The negative outcomes of past intuitive treatment reinforced one of the most common and fundamental beliefs of PTSD: “I am incompetent.” The woman perceived through past experiences in and out of therapy that something within her was so broken that she was beyond help, leading to a cycle of hopelessness, suicidality, and treatment avoidance.
To reduce or eliminate the experiences of non-fear emotions, such as shame and guilt, the individual needs to correct these unhelpful and inaccurate cognitions using CBT exposure strategies.
Depressed clients often isolate themselves from others and withdraw from life. A depressed client of mine I’ll call Adam did exactly this. He began feeling depressed after his marriage ended. He stopped responding to calls and social invitations from friends and family members. He also stopped going to the gym and gave up his favorite hobby, golfing. When clients withdraw from life, they give up any chance of meaningful or pleasurable experiences, so their depression is more likely to continue and become more intense.
To counter the isolation and withdrawal common to depression, therapists can introduce behavioral activation. This strategy entails getting clients more active and involved in life by scheduling activities that have the potential to improve their mood. Research suggests that behavioral activation alone is an evidence-based treatment for depression, and may be particularly well-suited for chronically depressed clients (Sturmey, 2009). The following tip from the Beck Institute therapists can help make behavioral activation even more effective.
It’s important to focus on valued or meaningful activities instead of, or in addition to pleasurable activities as part of behavioral activation. Many depressed clients (especially those with chronic or severe depression) state that there aren’t any activities that give them a sense of pleasure. They may also come to the following session feeling frustrated and hopeless because they didn’t enjoy the activities as much as they had before they became depressed, or they didn’t enjoy them at all. While emotions and moods are temporary, values tend to be more stable and can serve as a guide for behavioral activation. We can obtain the client’s values by listing different value categories and then asking the client to rate the strength of each category from 0 (not valuing it at all) to 10 (the most they can value something). The categories we include are work, self-education/learning, volunteering, intimacy, family, friendship, religion/spirituality, entertainment/recreation, and health/fitness. Adam’s most valued categories were friendship (10), family (9), recreation/entertainment (8), and health/fitness (8).
The client’s value ratings indicate the best place to begin with behavioral activation. Start with the highest value rating, which, for Adam, was friendship. We ask our clients, “Why is [the value] important to you?” Adam responded that friendship was important to him because it provided mutual support and shared experiences. We then ask the client to list specific, concrete activities that make up the value category. For friendship, Adam’s list of activities included: poker night, golfing, watching sports together, going out to dinner, and regular phone calls. We then repeat these steps for the remaining high value categories. Typically, we won’t ask about a category if the client rated it below a 5 out of 10.
Finally, we help the client decide which valued activities to engage in. Instead of telling the client what to do, we collaboratively ask the client which activities they want to schedule. In his friendship category, Adam decided to call his friend, Matt, to inform him that he would be attending their weekly poker night on Wednesday. During poker night, Adam decided to seek support from his friends by talking about having a difficult time after his divorce and making additional plans for the weekend with whoever was available. He agreed to suggest they play a round of golf on Sunday.
Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression. Behavior Modification, 33, 818-829.
Learn more about treating depression at the CBT for Depression and Suicide workshop.
Aims: Individual interviews were conducted and analyzed to learn about the engagement of suicidal veterans in safety planning.
Method: Twenty suicidal veterans who had recently constructed safety plans were recruited at two VA hospitals. In semistructured interviews, they discussed how they felt about constructing and using the plan and suggested changes in plan content and format that might increase engagement.
Results: The veterans’ experiences varied widely, from reviewing plans often and noting symptom improvement to not using them at all and doubting that they would think of doing so when deeply depressed.
Conclusion: The veterans suggested ways to enrich safety planning encounters and identified barriers to plan use. Their ideas were specific and practical. Safety planning was most meaningful and helpful to them when they experienced the clinician as a partner in exploring their concerns (e.g., fear of discussing and attending to warning signs) and collaborating with them to devise solutions.
