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Workshop: Cognitive Processing Therapy © Patricia A. Resick, Candice M. Monson & Kathleen M. Chard, 2006.

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Presentation on theme: "Workshop: Cognitive Processing Therapy © Patricia A. Resick, Candice M. Monson & Kathleen M. Chard, 2006."— Presentation transcript:

1 Workshop: Cognitive Processing Therapy © Patricia A. Resick, Candice M. Monson & Kathleen M. Chard, 2006

2 2 First, let’s talk implementation What would it take for you to try this therapy protocol? What barriers exist to impede your learning to conduct a new therapy? What can you do to facilitate your learning?

3 3 Let’s start with the current criteria for PTSD A: Stressor Criterion B: Reexperiencing C: Avoidance D: Arousal E: Time Criterion F: Functional Impairment or Distress

4 4 Foreshortened future Thoughts, feelings & conversations Activities/Places/People Amnesia Loss of interest Detachment Restricted affect PTSD 13 2 Physiological reactivity PTSDPTSD ost raumatic tress isorder Startle Sleep difficulties Irritability & anger Concentration Hypervigilance Flashbacks Distressing recollections Dreams Psychological distress w/ reminders Arousal Reexperiencing Avoidance Symptom Criteria for PTSD

5 5 A new model of posttraumatic stress disorder

6 Think of PTSD as a failure to recover from a traumatic event. Let’s start with the most homogeneous severe event: rape If the event is severe enough, nearly everyone will have symptoms reflective of PTSD.

7 7 Normal Recovery = Rothbaum et al = Resick et al.= Riggs et al.

8 8 PTSD Among Rape Victims Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock, T. & Walsh, W. (1992). A prospective examination of posttraumatic stress disorder in rape victims. Journal of Traumatic Stress, 5,

9 9 The three symptom clusters of PTSD have not held up to research Let’s rearrange and think about post- trauma symptoms a bit differently So, what happens that either facilitates or hinders recovery?

10 10 1. Intrusive images and sensations Flashbacks Nightmares Sensory memories Images Intrusions EVENTEVENT

11 11 2. Cognitions and Cognitive Processes Intrusions Cognitions EVENTEVENT Processes Attentional bias Rumination Assimilation Accommodation Overaccommodation Content Autobiographical memory Schemas Appraisals Assumptions Thoughts Beliefs

12 12 3. Negative Affect and Hyperarousal Emotions/Arousal Intrusions Cognitions Fear Sadness disgust Anger Startle EVENTEVENT Hyperarousal

13 13 In normal recovery, intrusions and emotions decrease over time and no longer trigger each other Emotions/ Arousal Intrusions Cognitions

14 14 However, in those who don’t recover, strong negative affect leads to escape & avoidance Escape/ Avoidance Emotion/ Arousal Intrusions Cognitions Core reactions

15 15 4. Avoidance Research supports association of a range of behaviors with affect/tension reduction: Substance abuse (Kilpatrick et al. 1997; Nishith et al. 2001) Binging (Agras & Telch, 1998; Cools et al. 1992; Polivy et al. 1994) Self-injury (Briere & Gil, 1998; Favazza & Conterio, 1989) Dissociation (Bonanno et al. 2003; Feeney et al. 2000) Social withdrawal (Riggs et al. 1998; Ruscio et al. 2002)

16 16 Avoidance Criterion This list is not exhaustive Any behavior that functions to escape/avoid negative trauma- related emotion meets the criterion.

17 17 Escape/ Avoidance Successful Avoidance = Chronic PTSD Emotion/ Arousal Intrusions Cognitions Core reactions

18 18 Emotion/ Arousal Intrusions Cognitions Core reactions Escape/ Avoidance Very Successful Avoidance = Chronic Subthreshold PTSD

19 19 Mediators and Moderators Emotions/ Arousal Intrusions Cognitions EVENTEVENT Post trauma environmental factors Social support (+/-) Resource strain/loss Externally imposed inhibition of processing Pretrauma Escape/ Avoidance

20 20 Simple versus Complex PTSD Emotions/ Arousal Intrusions Cognitions Internalizing Simple Externalizing Core Reactions Coping with Escape And Avoidance Simple vs Complex PTSD

