PTSD and Cognitive Processing Therapy

Presented by

Patricia A. Resick, PhD, ABPP

2016 ABPP Annual Conference & Workshops

Chicago, IL
Saturday, May 14, 2016
Exposure to actual or threatened a) death, b) 
serious injury, or c) sexual violation, in one or  Presence of one or more of the following intrusion 
more of the following ways: symptoms associated with the traumatic event(s), 
1. Directly experiencing the traumatic event(s)  beginning after the traumatic event(s) occurred:
2. Witnessing, in person, the traumatic event(s) as they  1. Spontaneous or cued recurrent, involuntary, and 
occurred to others intrusive distressing memories of the traumatic event(s).
3. Learning that the traumatic event(s) occurred to a close  2. Recurrent distressing dreams in which the content or 
family member or close friend; cases of actual or threatened 
death must have been violent or accidental affect of the dream is related to the event(s) 
4. Experiencing repeated or extreme exposure to aversive  3. Dissociative reactions (e.g., flashbacks) in which the 
details of the traumatic event(s) (e.g., first responders  individual feels or acts as if the traumatic event(s) are 
collecting human remains; police officers repeatedly exposed  recurring (such reactions may occur on a continuum, with 
to details of child abuse); this does not apply to exposure 
through electronic media, television, movies, or pictures,  the most extreme expression being a complete loss of 
unless this exposure is work‐related. awareness of present surroundings. 

Presence of one or more of the following 
intrusion symptoms associated with the  C. Persistent avoidance of stimuli associated with the 
traumatic event(s), beginning after the traumatic  traumatic event(s), beginning after the traumatic 
event(s) occurred: event(s) occurred, as evidenced by avoidance or efforts 
4. Intense or prolonged psychological distress at exposure 
to avoid one or more of the following:
to internal or external cues that symbolize or resemble an  1. Distressing memories, thoughts, or feelings about or 
aspect of the traumatic event(s) closely associated with the traumatic event(s)
5. Marked physiological reactions to reminders of the  2. External reminders (i.e., people, places, 
traumatic event(s) conversations, activities, objects, situations) that arouse 
distressing memories, thoughts, or feelings about, or 
that are closely associated with, the traumatic event(s)
Negative alterations in cognitions and mood  Negative alterations in cognitions and mood 
associated with the traumatic event(s), beginning or 
worsening after the traumatic event(s) occurred), as  associated with the traumatic event(s), beginning or 
evidenced by two or more of the following: worsening after the traumatic event(s) occurred), as 
1. Inability to remember an important aspect of the  evidenced by two or more of the following:
traumatic event(s) (typically due to dissociative amnesia that 
is not due to head injury, alcohol, or drugs). 4. Persistent negative emotional state (e.g., fear, horror, 
2. Persistent and exaggerated negative beliefs or  anger, guilt, or shame).
expectations about oneself, others, or the world (e.g., “I am  5. Markedly diminished interest or participation in 
bad,” “No one can be trusted,” "The world is completely 
dangerous"). (Alternatively, this might be expressed as, e.g.,  significant activities.
“I’ve lost my soul forever,” or “My whole nervous system is  6. Feelings of detachment or estrangement from others.
permanently ruined”).
3. Persistent, distorted blame of self or others about the  7. Persistent inability to experience positive emotions 
cause or consequences of the traumatic event(s). (e.g., unable to have loving feelings, psychic 
numbing).

Marked alterations in arousal and reactivity associated  F. Duration of the disturbance (Criteria B, C, D, and 
with the traumatic event(s), beginning or worsening  E) is more than 1 month.
after the traumatic event(s) occurred, as evidenced by  G. The disturbance causes clinically significant 
two or more of the following:
distress or impairment in social, occupational, or 
1. Irritable or aggressive behavior
other important areas of functioning.
2. Reckless or self‐destructive behavior
3. Hypervigilance
H. The disturbance is not attributed to the direct 
physiological effects of a substance (e.g., 
4. Exaggerated startle response
medication, drugs, or alcohol) or another medical 
5. Problems with concentration
condition (e.g. traumatic brain injury).
6. Sleep disturbance (e.g., difficulty falling or staying 
asleep or restless sleep)
Subtype: Posttraumatic Stress Disorder – With 
Prominent Dissociative 
(Depersonalization/Derealization) Symptoms
A.The individual meets the diagnostic criteria for PTSD and 
in addition experiences persistent or recurrent symptoms of 
A1, A2, or both:
A1. Depersonalization: Experiences of feeling detached from, and as if  A Functional Model 
one is an outside observer of, one’s mental processes or body (e.g., 
feeling as though one is in a dream, sense of unreality of self or body, 
or time moving slowly.
of 
A2. Derealization: Experiences of unreality of one’s surroundings (e.g., 
world around the person is experienced as unreal, dreamlike, distant, 
or distorted)
Posttraumatic Stress 
B. The disturbance is not due to the direct physiological 
effects of a substance (e.g., blackouts, or behavior during 
Disorder
alcohol intoxication), or another medical condition (e.g., 
complex partial seizures).

