Posttraumatic Stress Disorder 543
when I first enlisted” and “I was powerless to prevent the genocide; officers with access
to more resources and authority than me could do nothing to stop it so I can not be held
responsible in any way.” Finally, Edward was taught to take a more detached, distancing
perspective on his negative thoughts and beliefs. He learned to counter the emotional
negative beliefs with more reality-based alternatives, and he also learned that is was safe
to let the unhelpful thoughts float through conscious awareness because they were not
true. As a result of cognitive restructuring, Edward experienced an improvement in his
level of depression and almost complete elimination of suicidal ideation.
Clinician Guideline 12.24
Identification of unhelpful thoughts and beliefs related to trauma, its cause, and consequence
on perspectives about the self, world, future, and other people are obtained through Socratic
questioning and guided discovery. Asking clients to write an Impact Statement can be helpful
in identifying trauma- related maladaptive thinking, while evidence gathering, cost– benefit
analysis, cognitive error identification, empirical hypothesis testing, and generating alterna-
tive interpretations are used to modify negative appraisals and beliefs.Imaginal Exposure to Trauma Memory
Modification of the trauma memory through repeated imaginal exposure, verbal discus-
sion and Socratic questioning is an important component of cognitive therapy for PTSD
that should begin within the fifth or sixth session. Most individuals with PTSD will be
very reluctant to engage in imaginal exposure to the trauma because they believe this
will make their anxiety and distress worse and increase the frequency of reexperiencing
symptoms. Also imaginal exposure is completely contrary to common sense, which is
that avoidance of painful memories is the best way to reduce anxiety and distress. Thus
effective imaginal exposure to the trauma must begin with a rationale for the procedure
and opportunity to address any of the client’s misconceptions about intentional trauma
exposure.
Foa and Rothbaum (1998) begin their rationale by acknowledging that although
individuals who experience traumatic events believe that avoiding thoughts or memo-
ries about the trauma is the best coping strategy, in reality it is never successful because
“no matter how hard you try to push away thoughts about the assault, the experi-
ence comes back to haunt you through nightmares, flashbacks, phobias, and distressing
thoughts and feelings” (p. 159). The authors explain that the goal of repeatedly reliving
the trauma in imagination is to process the memories, to stay with the memories until
the anxiety and distress associated with them decreases. They state that their aim “is to
help you gain control over the memories rather than having the memories control you”
(p. 160). In addition, the cognitive therapist can explain that by repeatedly imagining the
trauma and probing the memories through extended verbal discussion and questioning
in therapy, the client will begin to think differently about the trauma. The memory will
become less emotional, turning it from a “hot” memory to a “bad” memory (Smyth,
1999). This new way of remembering the trauma will reduce the frequency and distress
of the reexperiencing symptoms of PTSD (e.g., intrusive thoughts, images, memories of
the trauma, nightmares, flashbacks).