be close to acquaintance) may leave you
another person. believing that you could never
be intimate with anyone again.
Posttraumatic Experience
You may also experience a disruption in your belief about
your ability to be intimate with others if you were blamed or
rejected by those who you thought would be supportive.

Others-Esteem Beliefs
¾ Pervasive loneliness
¾ Emptiness or isolation
¾ Failure to experience connectedness with others even in
relationships that are genuinely loving and intimate
Resolution
New beliefs Possible self-statements about [ ]

may be…
In order for you to again have intimate [New relationships] “Even though a former
relationships with others, you will need to relationship did not work out, it does not mean
adopt new, more adaptive beliefs about that I cannot have satisfying intimate
intimacy. Intimate relationships take time to relationships in the future. I cannot continue to

develop and involve effort from both people. believe and behave as though everyone will
You are not solely responsible for the failure of betray me. I will need to take risks in
prior relationships. The development of developing relationships in the future, but if I
relationships involves risk taking, and it is take it slow, I will have a better chance of
possible that you may be hurt again. Staying telling whether this person can be trusted.”
away from relationships for this reason alone,
however, is likely to leave you feeling empty
and alone.
Attempt to resolve your issues with the people

who let you down and hurt you by asking them
for what you need and letting them know how
you feel about what they said or did. If they are [Existing relationships] “I can still be close to
unable to adjust to your requests and are unable people, but I may not be able (or want) to be
to give you what you need, you may decide intimate with everyone I meet. I may lose prior
that you can no longer be close to those people. or future intimate relationships with others
You may find, however, that they responded as who cannot meet me half-way, but this is not
they did out of ignorance or fear. As a result of my fault or due to the fact that I did not try.”
your efforts, communication may improve and
you may end up feeling closer to them than
you did before the traumatic event.

Summary of Session 12: Intimacy Issues and Meaning of the Event
2. Help patient identify intimacy issue, assumptions, and any remaining stuck points,
and challenge them using Challenging Beliefs Worksheet (15 minutes)
¾ Focus on development and maintenance of relationships
¾ Be watchful for deficits in self-soothing (Food? Alcohol? Spending?)
¾ Intimacy
- Interpersonal Intimacy—withdrawal from others
- Sexual Intimacy—physical cueing
3. Patient to read Impact Statement(s) (15 minutes)

¾ Patient to read final Impact Statement and go over its meaning
¾ Therapist to read original Impact Statement
¾ Compare the two
¾ Note how beliefs have changed by work in therapy in only a short period
¾ Reinforce patient’s progress as a result of the work done
¾ Any remaining distortions or problematic beliefs?
4. Involve patient in reviewing the course of treatment and patient’s progress

(10 minutes)
¾ Review concepts and skills
¾ Patient to reflect on own good work, progress, and changes made
¾ Patient to take credit for facing and dealing with difficult and traumatic event
¾ Continuing success depends on patient’s continuing practice of skills learned
5. Help patient identify goals for the future and delineate strategies for meeting them
(5 minutes)
¾ Also remind patient that he is taking over as therapist now and should continue to
use the skills that he has learned

1. To review Challenging Beliefs Worksheets on intimacy and work on resolving • Session 12

goals
any stuck points that might interfere with the development or maintenance of
relationships with self and others.
2. To have the patient read the final Impact Statement.
3. To read the first Impact Statement and compare the two statements.
4. To review the course of treatment.
5. To identify goals for the future.
6. To remind patients that they are taking over as the therapist now and should
continue to practice the skills they have learned during treatment.
Identifying Intimacy Issues and Assumptions
The final session begins with a review of Challenging Beliefs Worksheets on

intimacy. The purpose of the session is to help the patient to identify the patient’s
stuck points for intimacy. The goal for the patient is to work on these stuck points
over time with the new skills she has learned in therapy.
• Self-intimacy
Self-intimacy is the ability of someone to engage in coping, self-control, and
appropriate self-soothing without relying heavily on external methods of
soothing. Problems with self-intimacy are evident if the patient has been abusing
substances, including food, or compulsively spending or gambling, or is so
dependent on others that she does not believe that she can take care of herself.
When given the assignment to write about the traumatic events, one patient
announced that she would have to eat a gallon of ice cream and smoke two packs
of cigarettes to get through it. This was a good clue to the therapist that she had
issues about self-comforting. Over the course of the therapy and particularly
during these last two sessions, this issue was addressed. These issues about self-
soothing are often related to control issues, so the issue of substance abuse is
frequently addressed earlier in treatment as well. We encourage patients to grab a
worksheet rather than grabbing for food, cigarettes, alcohol, or a credit card; to
think through what they were saying to themselves; and to calm themselves with
more appropriate self-statements and behaviors. However, if the patient has
serious problems with substances, those problems should be treated before or
simultaneously with CPT. Normally we do not start CPT unless the patients
promise to refrain from using their problematic substances while they are in
treatment. Then, although we may plant seeds and weave these issues into
treatment earlier as appropriate, we do not focus on self-intimacy as a theme until
late in therapy as we work on relapse prevention.
With regard to intimacy with others, two types of intimacy are often issues: • Nonsexual
intimacy with
closeness with family/friends and sexual intimacy. Many people with PTSD
others
withdraw from people who could be supportive and avoid being close to others,
as a way of protecting themselves from possible rejection, blame, or further harm.

