Posttraumatic Stress Disorder 547
Empirical hypothesis testing involved collecting evidence that Edward could engage in
specific pleasure or mastery activities (e.g., having a friend over for dinner, golfing with
friends) despite experiencing PTSD symptoms.
Clinician Guideline 12.26
Unhelpful thoughts and beliefs about PTSD and its symptoms are identified and subjected
to cognitive restructuring in order to help clients view PTSD as a manageable condition in
which acceptance and detached mindfulness may be the optimal response style to symptom
occurrence.In Vivo Exposure
Escape and avoidance are common maladaptive coping responses in PTSD so in vivo
exposure to situations that trigger anxiety and PTSD-related reexperiencing and arousal
symptoms is a major focus in cognitive therapy. The purpose of prolonged exposure to
PTSD and anxiety- eliciting situations is to (1) provide disconfirming evidence of negative
trauma- and disorder- related beliefs; (2) reduce escape, avoidance, and safety- seeking
behaviors; (3) increase self- efficacy and perceived ability to cope; and (4) reduce negative
emotional responses like anxiety. In vivo exposure may also involve revisiting the site
of a traumatic event in order to help in the reconstruction of a more elaborated trauma
memory so that the intrusive recollections become less responsive to cue- driven retrieval
(Ehlers et al., 2005).
Chapter 7 provides a detailed description of how to conduct in vivo exposure. The
steps for implementing this type of exposure in PTSD will be similar to the procedure in
other anxiety disorders with the exception that concerns about re- experiencing symptoms
during exposure exercises may require additional attention by the therapist. A graded
fear hierarchy should be constructed and exposure sessions often begin with therapist
assistance. Prolonged, repeated, and daily exposure continues with each situation until
the client experiences a clinically significant decline in anxiety and reexperiencing symp-
toms. For the cognitive therapist, in vivo exposure often provides opportunity to modify
negative trauma- and disorder- related beliefs and appraisals. For further description of
in vivo exposure in PTSD, see Foa and Rothbaum (1998) and Taylor (2006).
Clinician Guideline 12.27
Graded in vivo exposure to avoided situations that elicit anxiety and reexperiencing symp-
toms is an important therapeutic element of cognitive therapy of PTSD used to provide dis-
confirming evidence for maladaptive thoughts and beliefs, increase perceived coping ability,
and reduce heigthened situationally induced anxiety.Modify Maladaptive Cognitive and Behavioral Control
Reduction of maladaptive cognitive and behavioral safety- seeking and avoidant coping
strategies is another important goal of cognitive therapy (Ehlers & Clark, 2000; Ehlers