554
From
Cognitive Therapy of Anxiety Disorders: Scienc
e and Practice
by David A. Clark and Aaron T. Beck. Copy
right 2010 by The Guilford Press. Permission to photocopy
this appendix is granted to purchasers of this book fo
r personal use only (see copyright page for details).
aPPENDIX 12.1
Trauma Intrusion Self-Monitoring Form
Name:
Date:
from
to:
Instructions:
Please use this form to record any intrusive thoughts, images, o
r memories related to the trauma and its consequences that you
experienced in the past week. Try to complete the form around the sam
e time that you reexperienced symptoms related to the trauma in order to
increase the accuracy of your remarks.Date, Time, and Duration of Intrusion
Situations or Cues That Triggered the Intrusion
Briefly Describe the Intrusive Thought, Image, or Memory
1
Label and
Rate Severity of a
ssociated
Emotions (0–100)
Personal Significance
of the Intrusion
2
Coping Responses and
Effectiveness
3
1 Indicate by marking an asterisk (*) beside each intrusion t
hat occurred as a “flashback” (i.e., a momentarily reliving o
f some aspect of the trauma).
2 In a few words indicate what was so distressing about t
his particular intrusive thought or memory of the trauma for yo
u. What was so personally significant about the intrusive
experience?^3 What did you do to get rid of the intrusive thought, imag
e, or memory? How effective was it?