Frequently, relationships dissolve and traumatized patients avoid developing new
relationships. As a result, many of these people feel isolated and alone during
their recovery from the traumatic event.
Sexual intimacy can be a particular problem with victims of sexual assault, • Sexual
although sexual functioning can be interrupted as well, in response to other kinds intimacy
of trauma. Symptoms of PTSD and depression can interfere with normal sexual
functioning, particularly sexual desire. However, to sexual assault victims, sexual
behavior becomes particularly threatening because the act of being sexual has
become a cue associated with the assault, and because of the level of trust and
vulnerability that is necessary for sexual intimacy. The patients’ withdrawal from
others, however, is in direct conflict with their need for comfort and support from
others. These intimacy issues are often interwoven with trust issues that may still
be unresolved and deserve continued attention from the patient. Although CPT is
not intended as a sex therapy, this cognitive therapy can be useful in identifying
and correcting problematic cognitions that may interfere with sexual functioning.
However, more serious dysfunctions should be treated with other therapy
protocols designed specifically for the purpose.
Patient Reading of the New Impact Statement
The therapist and patient should go over the new Impact Statement about the • New Impact
meaning of the event. The patient should first read his new Impact Statement to Statement
the therapist. Below is an example of a new Impact Statement written by
“Chazz,” an Iraq veteran who had been forced to shoot at a car that did not heed
warnings to stop at a checkpoint. A woman and child died in the event.
“There is no doubt that this traumatic event has deeply impacted

me. My thoughts about myself, others, and the world were changed,
and changed again. When I started therapy, I believed that I was a
murderer. I blamed myself completely. Now, I believe that I shot a
family, but I did not murder them. I realize that I had to do what I
did at the time, and that others around me also chose to shoot
because we had to. I will never know what that man or maybe even
family was trying to do by going through that checkpoint, but I know
now that I had no choice but to shoot to stop them. Regarding safety,
I used to think that there were people that were out to get me, but
now I realize that the probability of that is slim. Now I worry about
the stuff that everyone worries about like crazy drivers, illness, or
some accident. I also used to worry that I was going to go off and
hurt my family. I don’t believe that I will do that because I’ve never
done that before and basically this trauma messed with my head
about how likely I would be to hurt someone unless I had to. I’m
trusting myself more in terms of the decisions I make, and I have
some more faith and trust in my government now that I realize that I
really needed to shoot in that situation. I think I may always struggle
with wanting to have power and control over things, but I’m working

on not having control over everything. The fact is that I don’t have
control, even though I like to think that I do. My self-esteem is
improving. I have to remember that not every bad thing that happens
is my fault and that I deserve to be happy even if I don’t fully believe
it yet. One of the biggest things that seems to be changing is that I’m
enjoying being close to my wife and my new daughter. I used to
avoid my wife because I thought I didn’t deserve to be happy and
that I might hurt her and my daughter. Slowly I’m realizing that it is
not very likely that I’ll hurt them, or at least mean to hurt them. My
wife seems much happier now. I want to hold onto this time in my
life, and provide a good life for my daughter and wife. I’m happy to
know that my daughter is not going to know someone who thought
that snipers were out to get him, anxious, and avoiding everything. It
sounds silly, but I’m kind of glad that I went through this, because I
think I’m going to be better because of it.”
The therapist subsequently reads to the patient his original Impact Statement that
the therapist kept from the second session (or subsequent session if not brought to
the second session) so that the patient can see how much change has taken place
in a rather short period. Usually, there is a remarkable change in the second
Impact Statement from the first, and a typical patient remark is “Did I really think
that?” The patient should be encouraged to examine how his beliefs have
changed as a result of the work he has done in therapy. The therapist should also
look for any remaining distortions or problematic beliefs that may need further
intervention.
Review of the Course of Treatment and Patient Progress
The rest of the session is saved for review of all the concepts and skills that have • Reviewing
been introduced over the course of therapy. The patient is reminded that her concepts with
success in recovering will depend on her persistence to practice her new skills and patient
resistance to returning to old avoidance patterns or problematic thinking patterns.
Any remaining stuck points should be identified and strategies for confronting
them should be reiterated. Patients are asked to reflect on the progress and
changes they have made during the course of therapy and are encouraged to take
credit for facing and dealing with a very difficult and traumatic event.
Patient Goals for the Future
Goals for the future are discussed. Patients with traumatic bereavement issues • Goals for the
would not be expected to be over their grief but should be encouraged to allow future
themselves to continue with the process as they work to rebuild their lives.
Patients should be reminded that if they encounter a reminder and have a
flashback, nightmare, or sudden memory they had not accessed before, it doesn’t
mean that they are relapsing. In response to any of these intrusive experiences, the
patient should be encouraged to write an account if needed or to utilize with his

