548 TREATMENT OF SPECIFIC ANXIETY DISORDERS
et al., 2005). First the cognitive therapist must determine how the client tries to reduce
anxiety or reexperiencing symptoms. The Behavioral Responses to Anxiety Checklist
(Appendix 5.7) and the Cognitive Responses to Anxiety Checklist (Appendix 5.9) from
Chapter 5 can be assigned to obtain this information. These forms should be expanded
to include responses to reexperiencing symptoms as well as anxiety for individuals with
PTSD.
The next step in this phase of treatment is educating the client on the negative con-
sequences of the maladaptive coping response. Although safety- seeking and avoidant
responses may lead to an immediate decrease in anxiety or termination of reexperienc-
ing symptoms, in the long term they significantly contribute to the persistence of PTSD.
Reliance on alcohol or other drugs to avoid trauma- related thoughts and feelings, inten-
tional suppression of intrusive thoughts or memories, avoidance of situations that elicit
PTSD symptoms, and dependency on safety- seeking cues are all maladaptive avoidant
strategies. Evidence gathering and behavioral experiments can be used to demonstrate
the adverse effects of avoidance. Within- session demonstrations such as the “camel
effect for thought suppression” (see Chapter 11) can also be used to highlight the nega-
tive effects of cognitive avoidance. Response prevention is used to reduce or eliminate
escape responses (see Chapter 7). Many individuals with PTSD have substance abuse or
dependence which may require referral for addictions rehabilitation and treatment.
The final step in this phase of treatment is teaching clients to adopt a passive, non-
judgmental, and accepting attitude to their episodes of anxiety and trauma- related intru-
sions. Often this involves teaching individuals to engage in a response that is opposite
to their automatic avoidant response (Ehlers et al., 2005). For example, individuals with
PTSD often try to suppress thoughts or memories of the trauma because they believe
this is the best way to reduce anxiety. As an alternative the client is encouraged to allow
the trauma intrusions to enter conscious awareness and to intentionally direct attention
to the intrusion until it subsides naturally. Prolonged attention to the trauma intrusion
provides disconfirming evidence against the belief “if I don’t stop thinking about the
trauma, I will become overwhelmed with anxiety” and it also teaches a detached, mind-
ful acceptance of the anxiety- provoking thoughts and images.
Edward engaged in a number of avoidant strategies in an effort to control his
anxiety and reexperiencing symptoms. He became severely dependent on alcohol to
blunt unwanted thoughts and feelings, he avoided any situations or stimuli that trig-
gered memories of Rwanda, and he desperately tried to suppress intrusive images of
the “little orphan girl.” He joined Alcoholics Anonymous (AA) and completed a sub-
stance abuse rehab program sponsored by the military. In vivo and imaginal exposure
exercises were used to reduce Edward’s cognitive and behavioral avoidance of trauma-
related intrusions. In addition Edward practiced allowing (i.e., accepting) intrusive
images and memories of Rwanda to occupy his mind and to attend to these thoughts
until they decayed naturally. Much to his surprise, Edward learned that the frequency,
intensity, and heightened anxiety associated with the unwanted intrusions declined sig-
nificantly when he adopted a more benign, accepting attitude toward the thoughts and
images.
Worry and rumination are often evident in PTSD. Individuals may worry about the
negative consequences of chronic PTSD or they might ruminate over various ways in
which they could have prevented the trauma. Many of the interventions for generalized
worry discussed in Chapter 10 can be applied to the worry manifested in PTSD (e.g.,