21 21 Developing Axis I and Axis II Comorbid Disorders Emotions/ Arousal Intrusions Cognitions Internalizing Simple Externalizing Core ReactionsCoping with Escape And Avoidance Simple vs Complex PTSD Comorbid Axis 1 or Axis 2 Disorders Fear Anxiety Disorders, Avoidant-PD Anxious Misery MDD GAD Schizoid Somatization SUD Cluster B Bulimia ADHD Avoidance

22 22 Two examples …and why they look so different Jim was physically abused by his father as a child. He tended to blame other people for his problems and began drinking with friends in adolescence Jen had an episode of depression in her early 20s. She grew up thinking that when things went wrong, it must have been her fault Both of them were victims of sexual abuse

23 23 Jim Internalizing Emotions/ Arousal Intrusions Cognitions Simple Externalizing Core Reactions Coping with Escape And Avoidance Simple vs Complex PTSD Comorbid Axis 1 or Axis 2 Disorders Fear Anxiety Disorders, Avoidant-PD Anxious Misery MDD GAD Schizoid Somatization SUD Cluster B Bulimia ADHD Abuse External- Angry “Others bad”

24 24 Jen Internalizing Emotions/ Arousal Intrusions Cognitions Simple Externalizing Core Reactions Coping with Escape And Avoidance Simple vs Complex PTSD Comorbid Axis 1 or Axis 2 Disorders Fear Anxiety Disorders, Avoidant-PD Anxious Misery MDD GAD Schizoid Somatization SUD Cluster B Bulimia ADHD Abuse Internal- Sad, guilt “I’m bad”

25 25 Emotions/ Arousal Intrusions Cognitions Internalizing Simple PTSD Externalizing Core Reactions Coping with Escape And Avoidance Simple vs. Complex PTSD Comorbid Axis 1 or Axis 2 Disorders Anxious Misery MDDGADSchizoidSomatization SUD Cluster B Bulimia ADHD PTSD as a Mediator Fear Anxiety Disorders, Avoidant-PD Health Social Family Work Functional Outcomes Avoidance

26 26 Treatment of PTSD Escape/ Avoidance Emotions/ Arousal Intrusions Cognitions Core Symptom Clusters

27 27 1. Prevent Avoidance Emotions/ Arousal Intrusions Cognitions Core Symptom Clusters Escape/Avoidance

28 28 2. Intervene into one or more of core symptom clusters Escape/ Avoidance Emotions/ Arousal Intrusions Cognitions PE CT CPT Nightmare rescripting MEDs

29 29 Research on CPT There have been four randomized clinical trials of CPT and several effectiveness studies. See the manual for the exact references. Randomized Clinical Trials 1. Rape victims (Resick et al., 2002, JCCP) 2. Child Sexual abuse (Chard, 2005, JCCP) 3. Veterans (Monson et al., 2006, JCCP) 4. Rape and assault (Resick et al unpublished)

30 30 Study CPT Sample ITT Depression Comorbidity Gender/Age Compared to: Resick et al. (2002) 82 rape victims (86% had other crimes) 44%Female/32 Prolonged exposure, wait list Chard (2005) 36 adult survivors of CSA (57%> 100 incidents) 40% Female/32.8 Delayed treatment 17 wk protocol Monson et al. (2006) 30 Combat veterans (78% Vietnam) 53% 93% male/ 54.9 Treatment as usual Resick et al. (unpublished) Rape or assault 58 CPT, 51 CT, 55 WE 50%Female/35.4 Dismantling study

31 31 CAPS severity pre and post-treatment (ITT)

32 32 CAPS severity pre and post-treatment: Tx Completers

33 33 CAPS diagnosis pre and post-treatment (ITT)

34 34 CAPS diagnosis pre and post-treatment (Tx completers)

35 35 BDI pre and post-treatment (ITT)

36 36 BDI pre and post-treatment (TX completers)

37 37 Chard (2006): Effectiveness of CPT in VA Residential Program 7 week residential program CPT conducted twice a week in individual and group treatment 23 other hours of psych. programming Pre-post data on 82 residents, 59 men and 23 women admitted as cohorts of 12 Next slides compare this program with the RCT with veterans by Monson et al. (2006) Chard, Unpublished data

38 38 CAPS pre and post-treatment (TX completers)

39 39 BDI pre and post-treatment (TX completers)

40 Some other findings of note… 1. Can We Cure PTSD? Long-term Follow-up of a Clinical Trial Comparing CPT and PE. Patricia A. Resick, Lauren Williams Robert Orazem and Cassidy Gutner ISTSS & ABCT, Nov., 2005