Kayman, J. D., Goldstein, F. G., Dixon, L., & Goodman, M. (October 27, 2015). Perspectives of suicidal verterans on safety planning: Findings from a pilot study. The Journal of Crisis Intervention and Suicide Prevention, 36, 371-383.
Worried about their reputation and career prospects, returning service members with PTSD may avoid seeking treatment. In a randomized controlled trial, the authors examined engagement in treatment and symptoms among veterans with PTSD who received a brief phone-based intervention to discuss why they had avoided treatment. Veterans who received a call entered treatment sooner and experienced more immediate reductions in PTSD symptoms than veterans who received usual care. By six months, differences between the two groups had faded, suggesting that adding a second phone call might be warranted.
Many service members do not seek care for mental health and addiction problems, often with serious consequences for them, their families, and their communities. This study tested the effectiveness of a brief, telephone-based, cognitive-behavioral intervention designed to improve treatment engagement among returning service members who screened positive for posttraumatic stress disorder (PTSD).
Service members who had served in Operation Enduring Freedom or Operation Iraqi Freedom who screened positive for PTSD but had not engaged in PTSD treatment were recruited (N=300), randomly assigned to either control or intervention conditions, and administered a baseline interview. Intervention participants received a brief cognitive-behavioral therapy intervention; participants in the control condition had access to usual services. All participants received follow-up phone calls at months 1, 3, and 6 to assess symptoms and service utilization.
Participants in both conditions had comparable rates of treatment engagement and PTSD symptom reduction over the course of the six-month trial, but receiving the telephone-based intervention accelerated service utilization (treatment engagement and number of sessions) and PTSD symptom reduction.
A one-time brief telephone intervention can engage service members in PTSD treatment earlier than conventional methods and can lead to immediate symptom reduction. There were no differences at longer-term follow-up, suggesting the need for additional intervention to build upon initial gains.
Stecker, T., McHugo, G., Xie, H., Whyman, K., & Jones, M. (January 01, 2014). RCT of a brief phone-based CBT intervention to improve PTSD treatment utilization by returning service members. Psychiatric Services (washington, D.c.), 65, 10, 1232-7.
Marjan G. Holloway, Ph.D., Beck Institute Faculty
As an educator, I have noticed that two subgroups of clients are highly likely to activate anxiety and other types of emotional distress (e.g., professional burnout) among clinicians. The first subgroup consists of traumatized clients and the second subgroup consists of suicidal clients. When working with clients who are traumatized and suicidal, the potential for therapy-interfering emotions such as excessive worry and therapy-interfering behaviors such as avoidance on the part of the clinician notably increases. These problematic emotional and behavioral reactions often stem from a series of maladaptive clinician cognitions, as described below.
- All-or-None Thinking (Example: “After months of therapy, nothing has changed.”)
- Catastrophic Thinking (Example: “If I ask too many questions about the traumatic event, the client will deteriorate, fall apart, and may even become suicidal.”)
- Labeling (Example: “This client is resistant to change – wants to remain a victim.”)
- Personalizing (Example: “As an incompetent therapist, it’s my fault that the client remains symptomatic.” )
We have all been there. I recall my excitement after having received a new client referral in the early years of my practice. This excitement quickly transformed to anxiety, indecisiveness, and self-doubt as I learned about this particular client’s history of multiple lifetime traumas and suicidal behaviors. I was terrified to accept the case as a newly licensed psychologist and I frankly questioned my ability to work effectively with the client (even after years of solid clinical training). Not surprisingly, I avoided taking the case. To address my sense of responsibility and guilt, I started to call other community clinicians and colleagues in private practice to find a good referral source. Very quickly, I discovered that other clinicians, regardless of their seasonality, were similarly not available to accept a “complex” trauma case who was also considered at high risk for suicide. As I listened to the justifications provided by these clinicians, I had an opportunity to examine my own beliefs about the client. I realized that these beliefs – along with my negative emotions – were dictating my decision to avoid.