worksheets. He should be encouraged to experience his natural emotions and to
check his thoughts to make sure they are not extreme.
A topic that sometimes emerges among people who have had PTSD for decades
is a question about who they are or will be without their PTSD. If someone has
carried a diagnosis for many years and has organized his life around avoidance
and managing flashbacks and other symptoms, he may wonder who he is now.
For some disabled Vietnam veterans, we have introduced the concept of “PTSD
Retirement.” We remind patients that people change their roles, and to some
extent their identity, at different points in their lives, including retirement, and
many of their age mates are asking themselves the same questions, because of
retirement from work. What will I do when I retire? How will I spend my time?
Who will be in my life? The therapist should help the patient to see that these are
normal questions, and instead of fearing the future, he now has the opportunity to
explore and decide how he wants to spend his time. Many older adults are
changing careers or working part time. They adopt new leisure activities or do
volunteer work. They spend time with grandchildren. The therapist should guide
the patient to see these changes in a positive light and should encourage him to
explore his options.
Younger patients are also going through important developmental milestones in • PTSD in
terms of jobs and careers, as well as relationships and family. The reduction of younger
PTSD symptoms can help these patients get back on their developmental patients
trajectory, and this process should be normalized. Those who have experienced
permanent injuries will need some assistance in considering alternative jobs than
those they might have considered.
A Note on Aftercare
We recommend that after completing the protocol, whether conducted weekly or • Aftercare
twice a week, the therapist set up a follow-up appointment for a month or two into
the future. The patient should be encouraged to continue to use her Challenging
Beliefs Worksheets on any remaining stuck points. The follow-up session should
include the same assessment measures that were used during treatment and can be
used to get the patient back on track or to reinforce gains. This practice is also
helpful in instilling with patients the notion of episodes of care. They are
encouraged to work as their own cognitive therapist on their stuck points and
daily events that arise, and then present for treatment when they have difficulty
resolving a stuck point or recent event. A specific goal-oriented piece of work can
be done, and then they are encouraged to continue using the skills they develop in
the therapy episodes.
One VA program we know of has instituted an aftercare program for patients who
have completed CPT. It is a group that meets monthly. Patients bring in topics
they would like to discuss and use the worksheets and modules to challenge stuck
points. It has been set up as a drop-in group in which the patients may attend for
one session or a number depending on what they are working on. The facilitator

of the group has reported to us that the group has been very helpful in maintaining
gains and giving the patients a place to continue to work on stuck points without
needing to return to a more formal therapy.

Content: This was the 12th and final session of CPT for PTSD. The patient completed his
practice assignment related to completing the Challenging Beliefs Worksheet daily and
writing a final Impact Statement. Examples from the worksheets were reviewed for further
cognitive restructuring, especially aimed at the development and maintenance of
relationships. The first and final Impact Statements were compared, which led to discussion
about the course of therapy. Goals for the future were established, and the patient was
encouraged to continue using his developed skills and to share his treatment experiences with
his referring clinician (e.g., what worked, how he might use the skills in future therapy).
Plan: Conclusion of CPT. Follow-up appointment scheduled for 1 month from date.

PCL-S: WEEKLY
Instructions:

(event)
A
Not Quite
at all a bit
bit
1 2 3 4 5

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
experience?

1 2 3 4 5
Science Division.

patterns. Write in the stuck point under the appropriate pattern and describe how it fits that
pattern. Think about how that pattern affects you.

evidence for this).

Belief: ______________________________________________________________________

FOR:
AGAINST:
need, should, must, can’t and every time)?

Evidence Against?
Habit or fact?

All or none?
Oversimplifying:
Mind reading:
H. Emotion(s)
Irrelevant factors?

| Part 3: | Alternatives and Considerations in
Conducting CPT
CPT Without the Trauma Account (CPT-C)
Recently, Resick and colleagues completed a dismantling study of CPT (Resick et

• CPT,
al., 2008). In that study we compared the full 12-session CPT protocol with its CPT-C,
constituent parts: CPT without the written trauma account (CPT-C) and the CPT-W
written trauma account without the cognitive therapy (CPT-W). We found that all
three conditions were the same by post-treatment, but the trajectory of change
was different. Throughout the course of therapy, the CPT-C group showed
significantly faster improvement than the CPT-W condition, which only caught
up at the end. CPT-C also showed faster improvements than CPT until the two
trauma account sessions were completed. CPT fell between the other two groups
after that. The CPT-C group also had only a 15% drop-out rate compared to 26%
each for the other two conditions.
Because the above results need to be replicated, and because the first study with
veterans used the full CPT protocol (Monson et al., 2006), we have included the
full protocol here for training and implementation. However, these recent results
indicate that CPT-C is a good alternative for those veterans for whom the trauma
account is problematic. It also provides a good solution to the dilemma of how to
handle the trauma accounts in group treatment. For whom is the trauma account
problematic? In our studies of CPT, we have never excluded people with
personality disorders or other comorbidities as long as the person was lucid, not
engaging in any self- or other-harm behaviors, or under current risk by others
(e.g., domestic violence or stalking). Therefore, CPT was tested with people who
had a range of disorders who did not worsen with the administration of the trauma
account. However, one might consider using CPT-C if a patient is so avoidant
that he already has one foot out the door. Some patients arrive in therapy
announcing that they cannot or will not talk about the traumatic event. Most of
the time we have been able to do cognitive therapy around these stuck points, and
they find the account to be a beneficial component. If the patient will quit
treatment rather than do the account, CPT-C should be used. In giving people a
choice of which version of the protocol to use, we have found some veterans will
choose the CPT protocol.
The CPT-C protocol does not ignore the processing of emotions. Patients are • CPT-C
encouraged to both feel and label their natural event-related emotions and to
challenge those that are secondary to appraisals and thoughts (manufactured).
However, because the trauma account is an assignment that tends to elicit
stronger emotions, the therapist using the CPT-C protocol needs to make a
specific effort to draw out natural emotions and to help the patient notice the
differences in emotions when she changes her self-dialogue. Also, the therapist
cannot wait until the account is read to determine the patient’s stuck points. The