41 41 Long term follow-ups Follow-up conducted at five + years post-treatment (M= 6 yrs, range 5-10). 171 women were in the intent-to-treat sample. We did not locate 25 and 3 were deceased. Of the 143 we located: 17 refused to participate (12%) 2 were located but were not appropriate. We conducted at least the diagnostic interviews on 124 and have complete assessments on % participation rate

42 42 ITT CPT and PE “cross-sectional” CPT, N= PE, N=

43 43 CPT and PE on CAPS across 5 years (all assessments) CPT, N= 35 PE, N= 32

44 44 CPT & PE ITT on PTSD Diagnosis at Pretreatment and long term

45 2. A Dismantling Study of the Components of Cognitive Processing Therapy Patricia A. Resick National Center for PTSD, Boston VA Healthcare System and Boston University Tara Galovski, Kelly Phipps, Mary Uhlmansiek, Jennifer Ansel and Michael Griffin University of Missouri- St. Louis

46 46 ITT CAPS Severity (no differences between groups)

47 47 Random Regression of PDS *****

48 Cognitive Processing Therapy Resick, P.A., Monson, C.M., & Chard, K. M. (2006) Cognitive Processing Therapy Veteran/Military Version Produced by VA Office of Mental Health, VA National Center for PTSD/ VA Boston Healthcare System and Cincinnati VA Medical Center

49 49 Pre-treatment Issues Please assess patients formally to determine whether they have PTSD, and if needed, other comorbid conditions. Describe the therapy you are offering, how it might differ from other former treatment. Therapist contract.

50 50 Other pretreatment issues CPT for whom and when –Substance abuse/dependence –Self-harm/suicidality/homicidality –Dissociation –Literacy –Other comorbidity Medications and other treatments How early can you start? Risk to re-exposure (redeployment) Sufficient skills needed to start?

51 51 Recommended Assessment Measures CAPS interview for diagnosis, frequency and severity (pre and post-treatment) Self-report scales (weekly) PTSD Checklist (PCL) Beck Depression Inventory or other depression checklist

52 52 Structuring Sessions Brief update (mood and PTSD symptoms) –Objective symptom measures –Complete Practice Assignment Review (“How did your practice go?” rather than “How was your week?” Review of Practice Assignment –Reviewing practice reinforces completion –Content is the “meat” of the session –Use Socratic questioning and model challenging thoughts –Use relevant forms regardless of the content

53 53 Structuring Sessions (cont.) Setting new practice assignment –Review rationale –Explain the concept and new assignment –Start assignment in session –Problem solve any barriers to assignment completion

54 54 Session 1. Symptoms and Rationale Describe symptoms of PTSD (handout) PTSD as a disorder of non-recovery Fight-flight-freeze reactions Cognitive theory of PTSD –Just world belief –Assimilation versus over-accommodation –Goal of accommodation

55 55 Assimilation Traumatic event is remembered differently to preserve original beliefs and assumptions Modified memory of the traumatic event doesn’t fit with emotions experienced Creates disconnect between the memories and the emotions Original Belief Rape=Stranger Traumatic Event Raped by friend Assimilation Misunderstanding Undoing and Self-Blame

56 56 Over-accommodation Overall beliefs and assumptions about self and the world change too much following the traumatic event and are no longer accurate Original Belief World=Safe Traumatic Event AssaultedOver-accommodation World=Dangerous

57 57 Session 1 Therapist Explaining Cognitive Theory “Carol”

58 58 Session 1. Symptoms and Rationale Types of emotions –Goal for natural emotions –Goal for manufactured emotions Choosing index traumatic event

59 59 Session 1 Selecting Worst Trauma “Matt”

60 60 Session 1. Symptoms and Rationale Stuck points –Handout –Log Anticipating avoidance and increasing practice compliance Overview of treatment

61 61 Session 1. Group Notes Discuss group rules –Allow patients to create their own and add to their list (e.g. confidentiality, timeliness, no cross talking) Discuss patient responsibilities in group –Attending, participating, doing practice Ask if group members would like a phone list (if outpatient group)

62 62 Session 1. Group Notes Discuss group rules –Allow patients to create their own and add to their list (e.g. confidentiality, timeliness, no cross talking) Discuss patient responsibilities in group –Attending, participating, doing practice Ask if group members would like a phone list (if outpatient group)

63 63 Session 1. Practice Assignment “Please write at least one page on why you think this traumatic event occurred. You are not being asked to write specifics about the traumatic event. Write about what you have been thinking about the cause of the worst event. Also, consider the effects this traumatic event has had on your beliefs about yourself, others, and the world in the following areas: safety, trust, power/control, esteem, and intimacy. Bring this with you to the next session. Also, please read over the handout I have given you on stuck points so that you understand the concept we are talking about.”