During an upcoming 2016 Beck Institute Workshop on CBT for PTSD, I plan to review two evidence-based CBT interventions for trauma: Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007) and Cognitive Processing Therapy (CPT; Resick & Schnicke, 1996). While each intervention has a different theoretical underpinning and technical approach, both emphasize the following:
- The importance of having the client understand (i.e., “digest”) the traumatic event
- The importance of having the client understand that the memory of the traumatic event, by itself, is not dangerous and therefore, not to be avoided
By repeated exposure to the memories associated with the traumatic event and/or repeated examination of the impact of the traumatic event, the traumatized client can gain a sense of control and mastery over the traumatic memories.
To date, there is no scientific evidence to suggest that asking about trauma-related and/or suicide-related content exacerbates psychiatric symptoms. CBT clinicians can learn to effectively manage their own anxiety and emotional distress, while working with this highly vulnerable client population, by engaging in the following recommended activities:
- Gaining continuing education in evidenced-based CBT for PTSD
- Being mindful of their own therapist maladaptive emotions, cognitions, and/or behaviors
- Seeking peer consultation and/or supervision, as needed
- Listening carefully to the trauma/suicide narratives of their clients in order to construct meaningful cognitive behavioral conceptualizations for treatment planning
- Paying close attention to self-care and early signs of professional burnout
Working with traumatized clients is certainly not easy. However, we as CBT clinicians have the responsibility to intervene, rather than to avoid. Prolonged Exposure and Cognitive Processing Therapy are two CBT-oriented treatment packages that are evidence-based. Gaining familiarity and future competency in delivering these interventions will certainly prove to be beneficial to your clients and to you.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide. New York, NY: Oxford University Press.
Ghahramanlou-Holloway, M., Neely, L., & Tucker, J. (2014). A cognitive-behavioral strategy for preventing suicide. Current Psychiatry, 13(8), 18-25.
Resick, P. A., & Schnicke, M. K. (1996). Cognitive processing therapy for rape victims. Newbury Park, Sage Publications.
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Objective: The authors evaluated the effectiveness of brief cognitive-behavioral therapy (CBT) for the prevention of suicide attempts in military personnel.
Method: In a randomized controlled trial, active-duty Army soldiers at Fort Carson, Colo., who either attempted suicide or experienced suicidal ideation with intent, were randomly assigned to treatment as usual (N=76) or treatment as usual plus brief CBT (N=76). Assessment of incidence of suicide attempts during the follow-up period was conducted with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation with intent to die during the past week and/or a suicide attempt within the past month. Soldiers were excluded if they had a medical or psychiatric condition that would prevent informed consent or participation in outpatient treatment, such as active psychosis or mania. To determine treatment efficacy with regard to incidence and time to suicide attempt, survival curve analyses were conducted. Differences in psychiatric symptoms were evaluated using longitudinal random-effects models.
Results: From baseline to the 24-month follow-up assessment, eight participants in brief CBT (13.8%) and 18 participants in treatment as usual (40.2%) made at least one suicide attempt (hazard ratio=0.38, 95% CI=0.16–0.87, number needed to treat=3.88), suggesting that soldiers in brief CBT were approximately 60% less likely to make a suicide attempt during follow-up than soldiers in treatment as usual. There were no between-group differences in severity of psychiatric symptoms.
Conclusions: Brief CBT was effective in preventing follow-up suicide attempts among active-duty military service members with current suicidal ideation and/or a recent suicide attempt.
Rudd, M. D. (January 01, 2015). Brief Cognitive-Behavioral Therapy Effects on Post-Treatment Suicide Attempts in a Military Sample: Results of a Randomized Clinical Trial With 2-Year Follow-Up. American Journal of Psychiatry, 172, 5, 441-449.
Beck Institute for Cognitive Behavior Therapy is a leading international source for training, therapy, and resources in CBT.
Soldiers Suicide Prevention (Beck Institute) is a Combined Federal Campaign (CFC) Approved Charity: CFC # 11590
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