Posttraumatic Stress Disorder 533
Coping Strategies Profile
The cognitive case formulation should also include an assessment of individuals’ attempts
to minimize the presence of PTSD symptoms and their consequences. How prominent
is active and intentional thought suppression in clients’ response to unwanted trauma-
related intrusions? Are there other types of maladaptive cognitive strategies used to
prevent or terminate exposure to trauma- related intrusions? The checklist of cognitive
coping strategies presented in Chapter 5 (see Appendix 5.9) can be used to identify
maladaptive cognitive coping responses and their perceived effectiveness. Appendix
5.7 can also be utilized to assess for the presence of maladaptive behavioral coping
responses associated with PTSD symptoms. Furthermore, the clinician should deter-
mine if rumination about PTSD and its effects or preoccupation with having frequent,
unwanted trauma- related intrusions is prominent in the client’s experience of the dis-
order.
Dissociation, emotional numbing, and deliberate suppression of emotion are often
present in PTSD. Are these maladaptive coping responses frequent and what is their
perceived effectiveness? How tolerant or accepting is the client of negative emotion? Can
the client engage in healthy expression of negative emotion? How does the individual
evaluate or interpret (i.e., understand) his episodes of anxiousness, anger, dysphoria, or
guilt? Finally, are there adaptive strategies in the client’s coping repertoire? How often
are these strategies used, under what circumstances, and to what effect? The presence
of some capacity to engage in adaptive coping can be an important starting point in
therapy.
Avoidance and Safety Seeking
The final component of the cognitive case formulation involves a specification of the
range of situations or trauma- related cues that are avoided as well as the types of safety-
seeking behaviors employed and their perceived effectiveness. Foa and Rothbaum (1998)
discuss how to construct a hierarchy of avoided situations in their exposure-based ther-
apy for rape trauma. In Chapter 7 the Exposure Hierarchy (see Appendix 7.1) can be
used to identify the avoided situations and cues in preparation for in vivo exposure
which is an important part of cognitive therapy for PTSD. Clients should also be ques-
tioned about their use of safety seeking to minimize or prevent PTSD symptoms. Do
they rely on being accompanied by a partner, family member, or close friend to confront
avoided situations? Do they use medication or other substances to control PTSD symp-
toms? What other subtle cognitive or behavioral strategies are used to minimize anxi-
ety? It is important to obtain a profile of the client’s safety- seeking responses because
this will be a focus for change in subsequent CT sessions.
Case Illustration
A cognitive case formulation is illustrated by referring to the clinical example presented
at the beginning of this chapter. Edward developed PTSD after returning from a 6-month
tour of Rwanda, having witnessed the unspeakable horrors of genocide. Assessment
revealed that the genocide had shattered many of Edward’s preexisting beliefs about the
world, humanity, and himself. Edward expressed long-held beliefs in justice and the rule