If the event is severe enough, nearly everyone

will have symptoms reflective of PTSD.

Let’s start with the most 
homogeneous severe event:

rape 2 12 2 12
= Resick et al. = Riggs et al.
 30
PTSD

25 Non-PTSD

20
PTSD Severit y Score

15
Let’s rearrange and think 
10
about post‐trauma 
5
symptoms a bit differently
0 Weeks
1 2 3 4 5 6 7 8 9 10 11 12

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, 455-475.

Emotions
Cognitions
Persistent negative
Guilt/self-blame
Erroneous other Emotions
Lack of positive emotions
E blame
Detachment from others
V Intrusions Negative beliefs
E about future, self,
E Flashbacks V
others
Cognitions and
amnesia
N E Emotions
T N
T Intrusions
 irritable or aggressive 
behavior
reckless or self‐destructive 
behavior
problems with concentration
sleep disturbance Intrusions
E Emotions/
V Intrusions Cogntions
E Arousal
Arousal/Reactivity reactivity
N
T Cognitions
When intrusions occur, natural emotions and arousal run their 
course and thoughts have a chance to be examined and 
corrected. It is an active “approach” process of dealing with the 
event.

• This list is not 
exhaustive
• Any behavior that 
serves to 
Intrusions escape/avoid 
reactivity
Cognitions/ /Arousal
reminders, negative 
emotions trauma‐related 
emotions, images or 
thoughts is 
functioning as 
Avoidance of avoidance
Core Reactions external reminders and
And internal reminders
 Intrusions
Arousal/
Cognitions reactivity Intrusions
emotions Arousal/
Cognitions, reactivit
emotions y

Core Reactions
Core Reactions Escape/Avoidance
Escape/Avoidance

Well‐modulated emergency 
response

PFC

Can change in  Amygdala
Amygdala
PTSD symptoms 
be top‐down as 
well as bottom‐ Brain stem
up?
Threat (UCS)
Resick and Rasmusson, 2010
 PTSD Response

Bremner et al 
1999b; Milad, 
PFC et al. 2009; 
Rauch et al 
1998, 2000; 
Shin, et al. 
2001
Amygdala What is the 
role of  Can we find 
cognition? another route to 
Brain stem
change?

Trauma Triggers
(CS)
Resick and Rasmusson, 2010

A. Match B. Label

Angry Afraid

C. Shapes

Hariri, Bookheimer &  John C. Mazziotta
(1999)
 How Cognitive Therapy 
May Work

PFC
match label

BL Amygdala
CE

Brain stem
CT forces the frontal lobe on‐line which 
Trauma focused inhibits the amygdala and prevents 
cognitive therapy extreme emotional responses, even while 
the trauma circuit is simultaneously & 
sufficiently activated.

Resick and Rasmusson, 2010

Throughout their lives, people are taking in information 
through all of their senses. 
These beliefs work as long as there is no contradictory 
information.
We work to organize all of that information (words, 
categories, schemas, etc.) in an attempt to understand, 
predict and control. Traumas that lead to PTSD are schema (belief) 
incongruent with prior positive beliefs and/or schema 
Most people are taught the “just world belief” by parents,  congruent with previous negative beliefs.
teachers, religions, culture.

Intrusive symptoms occur as a result of the inability to 
We tend to believe that good behavior is rewarded and  accommodate the information .

mistakes or bad behavior are punished.
 Once the trauma is over, it is a memory. It is 
important information that has to be 
integrated.

≈
People have three possibilities:
Beliefs Trauma
• The information matches and is incorporated.
• They change their view of the world/themselves 
to incorporate the new information.
• They change too much and interpret everything 
in light of this new information.

It is a just I must have done

world People can be something bad to I am a bad People cannot
trusted deserve this person be trusted I deserved it

I knew I

Beliefs ≈
STUCK
Trauma
It is my
fault Beliefs
≈
STUCK
Trauma
shouldn’t
have
trusted
him/her

I could have I have no control See, I have no

I am in control
prevented this over anything control
 I can get Bad things
close to Good people
happen to good
I can’t get do bad things
others people
close to
anyone

Betrayal RECOVERY Betrayal

Beliefs
≈
STUCK
Trauma Beliefs Trauma

I have power over

The world is many things, but not A different action
The world is safe all things might have had a bad
completely unsafe outcome

The therapist needs 
There are two types 
to determine which 
of emotions
Over‐ kind of emotion it is
Assimilation Natural emotions emanate 
accommodation
directly from the event and are  If natural, clients need to 
(about the  hard‐wired
(about present and  feel and let it run its 
past/trauma) • fight‐flight response → fear‐
future) anger
course. Natural emotions 
dissipate quickly
• Losses → sadness 
• Disgust → withdrawal

Manufactured emotions are 
produced by thoughts and  If manufactured, clients 
Undoing, (“if only, should have”) Conclusions, implications of trauma beliefs need to change their 
guilt or blame about trauma (“never, always, no one”, all re: 5 themes) • Self‐blame thoughts → guilt thinking.
• Other‐blame thoughts →anger 
or rage
Challenging avoidance. Substance abuse/dependence
Self‐harm/suicidality/homicidality
Dissipation of natural emotions.
Dissociation
Changes in interpretation about the  Literacy
event changes manufactured emotions  
(no habituation required). Other comorbidity
Clients learn not to over‐generalize their  Medications and other treatments
thinking about a single bad event to all 
people or themselves as people (just because  How early can you start?
an event has bad consequences, it doesn’t 
• Risk to re‐exposure (upcoming deployment)
have to have big implications).
• Sufficient skills needed to start?