therapist may need to do more Socratic questioning to bring out enough details
about the traumatic event to challenge the stuck points adequately.
The CPT-C protocol is still 12 sessions. Rather than shortening the therapy
(which would be possible), we took advantage of the opportunity to reinforce new
skills and divide up two sessions with as much information as in the original
protocol. The first change is at Session 3. Instead of assigning the trauma account
or moving straight to challenging questions, we continue to focus solely on A-B-
C Worksheets. In the CPT protocol, patients are asked to continue working on A-
B-C Worksheets and write their accounts. We believe that 1 week of doing the
worksheets is often not sufficient, especially if the patient has difficulty
identifying his thoughts or labeling his emotions. Therefore, an additional week
of practice is very beneficial before the challenging questions are introduced. This
also gives the therapist an additional session to challenge the patient’s stuck
points about the worst traumatic event, and focus on assimilation regarding that
event before the patient is asked to begin doing it himself.
The next change occurs at Session 4. Instead of re-assigning the written account,
patients are asked to complete Challenging Questions Worksheets on a daily basis
with a focus on assimilation. In Session 5 the next worksheet, Patterns of
Problematic Thinking, is introduced.
The last major change involves dividing Session 7 of the CPT protocol (in CPT-C
Session 6), in which the Challenging Beliefs Worksheet and Safety Module are
both introduced after going over the Patterns of Problematic Thinking
assignment. In the CPT-C protocol, the Challenging Beliefs Worksheet is
introduced, but not the Safety Module. Again, this gives the therapist another
opportunity to elicit assimilated beliefs about the worst trauma that might have
emerged more naturally with the trauma account. The Safety Module and the
topic of over-accommodated safety are introduced in the next session (Session 7).
From Session 8 on, the protocols are identical. The outline for CPT-C is as
follows:
CPT Without the Trauma Account (CPT-C) Outline
Session 1: Symptoms of PTSD, explanation of symptoms (cognitive theory), • Outline of

description of therapy. Practice assignment: Write Impact Statement. CPT-C
Session 2: Patient reads Impact Statement. Therapist and patient discuss meaning
of trauma. Begin to identify stuck points and problematic areas. Review
symptoms of PTSD and theory. Introduction of A-B-C Worksheets with
explanation of relationship among thoughts, feelings, and behavior. Practice
assignment: Complete 1 A-B-C sheet each day including at least one on the worst
trauma.
Session 3: Review A-B-C practice assignment. Discuss stuck points with a focus
on assimilation. Review the event with regard to any acceptance or blame issues.

Begin Socratic questioning regarding stuck points. Practice assignment: Reassign
A-B-C Worksheets.
Session 4: Review A-B-C practice assignment and challenge assimilation with

Socratic questions. Introduce Challenging Questions Worksheet to challenge
specific assimilated beliefs regarding the trauma. Practice assignment: Challenge
one stuck point per day using the Challenging Questions Worksheet (focus on
assimilation/blame).
Session 5: Review Challenging Questions Worksheets. Introduce Patterns of

Problematic Thinking Worksheet. Practice assignment: Complete Patterns of
Problematic Thinking Worksheet on a daily basis. Continue using Challenging
Questions as needed. Make sure patient understands the importance of balance in
beliefs rather than extreme, either/or thinking.
Session 6: Review practice assignment. Determine patterns of problematic

thinking. Introduce Challenging Beliefs Worksheet. Teach patient to use the new
worksheet to challenge cognitions about the trauma(s). Practice assignment:
Complete Challenging Beliefs Worksheets daily on the trauma, as well as,
everyday events..
Session 7: Review Challenging Beliefs Worksheets. Introduce Safety Module.

Discuss how previous beliefs about safety might have been disrupted or
seemingly confirmed by the index event. Use Challenging Beliefs Worksheet to
challenge safety beliefs. Practice assignment: Read Safety Module and complete
Challenging Beliefs Worksheets on safety.
Session 8: Review Challenging Beliefs Worksheets and help patients to challenge

problematic beliefs they were unable to complete successfully on their own.
Introduce Trust Module. Pick out any stuck points on self-trust or other-trust.
Practice assignment: Read Trust Module and complete Challenging Beliefs
Worksheets on trust.
Session 9: Review Challenging Beliefs Worksheets. Introduce Power/Control

Module. Discuss how prior beliefs were affected by the trauma. Practice
assignment: Read Power/Control Module and complete Challenging Beliefs
Worksheets on power/control. Continue to challenge other stuck points on a daily
basis using the Challenging Beliefs Worksheets.
Session 10: Review Challenging Beliefs Worksheets. Introduce module on

Esteem (self-esteem and regard for others). Practice assignment: Read module
and complete Challenging Beliefs Worksheets on esteem, as well as assignments
regarding giving and receiving compliments and doing nice things for self.
Continue to challenge other stuck points on a daily basis using the Challenging
Beliefs Worksheets.

