532 TREATMENT OF SPECIFIC ANXIETY DISORDERS
within a number of thematic categories. It is important to determine the client’s causal
attributions for the trauma. Why does she think the trauma happened? What factors
contributed to its occurrence? Does she engage in self-blame for the trauma or how
she reacted during the trauma? Is there evidence of maladaptive personal responsibility
beliefs? The clinician should also identify maladaptive beliefs associated with feelings of
guilt, regret, or remorse that might be associated with the trauma.
Other types of negative self- referent thoughts and beliefs about the trauma and its
consequences may also be present. Does the client hold unrealistic probability estimates
of traumatic experiences happening to him in the future? Does he hold maladaptive
beliefs about the unpredictability and uncontrollability of trauma? In what way are
beliefs about the probability and severity of threat or danger exaggerated and those
dealing with safety minimized? What is the client’s thinking about the consequences of
the trauma? Does he believe that it has led to enduring or permanent damaging changes
to self or personal world? Does he believe it has changed how others relate to him? The
clinician should identify how the client believes others now perceive him as a result of
being a trauma victim.
The clinician also needs to identify beliefs and appraisals about future expectan-
cies. How has the trauma changed individuals’ attitudes and beliefs about their future?
Have they become much more pessimistic and cynical about life and the world more
generally? Does their future look bleak, empty, or meaningless? Do they believe they
are now helpless, a victim of circumstances that will continue to dictate their life in an
unpredictable and uncontrollable manner? Do they hold any ideas for change or for
improving their life in the foreseeable future?
Beliefs and Interpretations of Intrusions
Another core element of the cognitive case formulation involves a description of how the
person with PTSD interprets the unwanted intrusive thoughts, images, or memories of
the trauma as well as the other prominent symptoms of PTSD. Ehlers, Clark, and col-
leagues have written extensively about the importance of appraisals of trauma sequelae
in the persistence and severity of PTSD (D. M. Clark & Ehlers, 2004; Ehlers & Clark,
2000; Ehlers & Steil, 1995). These appraisals and beliefs focus on the personal mean-
ing or significance of having PTSD. For each individual the clinician should determine
what it is about having PTSD that is so personally distressing. What symptoms are most
distressing or interfere most in the person’s daily functioning? What negative effects are
caused by intrusive symptoms? Are these effects considered enduring or permanent?
The cognitive therapist should also determine the individual’s causal attributions
for PTSD and assess for the presence of catastrophizing thinking. Why does the client
think she has PTSD? How does she explain the presence of trauma- related intrusive
memories or flashbacks? Does the patient believe that all symptoms of PTSD or recol-
lections of the trauma must be eliminated before she can live a satisfying and productive
life? Does she believe her life has been ruined by PTSD? What is the perceived signifi-
cance or personal interpretation given to reexperiencing trauma memories, flashbacks,
nightmares, and the like? How does she explain her apparent inability to control these
symptoms or overcome the negative effects of the trauma? This in-depth assessment of
negative appraisals and beliefs associated with intrusive reexperiencing symptoms plays
an important role in shaping the treatment plan for cognitive therapy of PTSD.