Learn a comprehensive approach for trauma and PTSD in our CBT for Trauma virtual workshop.
Norman Cotterell, Ph.D. Senior Clinical Psychologist, Beck Institute for Cognitive Behavior Therapy
Posttraumatic Stress Disorder (PTSD) refers to a problematic and prolonged response to traumatic events. Ehlers and Clark (2000) note its puzzling nature, identified by both inattention and hyper-arousal, by memories that won’t go away and others that cannot be found, and by both recklessness and an excessive desire for safety. Rothbaum (2006) describes it as a failure of natural recovery.
Mike, a 49 year old production packer, was involved in an accident and suffered 3rd degree burns on the back of his right hand. He is right handed. He remembers watching the machine coming down on his hand. He remembers in vivid detail the smell of burning flesh.
Mike’s initial response is matter-of-fact. He tells his wife, “Everything is fine.” He makes it through surgeries and skin grafts without much overt difficulty. But he doesn’t own up to any emotional distress. So he misses out on the emotional support that could have helped him process the trauma. Why does he fail to reveal his feelings? One key belief he holds is, “If I reveal any vulnerability, people will lose faith in me and view me as weak.”
Shortly after the medical procedures are finished, Mike experiences cognitive intrusions: flashbacks and nightmares. While these intrusions are distressing, what is more distressing is the special meaning he puts to them. “[They show] I can’t control my own mind.” Dissociative amnesia is further evidence to Mike of his loss of control.
His perceived loss of control leads to Mike’s experiencing intense and distressing negative emotions. He feels highly anxious, sad, and ashamed. “I should be able to cope. I’m weak.” The experience of negative emotion, too, leads Mike to feel out of control. His core beliefs — “I’m out of control. I’m helpless. I’m weak. I can’t function” — become fully activated. He sees himself as being in grave danger, not from an external threat, but from one that he cannot escape. No matter where he goes, his mind goes with him. Mike adopts a battlefield mentality. He is alert, on-guard, aggressive, unable to sleep. Because he views this extreme mentality as unwarranted(“It’s only a burned hand!“) — he takes these symptoms as proof of his weakness.
Mike also engages in extensive behavioral avoidance. He believes he must avoid all that he loves, or risk tainting it with insanity. He also engages in emotional avoidance through the use of alcohol. But avoidance fuels his belief of weakness. He is in a double bind: “If I avoid, I’m in control, I can function. But If I avoid, it means I’m helpless, defective, out of control. But if I don’t avoid, I’m in danger.”
To summarize, when individuals develop PTSD, they put dysfunctional meanings to their symptoms: intrusions, cognitions, emotions, avoidance, and arousal, among others. Their dysfunctional behaviors and the intensity of their emotions are understandable once we grasp the assumptions they are making. Their assumptions make sense once we comprehend the core beliefs that have become activated. The trauma itself doesn’t directly lead to PTSD; rather it is the meanings they attribute to the trauma, to their cognitive, emotional, physiological, and behavioral symptoms, and to their changed circumstances that are more closely tied to the development of the disorder.
Readings:
Ehlers, A. & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder, Behaviour Research and Therapy 38, 319-345.
Foa, E.B., Hembree, E.A., & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD. Oxford: Oxford University Press.
Morris, D. (2015). The Evil Hours. New York: Houghton Mifflin Harcourt.
Resick, P. A. (2001). Cognitive therapy for posttraumatic stress disorder. Journal of Cognitive Psychotherapy, 15(4), 321 – 329.
Rothbaum, B.O. (2006). Virtual Vietnam: Virtual Reality Exposure Therapy. (2006). In M. Roy (Ed.), Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder. Amsterdam: IOS Press.
US Dept of Veteran’s Affairs: How common is PTSD? PTSD: National Center for PTSD. (n.d.). Retrieved May 26, 2015, from https://www.ptsd.va.gov/PTSD/public/PTSD-overview/basics/how-common-is-ptsd.asp