Posttraumatic Stress Disorder 549
worry induction, decatastrophizing, worry postponement and intentional expression,
cognitive restructuring of worry beliefs). Further discussion of treatment approaches for
PTSD worry can be found in Taylor (2006) and Wells and Sembi (2004).
Clinician Guideline 12.28
Elimination of dysfunctional cognitive and behavioral avoidant responses and their replace-
ment with a more passive accepting attitude of unwanted thoughts and feelings is a critical
component of cognitive therapy of PTSD.Emotion Reduction (Supplementary)
In some cases it may be necessary to introduce emotion reduction strategies in order to
help individuals with PTSD deal with exceptionally high levels of distressing emotions
during daily living or when anxiety becomes intolerable during imaginal or in vivo
exposure (Taylor, 2006). Instruction in progressive muscle relaxation, applied relax-
ation, or breathing retraining can be used to reduce anxiety (see Chapters 7 and 8).
Grounding exercises, in which individuals are taught to turn their attention from their
thoughts and feelings toward fully attending to specific stimuli in the external world,
are useful for reducing severe dissociative states and flashbacks (see Najavitis, 2002;
Taylor, 2006). Clients are asked to fully attend to the external world by describing the
properties of physical objects such as the furniture in a room, the weather outside, how
the floor feels against their feet, and so on. One purpose of grounding is to remind cli-
ents that the current environment is safe even though their imagined perception is one
of threat. From a cognitive perspective, grounding can be used as a “data- gathering
exercise” to challenge the individual’s exaggerated threat appraisals associated with
reexperiencing symptoms.
Emotion reduction strategies are not an integral part of cognitive therapy for PTSD.
One drawback, previously discussed in Chapter 8, is that anxiety- reduction strategies
can take on avoidant properties, which is counterproductive for therapy. Individuals
with PTSD may become reliant on these strategies to avoid unwanted thoughts and feel-
ings. For this reason caution should be exercised when employing emotion regulation
strategies in PTSD. In our case example, Edward received instruction in progressive
muscle relaxation and he joined a yoga group. Both interventions had minimal enduring
effect in reducing his generalized anxiety and practically no effect on his reexperiencing
symptoms. Edward did find grounding and attention refocusing (Wells & Sembi, 2004)
helpful in dealing with dissociation and flashbacks.
Clinician Guideline 12.29
Although considered an auxiliary intervention in cognitive therapy of PTSD, emotion reduc-
tion strategies are useful for coping with excessively high states of distressing emotions and
reluctance to tolerate the heightened anxiety associated with exposure. However, caution
must be exercised because emotional reduction can become an avoidant strategy that under-
mines the effectiveness of treatment.