Session 11: Review Challenging Beliefs Worksheets. Discuss reactions to two
behavioral assignments. Introduce final module on Intimacy. Practice assignment:
Continue giving and receiving compliments, read Intimacy Module, and complete
Challenging Beliefs Worksheets on stuck points regarding intimacy. Final
assignment: Write final Impact Statement. Continue to challenge other stuck
points on a daily basis using the Challenging Beliefs Worksheets.
Session 12: Go over all the Challenging Beliefs Worksheets. Have patient read
the final Impact Statement. Read the first Impact Statement and compare the
differences. Discuss any intimacy stuck points. Review the entire therapy and
identify any remaining issues the patient may need to continue to work on.
Encourage the patient to continue with behavioral assignments on compliments
and doing nice things for self. Remind patient that he is taking over as therapist
now and should continue to use skills he has learned.
Group CPT Administration
CPT has been shown to be effective in a group format, either alone or in • Group CPT
combination with individual therapy. Group CPT has been used to treat PTSD administration
successfully in a variety of patient populations, including rape victims, childhood
sexual abuse survivors, combat veterans, and military sexual trauma victims. The
format also has been used in residential treatment programs in conjunction with
other treatments (such as coping-skills building, Dialectical Behavior Therapy,
and Acceptance and Commitment Therapy to name a few). Please see the CPT
Group Manual for details on conducting CPT in a group.

Appendix A: Glossary of CPT Terms
Accommodation: The goal of CPT is to encourage accommodation, which involves
accepting that the traumatic event occurred and discovering ways to successfully integrate
the experience into the individual’s life (e.g., “In spite of this bad event happening to me, I
am a good person.”). Accommodation reflects balanced thinking.
Assimilation: Information about an event is absorbed without changing prior beliefs. The
incoming information may be altered to match prior beliefs in order to reconcile information
about the traumatic event with prior schemas. Assimilation frequently serves as a process of
engaging in undoing or self-blame for the trauma (e.g., ““If only I had…”, “I should have
stopped it” “It wasn’t really abuse”).
CPT: A 12-session trauma-focused, manualized therapy based on the social cognitive theory
of PTSD that focuses on how the traumatic event is construed and coped with by a person
who is trying to regain a sense of mastery and control in his or her life. CPT has been found
effective for posttraumatic stress disorder (PTSD) and other corollary symptoms following
traumatic events.
CPT COLLAGE website: A part of an interactive community of websites for VHA

employees on the VA intranet providing CPT materials and resources including consultation
opportunities. Information on cognitive processing therapy in general and the CPT
Implementation Program can be found on the CPT COLLAGE VA intranet.
http://vaww.collage.research.med.va.gov/collage/cpt/
CPT-C: 12-session cognitive-only CPT (without the written trauma account). The CPT-C
modification is indicated for certain patients (e.g., patients who refuse to write an account,
have impending redeployment, have less overall time available, or have no or limited
recollection of the event). CPT-C can also be indicated when therapists want to allot more
time for the patient to develop cognitive skills. CPT-C remains trauma-focused and does not
ignore the processing of emotions.
Emotional processing theory: A theory of PTSD developed by Foa, Steketee, and

Rothbaum (1989) derived from information processing theory (Lang, 1977). In this theory,
PTSD is believed to emerge due to the development of a fear network in memory that elicits
escape and avoidance behavior. Mental fear structures include stimuli, responses, and
meaning elements. Anything associated with the trauma may elicit the fear structure or
schema and subsequent avoidance behavior. Prolonged exposure therapy for PTSD is based
on emotional processing theory.
Fight-flight-freeze reactions: Natural and automatic, fear/flee/freeze or anger/aggression

reactions that occur when faced with a traumatic situation.
Grounding techniques: Techniques such as cueing to date, time, location, or safety; or

touching a predetermined object used when patients are dissociative to help orient back to the
present.
THERAPIST’S MANUAL – Cognitive Processing Therapy: Veteran/Military Version A1

Hindsight bias, 20/20 hindsight: An example of a distorted cognition associated with
assimilation. A person with hindsight bias may believe that he/she knew an outcome in
advance (e.g., “If only I had ___________, this would not (might not) have happened.” “I
knew that I shouldn’t trust him”).
Impact statement: A written description of how the patients’ worst trauma has affected their
life including a discussion of the patients’ beliefs about the cause of the event and of each of
the following five primary themes that are be addressed in CPT: safety, trust, power/control,
esteem, and intimacy. The impact statement is given as a practice assignment in session 1
and again in session 11.
Index trauma: The trauma chosen for the written trauma account by the patient and
therapist. The index trauma is generally the worst trauma. One of the major benefits of
selecting the worst trauma is that there is more likely to be generalization of new, more
balanced cognitions from worst event to less severe event than the other way around.
Additionally, the worst trauma account may yield the most relevant stuck points and can
reinforce a sense of mastery for the patient.
Just world belief: The belief that the world is an orderly, predictable, and fair place, where
people get what they deserve (i.e. good things happen to good people, bad things happen to
bad people). This is a cognitive distortion theorized to impact trauma recovery and is
addressed in CPT.
Military sexual trauma (MST): Sexual assault or repeated, unsolicited, threatening acts of
sexual harassment that occurred while the veteran was in the military.
Natural emotions vs. manufactured emotions: Natural emotions are emotions that follow
directly after an event and would be universally experienced, i.e. a hard-wired response, such
as fear when in danger, or sadness in response to loss. Manufactured emotions are feelings
experienced not directly from an event but instead based on an interpretation of an event
(e.g., guilt, shame).
Over-accommodation: Altering one’s beliefs about oneself and the world to the extreme to
feel safer and more in control in order to reconcile information about the traumatic event
with prior schemas. Over-accommodation typically involves generalizing trauma-based
reactions to non-traumatic situations (e.g., “I can never trust anyone again.”). These beliefs
often fit into the themes that constitute the final five sessions of CPT.
PCL (PTSD Checklist): The PCL is a 17-item self-report measure of the 17 DSM-IV
symptoms of PTSD. Respondents rate how much they were bothered by that problem in the
past week or month.