64 64

65 65 Session 1a. Traumatic Bereavement Patient reads Impact Statement and therapist begins to identify stuck points Therapist provide education on normal bereavement Therapist looks for stuck points that are interfering with normal bereavement Therapist reviews Myths of Mourning Handout Therapist assigns practice assignment on Impact Statement related to traumatic bereavement

66 66 Session 2. Impact statement Patient reads impact statement. Discuss implications of statement. Review material from first session. Introduce events-thoughts-feelings relationship.

67 67 Session 2. Patient reads impact statement If patient doesn’t do practice assignment –1. Discuss the role of avoidance in maintenance of symptoms –2. Have the patient say what they would have written if they had done so –3. Therapist asks patient to write impact statement for next week –4. Therapist also assigns the next practice assignment as well.

68 68 Session 2. Patient reads impact statement Goal: Patients examine the impact of the traumatic event on their lives. Therapist’s role is to determine whether this has been achieved and to use this examination to increase motivation for change Help identify stuck points in statement Ask about other areas that were not touched upon Highlight connection between thoughts and feelings

69 69 Session 2 Impact Statements Being Processed “Carol”, “Matt”, & “Stacy”

70 70 Session 2. Introduce ABC worksheet Using an example from the impact statement or something that the patient has mentioned, introduce the concept of labeling events, thoughts and emotions. Use an example from life of how most events are open to interpretation. Put on worksheet.

71 71 A-B-C Sheet Date: ___________ patient #: ______ ACTIVATING EVENT BELIEFCONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” Is it reasonable to tell yourself “B” above? _____________________ _________________________________________________________ What can you tell yourself on such occasions in the future? ________________________________________ _____________________________________________________________________________

72 72 Session 2. Group Notes Introduce check-in and asking for group time ideas Pass out written group rules Have members read impact statements to group and look for stuck points Pass out phone list and ask everyone to call the person below them on the list

73 73 Session 2. Practice Assignment “Please complete the A-B-C Worksheets to become aware of the connection between events, your thoughts, feelings, and behavior. Complete at least one worksheet each day. Remember to fill out the form as soon after an event as possible. Complete at least one worksheet about the worst traumatic event. Also, please use the Identifying Emotions Handout to help you determine what emotions you are feeling.”

74 74 Session 3. Events, Thoughts & Emotions Review A-B-C sheets. Using Socratic questions, help patient generate alternative thoughts and consequent feelings. Gently begin to challenge undoing or self-blame statements.

75 75 A-B-C Sheet Date: ___________ patient #: ______ Mr.A ACTIVATING EVENT BELIEFCONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” I get hit by an IED How did I make it and the guy next to me lost his leg? Confused Scared. Is it reasonable to tell yourself “B” above? _____________________ _____________________________________________________________________ What can you tell yourself on such occasions in the future? ___________________________ __________________________________________________

76 76 A-B-C Sheet Date: ___________ patient #: ____ Mr. B ___ ACTIVATING EVENT BELIEF CONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” Child dies in my arms. “It was my fault that she died.” I feel incompetent and helpless. I avoid holding children and getting close to anyone. Is it realistic to tell yourself “B” above? _No. I did what I could to save her.____ What can you tell yourself on such occasions in the future? It wasn’t my fault. I did the best I could for her.

77 77 A-B-C Sheet Date: ___________ patient #: ____ Ms. C ACTIVATING EVENT BELIEFCONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” My grandfather abused me and I was hurt by other men in different ways “It was my fault because I looked like my grandmother and mother. All men cannot be trusted. Guilt Fear Rage Disgust Is it realistic to tell yourself “B” above? _ The guilt was unreasonable- it wasn’t my fault- All men can’t be trusted is an unreasonable statement. What can you tell yourself on such occasions in the future? Each man is an individual- some men can’t be trusted, but not all.

