540 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Clinician Guideline 12.23The educational component of cognitive therapy for PTSD focuses on (1) correcting any mis-
conceptions about PTSD and its consequences, (2) explaining the role of negative trauma-
related and disorder- focused appraisals and beliefs in the persistence of PTSD symptoms,
(3) elucidating the problem of poorly elaborated trauma memories, and (4) highlighting the
effects of maladaptive cognitive and behavioral avoidance and safety- seeking strategies. Cli-
ent collaboration with treatment is determined by acceptance of the therapy rationale which
is based on the cognitive model of PTSD.Trauma- Focused Cognitive Restructuring
After educating the client into the cognitive model of PTSD, the next phase of treatment
involves the identification and modification of the client’s negative beliefs and apprais-
als about the trauma and its consequences. We believe it is important to focus on these
beliefs before engaging in any trauma- related exposure in order to correct any biases
that might undermine the acceptance of exposure. Also, for most people, dealing with
trauma- related beliefs will be less threatening than in vivo or imaginal exposure.
In cognitive processing therapy developed by Patricia Resick and colleagues, clients
with PTSD are first asked to write an Impact Statement about the meaning of the trau-
matic event(s) (Resick & Schnicke, 1992; Resick, Monson, & Rizvi, 2008; Shipherd et
al., 2006). We have found this an excellent exercise for identifying negative appraisals
and beliefs about the trauma and its consequences. It should be given as a homework
assignment at the end of the first session. The following are instructions for writing an
Impact Statement (Resick, Monson, & Rizvi, 2008, p. 90):
“Please write at least one page on what it means to you that this traumatic experi-
ence happened. Please consider the effects that the event has had in your beliefs
about yourself, your beliefs about others, and your beliefs about the world. Also
consider the following topics while writing your answer: safety, trust, power/com-
petence, esteem, and intimacy. Bring this with you to the next session.”Most of session two will be spent on the Impact Statement in which the therapist high-
lights, clarifies, and elaborates aspects of the client’s account that indicate negative
appraisals and beliefs about the trauma. These beliefs will tend to revolve around the
causes and consequences of the trauma as they relate to the self, world, other people,
and future. Resick and Schnicke (1992) suggest that beliefs about safety, trust, power,
self- esteem, and intimacy should be targeted because these are often disrupted by a
trauma. For example, a university student who was raped after leaving the bar with a
man she had just met believed that “it was my fault for drinking too much and putting
myself in a dangerous situation” and “I’ll never be able to trust or be intimate with
another man.”
Various cognitive restructuring strategies discussed in Chapter 6 can be used to
modify the negative trauma- related appraisals and beliefs. Evidence gathering will be
particularly useful in which clients can be asked, “Is there anything that happened
at the time of the trauma or afterward that supports or reinforces the negative inter-