Posttraumatic stress disorder (PTSD): Psychological disorder defined in the DSM-IV as
an intense reaction of fear, helplessness, or horror to the direct experience, witnessing, or
confrontation of a traumatic event. Symptoms are broken down into 3 distinct clusters:
• Re-experiencing: Intrusive thoughts, dreams, or flashbacks of the trauma; also
includes psychological and physiological distress to reminders of trauma.
• Avoidance: Avoidance and general numbing of responses to reminders of the trauma.
• Hyperarousal: General increase in arousal including difficulties sleeping or
concentrating, exaggerated startle response, hypervigilance, and angry outbursts.
Prolonged Exposure (PE): An empirically supported cognitive behavioral therapy that

treats PTSD across a variety of settings and trauma populations. The main therapeutic
components are direct (“in vivo”) and imaginal exposure to the traumatic event. Unlike CPT,
cognitive restructuring is not a main or required component of PE. PE construes PTSD as a
disorder induced by an overactive fear network which elicits avoidance and prevents full
emotional processing of the trauma. The goal of PE is to facilitate emotional processing
through activating and then modifying this fear network through exposure exercises.
Social cognitive theory: A theory that postulates that the way in which an individual
cognitively processes a traumatic event impacts his/her emotions. According to this theory,
recovery from PTSD relies on the activation, and subsequent correction, of faulty cognitions
and their related emotions. Full cognitive processing of the trauma will alleviate negative
emotions associated with the trauma and reduce symptomatology.
Socratic questioning: A cognitive therapy technique in which the therapist asks leading
questions to assist the patient in challenging the accuracy of his/her thinking and rectifying
inaccurate thought patterns in a way that alleviates psychological distress.
Six categories of Socratic questioning:
• Clarification - “Tell me more” questions which help patients examine their
beliefs/assumptions on a deeper level and provide information necessary for the
therapist to fully understand the situation.
• Probing assumptions – “Why” and “How” questions designed to challenge patients’
presuppositions and unquestioned beliefs.
• Probing reasons and evidence – Questions that assist patients in looking at the actual
evidence behind their beliefs. This is a similar process to probing assumptions.
• Questioning viewpoints and perspectives – Challenging patients’ position through
asking questions about alternative viewpoints and perspectives.
• Analyzing implications and consequences – Questions that help the patient examine
the potential outcomes of his/her beliefs to see if they are desirable or even make
sense.
• Questions about the question – A technique of responding when the therapist is
directly questioned by the patient. Instead of providing an answer to the question, the
therapist responds with another question that returns the focus back on the patient.

Stuck points: Patients’ problem-areas in thinking that interfere with the recovery process and
that are keeping them "stuck." Stuck points can include both assimilated and
overaccommodated beliefs. Stuck points are continually identified throughout CPT and
become primary targets for practice assignments and in-session work.
Survivor Guilt: A manufactured emotion associated with surviving a traumatic event that
others, often loved ones, did not survive. Survivor guilt is also applicable to situations in
which an individual did not suffer as serious injuries/consequences from a trauma as others,
often associated with feelings of worthlessness. The “why not me?” question is the flip side
of the question “Why me?” and implies a belief in a just world.
PTSD as a disorder of non-recovery: A perspective of PTSD as a “stalling-out” of the

normal trauma-recovery process rather than the development of a unique psychopathology.
This perspective is based on the evidence that PTSD symptoms are nearly universally
observed immediately following serious traumatic stressors, with most individuals achieving
recovery over the course of several months. Those who remain symptomatic after several
months are considered to have stagnated in this normal recovery process and can be
diagnosed with PTSD.
Traumatic bereavement: Bereavement in response to a traumatic death; the trauma

component adds unique issues to the typical course of bereavement. Additionally, PTSD may
interfere with the normal bereavement process, and bereavement may interfere with PTSD
treatment. CPT addresses these issues with an optional session 2a in which traumatic
bereavement is specifically addressed through psychoeducation of the grief process,
identification/processing of stuck points associated with the traumatic loss, and cognitive
adjustment to life without the deceased individual(s).
Vicarious traumatization: A reaction that occurs when an individual begins experiencing