78 78 Session 3: ABC Worksheet: Showing Link Between Words and Emotion ABC Worksheet: Showing Link Between Words and Emotion“Matt”

79 79 Session 3. Socratic questions At this point in therapy we do not strongly challenge maladaptive statements More important to help clarify thoughts and feelings Work gently with assimilation (self-blame & undoing)

80 80 Session 3: Best/Less Optimal Practices in Socratic Questioning “Chazz” “Chazz”

81 81 Session 3: Best/Less Optimal Practices in Socratic Questioning “Chazz” “Chazz”

82 82 Role-playing Activity with ABC Worksheet

83 83 A-B-C Sheet Date: ___________ patient #: ______ ACTIVATING EVENT BELIEFCONSEQUENCE A B C “Something happens” “ I tell myself something” “I feel something” Is it reasonable to tell yourself “B” above? _____________________ _________________________________________________________ What can you tell yourself on such occasions in the future? ________________________________________ _____________________________________________________________________________

84 84 Session 3. Group Notes Check-in/Group time Process the A-B-C sheets – each member shares at least one. Make process statement regarding silence and how that continues the trauma. Discuss ways patients avoid in group (e.g., story telling, silence, disruptive behavior). Have patients call the person 2 down on the phone list.

85 85 Session 3. Practice Assignment “Please begin this assignment as soon as possible. Write a full account of the traumatic event and include as many sensory details (sights, sounds, smells, etc.) as possible. Also, include as many of your thoughts and feelings that you recall having during the event. Pick a time and place to write so you have privacy and enough time. Do not stop yourself from feeling your emotions. If you need to stop writing at some point, please draw a line on the paper where you stop. Begin writing again when you can, and continue to write the account even if it takes several occasions.“ Read the whole account to yourself every day until the next session. Allow yourself to feel your feelings. Bring your account to the next session. Also, continue to work with the A-B-C Worksheets every day.”

86 86

87 87 Session 3 Group Therapy: Group Therapy: Assignment of Written Account

88 88 Session 4. First Account Patient reads account aloud to therapist. After patient reads account, patient and therapist discuss reactions to writing it/reading it. First work on emotions. Sit with them, name them. Then therapist gently challenges self-blame and hindsight bias.

89 89

90 90 Session 4 Reading of Written Account: Recovery from Mistakes “Victor”

91 91 Session 4 Written Accounts with Initial and Socratic Questioning “Carol” (2 clips) and “Matt”

92 92 Session 4. Group Notes Check-in/ Group time Discuss what is was like to write accounts. What new Stuck Points were found? For mixed traumas - remind patients not to share explicit details of their trauma in group Continue using ABC sheets and help challenge stuck points regarding self- blame, undoing, other assimilation. Call 3 down on the phone list

93 93 Session 4. Practice Assignment “Write the whole incident again as soon as possible. If you were unable to complete the assignment the first time, please write more than last time. Add more sensory details, as well as your thoughts and feelings during the incident. Also, this time write your current thoughts and feelings in parentheses (e.g., “I’m feeling very angry”). Remember to read over the new account every day before the next session. Also, continue to work with the A-B-C Worksheets every day.”

94 94 Session 5. Second Account Patient reads second account of incident. Patient and therapist continue to process any remaining self-blame or undoing. Therapist introduces Challenging Questions Worksheet.

95 95 Session 4 Group Therapy: Group Therapy: Challenge of Patient Not Wanting to Do Written Account

96 96 Below are a list of questions to be used in helping you challenge your maladaptive or problematic beliefs. Not all questions will be appropriate for the belief you choose to challenge. Answer as many questions as you can for the belief you have chosen to challenge below. Belief:_________________________________________ 1. What is the evidence for and against this idea 2. Is your belief a habit or based on facts? 3.Are your interpretations of the situation too far removed from reality to be accurate? 4.Are you thinking in all-or-none terms? Challenging Questions Worksheet

97 97 5. Are you using words or phrases that are extreme or exaggerated? (i.e., always, forever, never, need, should, must, can’t and every time). 6. Are you taking selected examples out of context and only focusing on one aspect of the event? 7. Is the source of information reliable? 8. Are you confusing a low probability with a high probability? 9. Are your judgments based on feelings rather than facts? 10. Are you focusing on irrelevant factors? Challenging Questions Continued

98 98 Session 5. Group Notes Check-in/Group time If needed, normalize that all emotions are permitted in group, including anger at group leaders. Discuss. Do 1 challenging questions sheet together in group on a common topic such as “I am never safe” or “ I don’t trust other people.” Have patients call anyone on phone list.

