Posttraumatic Stress Disorder 539
you are reliving the traumatic experience all over again. [Therapist should refer to
the client’s description of reexperiencing symptoms.] A third contributor to persis-
tent PTSD concerns one’s evaluation or interpretation of the reexperiencing symp-
toms of PTSD. For example, if a person considers the recurrent thoughts, images,
memories, or dreams of the trauma as having a substantial and enduring negative
effect on himself, then the reexperiencing will be considered a serious threat to
his ability to function that must be contained at all costs. Giving the symptoms of
PTSD, this serious negative evaluation will have the paradoxical effect of increas-
ing their persistence and salience or intensity. One’s life becomes more focused,
more dominated by the symptoms. [Therapist refers back to client’s interpretation
of reexperiencing symptoms to reinforce this point.] And finally, certain strategies
that are designed to reduce reexperiencing symptoms, such as the avoidance of
trauma cues, attempts to suppress thoughts of the trauma, failure to express natural
emotions, and reliance on safety- seeking behaviors, all contribute to the persistence
of PTSD symptoms. [Therapist questions client about the effects of avoidance and
safety- seeking.]”After presenting the cognitive explanation for PTSD, the therapist provides a
rationale for treatment. Foa and Rothbaum (1998) use the metaphor “psychological
digestion” in which it is explained that the goal of treatment is to help clients work
through what has happened so their brain can ”psychologically digest” the trauma.
Taylor (2006) describes cognitive- behavioral therapy as a means of helping individuals
make sense of a traumatic experience and to desensitize them to distressing but harm-
less reminders of the trauma. Resick, Monson, and Rizvi (2008) explain that therapy
focuses on modifying thoughts and beliefs that cause the individual to “get stuck,” and
on helping the person accept what happened, feel natural emotions, and develop more
balanced beliefs that will contribute to more helpful emotions. Smyth (1999) discusses
treatment of traumatic memories in terms of changing “hot” memories to “bad” mem-
ories, whereas Najavitis (2002) presents the goal of treatment as learning to manage
PTSD and achieving a sense of safety. Although the cognitive therapist may find refer-
ence to these ideas helpful in providing a treatment rationale, it is important to empha-
size that cognitive therapy focuses on the reduction of anxiety and PTSD symptoms by
(1) modifying negative and threatening appraisals and beliefs about self, world, future,
other people, and the reexperiencing symptoms of PTSD; (2) reconstructing a more
organized, meaningful, and complete memory of trauma that is associated with less
threat and distress; and (3) replacing maladaptive avoidance and other safety- seeking
practices with more effective trauma- related coping responses. In addition, cognitive
therapy focuses on eliminating substance abuse, dealing with negative thoughts and
behaviors that may underlie major depression or suicidality, and improving interper-
sonal functioning when these are associated clinical problems. Although the education
phase “formally ends” with a clear statement of the goals for treatment by referring
back to the case formulation, later in therapy a more specific rationale will be provided
when each of the therapeutic ingredients of cognitive therapy are first introduced. Also
the first session of therapy ends with the client assigned to self- monitor her trauma-
related thoughts, images, or memories. The self- monitoring form presented in Appen-
dix 12.1 can be used for this purpose.