Posttraumatic Stress Disorder 541
pretation or belief?” On the other hand, “Is there anything that happened during the
trauma or afterward that is inconsistent with the negative interpretation or belief?”
Cost– benefit analysis is another useful cognitive restructuring in which the client is
encouraged to consider the immediate and long-term costs of continuing to put the
most negative construction on the trauma and its consequences. The therapist should
also teach individuals how to identify thinking errors in their trauma- related beliefs and
appraisals. The cognitive therapist can also educate clients on how beliefs can affect
trauma memories and vice versa through the processes of accommodation and assimila-
tion (Shipherd et al., 2006). There are two goals to cognitive restructuring. First, the
therapist collaborates with the client in the adoption of an alternative, more helpful
understanding of the trauma and its enduring impact. And second, cognitive restructur-
ing should help patients develop a more distant or detached mindful attitude toward the
trauma- related intrusions (Taylor, 2006; Wells & Sembi, 2004). Individuals are encour-
aged to observe their thoughts in a detached manner without interpreting, analyzing,
or trying to control them in any way. The thoughts can be viewed simply as symptoms
that can be allowed “to occupy their own space and time without engaging with them”
(Wells & Sembi, 2004, p. 373) or the client can shift perspective by viewing the trauma
from another person’s perspective or from the distant future (Taylor, 2006). Although
cognitive restructuring of trauma- related intrusions is most intense during the early ses-
sions of cognitive therapy, this work will continue intermittently throughout treatment.
Appendix 12.2 can be used to help clients consolidate their cognitive restructuring skills
through homework assignments.
Taylor (2006) mentions a number of problems that can be encountered with cog-
nitive restructuring in PTSD. One is invalidation in which the individual believes the
therapist trivializes or does not appreciate the significance and amount of personal suf-
fering caused by the trauma. This can be avoided by giving clients the opportunity to
fully discuss their experiences, expressing appropriate levels of empathy, and directly
validating their feelings (see Leahy, 2001). Also Taylor (2006) recommends that thera-
pists avoid labeling thoughts/beliefs as “distorted,” “wrong,” “irrational,” or “dysfunc-
tional” but instead frame them in terms of what is “unhelpful” and “helpful” ways
of thinking. Another problem occurs when clients hold unyielding beliefs and so are
resistant to cognitive restructuring. Empirical hypothesis- testing exercises can be most
helpful when the client refuses to accept the therapist’s verbal disputations. In addition,
the individual can be encouraged to temporarily “try out the alternative interpretation
or belief” and record any positive or negative effects (see Chapter 6 for further discus-
sion). These experiences may help sow some doubt concerning the veracity of the nega-
tive trauma interpretation.
The following is a verbatim account of Edward’s Impact Statement:
“In Yugoslavia we were there to keep the peace [United Nations peacekeeping tour]
and de-mine and as a result I lost some good friends. I saw the remains of mass buri-
als and murders, vast destruction and I saw the effects of rape and the famous Ser-
bian Necktie [tire placed around victim’s neck and set ablaze]. We were constantly
being mortared on and in Sarajevo the snipers were everywhere and targets were
picked for no reason. I was kept at gunpoint at a UN checkpoint and threatened by
a Chechen with an AK-47. When I look back I see the family problems in a lot of the
soldiers and the drinking and drugs started. We were on the road to Hell.”