Conceptualizing Trauma: Identifying Key Cognitions in CBT for PTSD

Stefanie T. LoSavio, PhD, ABPP, Beck Institute Faculty

Trauma is ubiquitous in mental health settings, and many clients suffer from posttraumatic stress disorder (PTSD). Fortunately, PTSD is treatable, especially with Cognitive Behavior Therapy (CBT). Clinical practice guidelines recommend CBT that is “trauma-focused,” which involves approaching the trauma memory directly so that recovery can occur.

In CBT, we work to identify key cognitions—thoughts that, if addressed, are most likely to lead to symptom improvement. When considering key cognitions to address in trauma-focused CBT, it’s important to identify beliefs about the trauma itself, not just the consequences. This article will provide tips for enhancing the effectiveness and efficiency of trauma-focused CBT by identifying your clients’ key trauma cognitions.

Why Is Your Client Stuck with PTSD?

What kind of beliefs have you noticed in your clients with PTSD? It’s common for clients to have negative beliefs about themselves, others, and the world like, “No one is trustworthy,” and “I’m unlovable.” When we come across these beliefs, we know that they are ripe for exploration. However, these may not be the cognitions most at the root of their PTSD. They may be consequences of the trauma, but what about their beliefs about the trauma itself? As clinicians, we must consider how these overgeneralized beliefs might have developed and assess for related, underlying beliefs about the trauma itself—why it happened, what caused it, and how it could have been prevented.

Let’s take the example of “I’m unlovable,” which is certainly an important belief. Maybe it’s even a core belief—a long and deeply held belief that serves as the lens through which new experiences are viewed. If you have a client who you suspect may hold this belief, you ultimately will want to help them evaluate it. But where did the idea “I’m unlovable” originally come from?  Is it related to the trauma?

I was working with a client, “Chris,” who was suffering from PTSD from childhood physical abuse perpetrated by his mother. It was clear that Chris was struggling with his self-esteem. No matter how much he achieved, he still felt he was not good enough. Although Chris had colleagues who were interested in getting to know him, he remained isolated, avoiding social interactions, and refusing to disclose details about himself. He worried that people might get to know the “real” him and discover how “unlikeable” he was. You might already be recognizing beliefs such as, “I’m not good enough,” and “If people get to know me, they won’t like me.” However, where did these beliefs come from? How did he come to believe he’s not good enough and unlikeable? Does it have something to do with his thoughts about why his trauma occurred? 

Chris and I talked about how he was making sense of his childhood abuse. I was curious if he thought any of the ideas that were coming up in his everyday life—that he’s not good enough or not likeable—were related to why he thought his trauma happened. Working backwards from his beliefs about himself in general, I wondered if he thought his mom abused him because of something “bad” about him or not being “good” or “likeable” enough. Sure enough, Chris agreed that, while he had never really thought too deeply about it before I had asked, he did think that his mother must have abused him because he was bad and unlikeable. Individuals who have suffered childhood abuse frequently come to this kind of conclusion. Children are apt to think, “If something bad happens to me, it must be because I’m bad or I did something wrong.” So, it makes sense that Chris came to that conclusion, and that he then generalized it to mean that he’s not likeable or lovable overall. 

In treatment, we first worked to address Chris’s beliefs that his mom abused him because he was bad and unlovable. The specific case of his trauma was an important starting point. As we used guided discovery to examine these beliefs, Chris was able to re-consider these ideas and ultimately decided that no kid is unlovable, he had not behaved particularly badly, and, even if he had, it wouldn’t have justified his mother’s actions. Ultimately, he concluded that his mother’s abuse said more about her than it did about him. With that important trauma processing work behind us, Chris was in a much better position to examine the more overgeneralized beliefs about himself. Although he had been viewing his experiences through the lens of these beliefs for a long time, he was now able to examine whether these beliefs were true overall.

Chris made great progress resolving not only his beliefs about the trauma but also about the consequences. But targeting the beliefs in that order set him up for success because addressing the beliefs about the cause of the trauma helped weaken the broader beliefs.

How to Identify Key Cognitions About the Trauma

As you work with clients with PTSD, I recommend exploring their beliefs about the trauma itself to uncover key cognitions. You might ask the following questions:

• I want to understand what sense you’ve made of the trauma so far. What do you think are the reasons why the trauma occurred?
• Sometimes people blame themselves or others who weren’t directly responsible for the trauma. Has that been going on for you? Who do you think is to blame for what happened?
• Oftentimes people think about things they “could” or “should” have done differently, or think, “If only I had done such and such, then it wouldn’t have happened. Do you have any “shoulda-coulda-wouldas” or “if onlys” about this event?
• Do you have any thoughts about why this happened to you or why you had to experience it?  Sometimes people think it was something about them. Do you have any thoughts like these?

Clients with PTSD commonly struggle with one or more of the following thoughts. Discussing these thoughts with your client can help start the conversation:

• It’s my fault it happened.
• I could have prevented it.
• It happened because of something about me.
• It happened because I did something wrong.
• If only I did ______ differently, it never would have occurred.

Notice how these thoughts are about the trauma itself. While thoughts about the present and future also affect clients, research has shown that targeting beliefs about the trauma early in treatment can lead to greater PTSD symptom improvement. 

If you do notice more overgeneralized beliefs, you can also try to work backwards to identify key cognitions about the trauma itself, like I did with Chris. Consider the following examples:

Conclusion

As with any course of CBT, conceptualization is key. Take some time to reflect on what might be the key cognitions of your clients with PTSD. Addressing beliefs about the trauma itself can help get clients get unstuck and on the road to recovery.

References:

American Psychological Association (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. Available at: https://www.apa.org/ptsd-guideline/ptsd.pdf

Farmer, C. C., Mitchell, K. S., Parker-Guilbert, K., & Galovski, T. E. (2017). Fidelity to the cognitive processing therapy protocol: Evaluation of critical elements. Behavior Therapy, 48(2), 195-206.

National Institute for Health and Care Excellence (2018). NICE guideline: Posttraumatic stress disorder. Available at: https://www.nice.org.uk/guidance/ng116/resources/posttraumatic-stress-disorder-pdf-66141601777861

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About the Author

Stefanie LoSavio, PhD, ABPP is a licensed and board-certified psychologist and a Beck Institute Certified CBT Therapist and Faculty Trainer who specializes in trauma and PTSD. Dr. LoSavio is co-author of the new book, Getting Unstuck from PTSD: Using Cognitive Processing Therapy to Guide Your Recovery.