99 99 Session 5. Practice Assignment “Please choose one stuck point each day and answer the questions on the Challenging Questions Worksheet with regard to each of these stuck points. There are extra copies of the Challenging Questions Worksheets provided, so you can work on multiple stuck points. If you have not finished your accounts of the traumatic event(s), please continue to work on them. Read them over before the next session and bring all of your worksheets and Trauma Accounts to the next session.”

100 100 Session 6. Challenging Questions Patient and therapist review Challenging Questions Worksheets to question single statements or beliefs. Therapist introduces Patterns of Problematic Thinking Sheet to see if there are typical patterns of cognition.

101 101 Role-Playing Activity on Challenging Questions Worksheet

102 102 Patterns of Problematic Thinking Listed below are several types of patterns of problematic thinking that people use in different life situations. These patterns often become automatic, habitual thoughts that cause us to engage in self-defeating behavior. Considering your own stuck points, find examples for each of the patterns. Write in the stuck point under the appropriate pattern and describe how it fits that pattern. Think about how that pattern affects you. 1. Jumping to conclusions when evidence is lacking or even contradictory. 2. Exaggerating or minimizing the meaning of an event.

103 103 Patterns of Problematic Thinking 3. Disregarding important aspects of a situation. 4. Oversimplifying events or beliefs as good/bad or right/wrong. 5. Over-generalizing from a single incident. 6. Mind-reading. 7. Emotional reasoning.

104 104 Session 6. Group Notes Check-in/Group time Have members share a Challenging Questions worksheet with the group. Do another one as a group if needed. As they do multiple worksheets, are they detecting any themes across them? Have patients discuss items they wish they would have brought up in past groups. Have patients call anyone on the list.

105 105 Session 6. Practice Assignment “Consider the stuck points you have identified thus far and find examples for each of the problematic thinking patterns listed on the worksheet in your day to day life (or over the course of the next week). Look for specific ways in which your reactions to the traumatic event may have been affected by these habitual patterns. Continue reading your accounts if you still have strong emotions about them.”

106 106 Session 7. Problematic Patterns Patient and therapist review Patterns of Problematic Thinking. Therapist introduces Challenging Beliefs Worksheets. Therapist introduces Safety module.

107 107 Challenging Beliefs Worksheet Jumping to conclusions Exaggerating or minimizing Disregarding important aspects G. Re-rate old thoughts A. SituationB. ThoughtsD. Challenging Thoughts E. Problematic patterns F. Alternative Thought Describe the event, thought or belief leading to the unpleasant emotion(s). Write thought(s) related to Column A. Rate belief in each thought below from % (How much do you believe this thought?) Use Challenging Questions to examine your automatic thoughts from Column B. Is the thought balanced and factual or extreme? Use the Problematic Thinking Patterns sheet to decide if this is one of your problematic patterns of thinking. What else can I say instead of Column B? How else can I interpret the event instead of Column B? Rate belief in alternative thought(s) from 0-100% C. Emotion(s) Specify sad, angry, etc., and rate how strongly you feel each emotion from % Evidence? Habit or Fact? Interpretations not accurate? All or none? Extreme or exaggerated? Out of context? Source unreliable? Low versus high probability? Based on feelings or facts? Irrelevant factors? Jumping to conclusions Exaggerating or minimizing Disregarding important aspects Oversimplifying Overgeneralizing Mind reading Emotional reasoning G. Re-rate how much you now believe the thought in Column B from 0-100% H. Emotion(s) Now what do you feel? 0-100%