PTSD-like symptoms, questioning his/her own vulnerabilities, and /or feeling fear/concern
for his/her own safety in response to hearing a detailed or graphic account of another’s
trauma history. Vicarious traumatization is often observed in mental health professionals who
treat trauma patients, emphasizing the importance of self-awareness and self-care when
working with trauma populations.
5 CPT Themes: Five general themes of over-accommodation specifically are addressed in

the last 5 sessions of the CPT protocol. Each session includes psychoeducation, where a
theme is discussed in relation to self and others, and a theme-related practice assignment.
Specific theme-related stuck points are identified and targeted for practice assignment and in-
session work.
• Safety – Beliefs regarding one’s own ability to control events and protect self/others
from harm and the dangerousness/harmful intentions of others.
• Trust – Adopting a healthy balance of trust and mistrust. This includes both trust of
one’s own perceptions/judgments and the reliability of other’s promises, intentions,
and behavior.
• Power/Control – Beliefs of one’s own capability to meet challenges as well as the
ability to maintain power and control outcomes in the context of interpersonal

relationships. This also includes the extent to which others have control over one’s
life.
• Esteem – Perspectives of self-worth and the worth of others. This includes personal
needs of being understood and respected as well as fostering realistic views, and
challenging rigid/stereotypical views, of others.
• Intimacy – Fostering of self-intimacy (the ability to soothe oneself and be alone
without feeling lonely or empty) and ability to connect with others. This also focuses
on the innate human desire for closeness with others.

Appendix B: Literature on CPT
Ahrens, J., & Rexford, L. (2002). Cognitive processing therapy for incarcerated adolescents
with PTSD. Journal of Aggression, Maltreatment and Trauma, 6, 201– 216.
Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of

posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting
and Clinical Psychology, 73, 965–971.
Chard, K. M., Resick, P. A., & Wertz, J. J. (1999). Group treatment of sexual assault
survivors. In B. H. Young & D. D. Blake (Eds.), Group treatments for post-traumatic
stress disorders: Conceptualization, themes, and processes (pp. 35–50). Philadelphia:
Brunner/Mazel.
Chard, K. M., Weaver, T. L., & Resick, P. A. (1997). Adapting cognitive processing therapy
for child sexual abuse survivors. Cognitive and Behavioral Practice, 4, 31–52.
Clarke, S.B., Rizvi, S.L., & Resick, P.A. (2008). Borderline personality characteristics and
treatment outcome in cognitive-behavioral treatments for PTSD in female rape
victims. Behavior Therapy, 39, 72-78.
Difede, J., & Eskra, D. (2002). Cognitive processing therapy for PTSD in a survivor of the
World Trade Center bombing: A case study. Journal of Trauma Practice, 1, 155–165.
Ellis, L. F., Black, L. D., & Resick, P. A. (1992). Cognitive-behavioral treatment approaches
for victims of crime. In P. A. Keller & S. R. Heyman (Eds.), Innovations in clinical
practice: A source book (pp. 11, 23–38). Sarasota, FL: Professional Resource
Exchange.
Falsetti, S. A., Resnick, H. S., Davis, J., & Gallagher, N. G. (2001). Treatment of
posttraumatic stress disorder with comorbid panic attacks: Combining cognitive
processing therapy with panic control treatment techniques. Group Dynamics, 5(4),
252–260.
Falsetti, S. A., Resnick, H. S., & Lawyer, S. R. (2006). Combining cognitive processing
therapy with panic exposure and management techniques. In L. A. Schein, H. I. Spitz,
G. M. Burlingame, P. R. Muskin, & S. Vargo (Eds.) Psychological effects of
catastrophic disasters: Group approaches to treatment (pp. 629–668). New York:
Haworth Press.
Galovski, T.E. & Resick, P.A. (2008). Cognitive processing therapy for posttraumatic stress
disorder secondary to a motor vehicle accident: A single-subject report. Cognitive and
Behavioral Practice, 15, 287-295.
Hall, C. A., & Henderson, C. M. (1996). Cognitive processing therapy for chronic PTSD
from childhood sexual abuse: A case study. Counseling Psychology Quarterly, 9(4),
359–371.
THERAPIST’S MANUAL – Cognitive Processing Therapy: Veteran/Military Version B1

House, A. S. (2006). Increasing the usability of cognitive processing therapy for survivors of
child sexual abuse. Journal of Child Sexual Abuse, 15, 87–103.
Kaysen, D., Lostutter, T. W., & Goines, M. A. (2005). Cognitive processing therapy for
acute stress disorder resulting from an anti-gay assault. Cognitive and Behavioral
Practice, 12, 278–289.
Messman-Moore, T. L., & Resick, P. A. (2002). Brief treatment of complicated PTSD and
peritraumatic responses in a client with repeated sexual victimization. Cognitive and
Behavioral Practice, 9, 89–99.
Monson, C. M., Price, J. L., & Ranslow, E. (2005, October). Treating combat PTSD through
cognitive processing therapy. Federal Practitioner, 75–83.
Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S.
P. (2006). Cognitive processing therapy for veterans with military-related
posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74,
898–907.
Nishith, P., Nixon, R. D. V., & Resick, P. A. (2005). Resolution of trauma-related guilt
following treatment of PTSD in female rape victims: A result of cognitive therapy
targeting comorbid depression? Journal of Affective Disorders, 86, 259–265.
Nishith, P., Resick, P. A., & Griffin, M. G. (2002). Pattern of change in prolonged exposure
and cognitive processing therapy for female rape victims with posttraumatic stress
disorder. Journal of Consulting and Clinical Psychology, 70, 880–886.
Owens, G. P., Pike, J. L., & Chard, K. M. (2001). Treatment effects of cognitive processing
therapy on cognitive distortions of female child sexual abuse survivors. Behavior
Therapy, 32(3), 413–424.
Petrak, J. (1996). Current trends in the psychological assessment and treatment of victims of
sexual violence. Sexual and Marital Therapy, 11, 37–45.
Resick, P. A. (1992). Cognitive treatment of crime-related post-traumatic stress disorder. In

R. D. Peters, R. J. McMahon, & V. L. Quinsey (Eds.), Aggression and violence
throughout the life span (pp. 171–191). Newbury Park, CA: Sage Publications.
Resick, P. A. (2001). Cognitive therapy for posttraumatic stress disorder. Journal of

Cognitive Psychotherapy, 15(4), 321–329.
Resick, P.A., Galovski, T.A., Uhlmansiek, M. O., Scher, C.D., Clum, G. A., &
Young-Xu, Y. (2008). A randomized clinical trial to dismantle
components of cognitive processing therapy for posttraumatic stress
disorder in female victims of interpersonal violence. Journal of Consulting
and Clinical Psychology, 76, 243-258.

Resick, P.A., Monson, C.M., & Rizvi, S.L. (2007). Posttraumatic stress disorder. In D.H.
Barlow (Ed.), Clinical handbook of psychological disorders (4th ed.): A step-by-step
treatment manual (pp. 65-122). New York: Guilford Press.
Resick, P. A., Nishith, P., & Griffin, M. G. (2003). How well does cognitive-behavioral
therapy treat symptoms of complex PTSD? An examination of child sexual abuse
survivors within a clinical trial. CNS Spectrums, 8, 340–355.
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison
of cognitive processing therapy, prolonged exposure and a waiting condition for the
treatment of posttraumatic stress disorder in female rape victims. Journal of
Consulting and Clinical Psychology, 70, 867–879.
Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault
victims. Journal of Consulting and Clinical Psychology, 60(5), 748–756.
Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A
treatment manual. Newbury Park, CA: Sage Publications.
Schulz, P. M., Huber, L. C. & Resick, P. A (2006). Practical adaptations of cognitive

processing therapy for treating PTSD with Bosnian refugees: General implications for
adapting practice to a multicultural clientele. Cognitive and Behavioral Practice, 13,
310-321.
Schulz, P. M., Resick, P. A., Huber, L. C., & Griffin, M. G. (2006). The effectiveness of
cognitive processing therapy for PTSD with refugees in a community setting.
Cognitive and Behavioral Practice, 13, 322-321.
Westwell, C. A. (1998). Cognitive processing therapy in the treatment of marital rape.

Psychotherapy in Private Practice, 17(2), 63–77.

Cognitive Processing Therapist

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What is the purpose and structure of the manual?

What is the purpose and structure of the manual?

What are some common issues that may arise during CPT?

What are some common issues that may arise during CPT?

Cognitive Processing Therapy

Patricia A. Resick, Ph.D., and Candice M. Monson, Ph.D.

Correspondence should be addressed to:

When referencing this manual, please use the following citation:

| Part 1: | Introduction to Cognitive Processing Therapy (CPT) ............ 1

Theory Behind CPT ........................................................................................ 1

| Part 2: | CPT: Session by Session........................................................ 25

Group CPT Administration .......................................................................... 198

| Appendix A: | Glossary of CPT Terms……..…….…….…….…….…A1

| Appendix B: | Literature on CPT……………..…….…….…….…….…B1

Cognitive Processing Therapy (CPT) is a 12-session therapy that has been

Theory Behind CPT

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 1

Although social cognitive theories are not incompatible with • Social

In a social-cognitive model, affective expression is needed, not for habituation,

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 2

PTSD as Disorder of Non-Recovery

1. Who Is Appropriate for CPT?

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 3

If someone cannot engage in treatment for his PTSD because he is so dissociative

2. When Should the CPT Protocol Begin?

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 4

If changing formats within the context of a long-term therapy relationship appears

3. Treatment Contracting for CPT

Regardless of whether someone is a new or an established patient, before starting

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 5

In the Therapist Materials section of the Materials Manual there is a patient

Overview of CPT Sessions

It is strongly recommended that the protocol be implemented in the order • Order of

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 6

Socratic Questioning Within CPT

Socratic questioning originated from the early Greek philosopher/teacher

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 7

Applied to CPT, the purpose of Socratic questioning is to challenge the accuracy

Socratic questioning consists of six main categories: clarification, probing

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 8

Probing questions challenge the patient’s presuppositions and unquestioned • Probing

- How did you come to this conclusion?

3. Probing Reasons and Evidence

- How do you know this?

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 9

- What alternative ways of looking at this are there?

5. Analyzing Implications and Consequences

- Then what would happen?

6. Questions About the Question

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 10

Issues in Conducting CPT

Major depressive disorder, which occurs in approximately half of people with

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 11

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 12

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 13

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 14

THERAPIST’S MANUAL—Cognitive Processing Therapy: Veteran/Military Version Page 15

In summary, therapists should not be daunted by comorbid disorders

3. Needs of Returning OIF/OEF Veterans