108 108 Challenging Beliefs Worksheet Jumping to conclusions Exaggerating or minimizing Disregarding important aspects A. SituationB. ThoughtsD. Challenging ThoughtsE. Problematic patterns F. Alternative Thought Describe the event, thought or belief leading to the unpleasant emotion(s). Write thought(s) related to Column A. Rate belief in each thought below from 0-100% (How much do you believe this thought?) Use Challenging Questions to examine your automatic thoughts from Column B. Is the thought balanced and factual or extreme? Use the Problematic Thinking Patterns sheet to decide if this is one of your problematic patterns of thinking. What else can I say instead of Column B? How else can I interpret the event instead of Column B? Rate belief in alternative thought(s) from 0-100% I feel uncomfortable and unsafe with Asian people While I was in VN I couldn’t tell friend from foe. It was impossible to tell who was the enemy and might try to kill me. 80% C. Emotion(s) Specify sad, angry, etc., and rate how strongly you feel each emotion from 0-100% Fear 70%, Anger 50%, Frustration 50% Evidence? For: This did happen in VN.. Against: That was a long time ago in a totally different environment. Habit or Fact? It has become a habit to distrust all people, especially Asians. Low versus high probability? There is a low probability that any Asian would try to harm me. Based on feelings or facts? My feelings are derived from my service in VN. Are they relevant today? They are not relevant today. Irrelevant factors? Jumping to conclusions I am drawing the conclusion that all Asian people are untrustworthy and dangerous to me. Exaggerating or minimizing Disregarding important aspects Oversimplifying Overgeneralizing Mind reading Emotional reasoning Because I feel scared around Asian people, I am in danger around them. Because of my time in VN, I have some understandable, but irrelevant, feelings around Asian people. As a group, they are not dangerous to me. 90% G. Re-rate how much you now believe the thought in Column B from 0-100% 40% H. Emotion(s) Now what do you feel? 0-100% Fear 50% Anger 20% Frustration 30%

109 109 Session 7. Introduce Safety Beliefs related to Self –Belief you can protect yourself from harm and have some control over events –Associated symptoms include anxiety, intrusive thoughts about danger, irritability, startle responses, intense fears about future dangers

110 110 Session 7. Introduce Safety Beliefs related to Others –Belief abut dangerousness of other people and expectancies about the intent of others to cause harm, injury, or loss –Symptoms include avoidant or phobic responses, social withdrawal

111 111 Session 7. Group Notes Check-in/Group time Have each person identify their most problematic thinking patterns and talk about how they affect one’s life. Do Challenging Beliefs Worksheet together as a group on a common stuck point such as “I must be on guard or bad things will happen to me”

112 112 Session 7. Practice Assignment “Use the Challenging Beliefs Worksheets to analyze and confront at least one of your stuck points each day. Please read over the module on safety and think about how your prior beliefs were affected by the [event]. If you have safety issues related to yourself or others, complete at least one worksheet to confront those beliefs. Use the remaining sheets for other stuck points or for distressing events that have occurred recently.”

113 113 Session 8. CBW and Safety Patient and therapist review worksheets. Patient and therapist discuss safety issues. Therapist introduces Trust module.

114 114 Session 8 Using Challenging Beliefs Worksheet to Address Safety “Stacy”

115 115 Role-Playing Activity on CBW and Safety Issues

116 116 Session 8. Introduce Trust Beliefs related to Self –Belief you can trust or rely upon one’s own perceptions or judgments. Important part of self-concept and serves important self-protection function. – Associated symptoms include feelings of self-betrayal, anxiety, confusion, overcautious, inability to make decisions, self-doubt.

117 117 Session 8. Introduce Trust Beliefs related to Others –Belief that the promises of other people or groups with regard to future behavior can be relied upon. A person needs to learn a healthy balance of trust and mistrust and when each is appropriate. –Associated symptoms include disillusionment, fear of betrayal, anger and rage, suspiciousness, fleeing from relationships.

118 118 Session 8. Group Notes Check-in/Group time Each member discusses their Challenging Beliefs Worksheet. Encourage patients to help each other identify dysfunctional thinking. Do a Challenging Beliefs Worksheet together as a group if needed. What risks do you take in group and in your daily life? If this were the last group what would you regret not getting out of group?

119 119 Session 8. Practice Assignment “Please read the Trust Module and think about your beliefs prior to experiencing [event] as well as how the event changed or reinforced those beliefs. Use the Challenging Beliefs Worksheets to continue analyzing your stuck points. Focus some attention on issues of self or other-trust, as well as safety, if these remain important stuck points for you.”

120 120 Session 9. Trust Issues Patient and therapist review practice on trust issues and other completed Challenging Beliefs Worksheets. Therapist introduces Power/Control module.

121 121 Role-Playing Activity on CBW and Trust

122 122 Session 9. Introduce Power/Control Beliefs related to Self –Belief you can solve problems and meet challenges. Associated with capacity for self- growth. Belief one must be in control of oneself at all times Belief one is helpless to control anything –Symptoms include numbing, avoidance of emotions, passivity, hopelessness, depression, self-destructive patterns, outrage when events seem out of control.

123 123 Session 9. Introduce Power/Control Beliefs related to Others –Belief that others have more control than you do; that others have power or attempt to control you. – Associated symptoms include passivity, submissiveness, lack of assertiveness, or conversely, anger, controlling behavior.

124 124 Session 9. Group Notes Check-in/Group time Each person shares at least one Challenging Beliefs Worksheet Discuss cues that someone is trustworthy Identify trust beliefs by using the thoughts they had of each other when group first started compared to current thoughts

125 125 Session 9. Practice Assignment “Use the Challenging Beliefs Worksheets to continue to address your stuck points. After reading the Power/Control Module and thinking about it, complete worksheets on this topic.”

126 126 Session 10. Power and Control Patient and therapist review control/power issues and other Challenging Beliefs Worksheets Therapist introduces Esteem module.

127 127 Session 10 Using Challenging Beliefs Worksheet to Address Control “Carol”

128 128 Session 10. Introducing Esteem Beliefs related to Self –Belief in your own worth. Being understood, respected, and taken seriously is basic to the development of self-esteem. –Symptoms include depression, guilt, shame, self-destructive behavior.

129 129 Session 10. Introducing Esteem Beliefs related to Others –Beliefs about other people that match the reality of the other person and are revised as new information is received. –Examples: People are uncaring, indifferent, selfish People are bad, evil, or malicious. –Symptoms include anger, contempt, bitterness, cynicism, isolation or withdrawal, antisocial behavior.

130 130 Session 10. Group Notes Check-in/Group time Discuss ways of giving and taking power negatively and positively. Have group members generate ways in which they do all 4 of these, perhaps even in the group.

131 131 Session 10. Practice Assignment “After reading the Esteem Module, use the worksheets to confront stuck points regarding self- and other-esteem. In addition to the worksheets, practice giving and receiving compliments during the week and do at least one nice thing for yourself each day (without having to earn it). Write down on this sheet what you did for yourself and who you complimented.”

132 132 Session 11. Esteem Issues Patient and therapist review esteem issues and other Challenging Beliefs Worksheets. Patient and therapist review other practice. Therapist introduces Intimacy module.

133 133 Session 11 Using Challenging Beliefs Worksheet to Address Esteem “Stacy”

134 134 Session 11. Introducing Intimacy Beliefs related to Self –Self-intimacy is ability to soothe and calm oneself. Reflected in the ability to be alone without feeling lonely or empty. – Associated symptoms include inability to comfort or soothe self, fear of being alone, feeling of inner emptiness or deadness, use of external sources of comfort, needy or demanding relationships.

135 135 Session 11. Introducing Intimacy Beliefs related to Others –Need for intimacy, connection, and closeness is a basic human need. This can be damaged through insensitive, hurtful, or non-empathic responses from others. –Associated symptoms include loneliness, emptiness or isolation, inability to connect with others.

136 136 Session 11. Group Notes Check-in/Group time Discuss pressure group members may be putting on themselves to be further along in treatment or comparing themselves to each other Discuss worry they may have about aftercare

137 137 Session 11. Practice Assignment “Use the Intimacy Module and Challenging Beliefs Worksheets to confront stuck points regarding self- and other-intimacy. Continue completing worksheets on previous topics that are still problematic. Please write at least one page on what you think now about why this traumatic event(s) occurred. Also, consider what you believe now about yourself, others, and the world in the following areas: safety, trust, power/control, esteem, and intimacy.”

138 138 Session 12. Intimacy and Final Impact Patient and therapist review Challenging Beliefs Worksheets on intimacy Patient reads new Impact Statement Patient and therapist review course of therapy and skills learned Patient and therapist identify future goals and issues which still need attention

139 139 Session 12 Final Impact Statement “Carol”

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142 142 Session 12. Group Notes Check-in/Group time Patients read new Impact Statements Ask group members to identify changes they have seen occur in each other Discuss ways of staying in touch after the group ends

143 143 Recommended Readings for Learning Cognitive Therapy Approach Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press. Wright, J., Basco, M., & Thase, M. (2006). Learning cognitive-behavior therapy: An Illustrated guide. New York: American Psychiatric Press.


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