CAPS‐5 interview for 
diagnosis, frequency 
Motivational interviewing techniques may be 
and severity (pre and 
helpful (advantages and disadvantages of 
post‐treatment)
avoidance)
• PTSD Checklist (PCL‐5)
Patient needs to believe that improvement is  Self‐report scales  • Beck Depression 
possible for him/her Inventory or other 
(PCL required weekly)
depression checklist
Patient needs to believe that he/she has the 
ability to tolerate therapy and has sufficient skills
www.ptsd.va.gov
Desire to approach needs to be stronger than 
desire to avoid.
Brief update (mood  Review of practice 
and PTSD symptoms) assignment Setting new practice assignment
• Objective symptom  • Reviewing practice 
measures reinforces completion • Review rationale
• Complete practice  • Content is the “meat” of 
assignment review (“Let’s  the session • Explain the concept and new 
go over your worksheets”  • Use Socratic dialogue and  assignment
rather than “How was  model challenging 
your week?”)
• Start assignment in session
thoughts
• Use relevant forms  • Problem solve any barriers to 
regardless of the content assignment completion

Also 12 sessions
Analyze, 
Impact 
Information  ABC sheets
statement
gathering, feelings Outline of CPT‐C in Part 3 of manual

Still trauma‐focused therapy
Challenging  Problematic 
Challenge
questions patterns
Major Changes:
• Session 3: assign more A‐B‐C practice
Challenging 
Change (CBW) Beliefs  Themes • Session 4: Introduce Challenging Questions
Worksheet • Session 6: Introduction of Challenging Beliefs Worksheet 
WITHOUT Safety Module
• Session 7: Introduce Safety Module
 1. Describe symptoms of PTSD (handout)

2. PTSD as a disorder of non‐recovery

3. Fight‐flight‐freeze reactions

4. Cognitive theory of PTSD

• Just world belief
• Assimilation versus over‐accommodation
• Goal of accommodation

5. Types of emotions 7. Stuck points
• Natural emotions result directly from event‐ • Handout
the hardwired response (goal is to feel them  • Log
and let them run their course).
• Manufactured emotions are based on  8. Anticipating avoidance and 
interpretations of the event (goal is to  increasing practice compliance
change the thought, which changes the 
emotion).
9. Overview of treatment
6. Choosing index traumatic event
There are two logs Thoughts not 
Black and white All or nothing
Patient log & therapist log feelings

The stuck point log is a living document (keep adding to 
it):
Thought behind 
Use it for ABC sheets (B Column) the moral  If/then  Not always 
Use it for CQW & PPT statement or  statements “I statements”
golden rule
Use it for CBW
Use it to ID SPs based on 5 themes as they are introduced
Use it for pt to continue to identify SPs they need to work  Not always 
on AFTER treatment termination Not behaviors Concise linked to 
traumatic event

Goal: Patients examine impact of 
traumatic event on their lives.

Therapist determines whether this has been 
achieved uses this examination to increase 
motivation for change.

Patient  Review  Introduce 

Discuss  material  events‐ Help identify stuck points in 
reads  statement.
Impact  implications of  from  thoughts‐
Statement   statement first  feelings 
session relationship Ask about other areas that were not 
touched upon.

Highlight connection between 
thoughts and feelings.
 A-B-C Sheet

ACTIVATING EVENT BELIEF/STUCK POINT CONSEQUENCE

A B C
Using an example from impact statement  “Something happens” “ I tell myself something” “I feel something”
or something the patient has mentioned, 
introduce  concept of labeling events, 
thoughts and emotions

Use an example from life of how most 
events are open to interpretation

Is it reasonable to tell yourself “B” above? ___________________________________

______________________________________________________________________
What can you tell yourself on such occasions in the future?
Put example on worksheet _____________________________________________________________________
______________________________________________________________________________

A-B-C Sheet
ACTIVATING EVENT BELIEF/STUCK POINT CONSEQUENCE

A B C
“Something happens” “ I tell myself something” “I feel something”

Review A‐B‐C Worksheets
I was raped by my I must have done Guilty
friend. something that made Confused
Using Socratic questions, help  him think it was OK. Scared
patient generate alternative 
thoughts and consequent feelings
Is it reasonable to tell yourself “B” above?
_______________________________________________________________________
Gently begin to challenge  _______________________________________________________________________
undoing or self‐blame statements
What can you tell yourself on such occasions in the future?
_______________________________________________________________________
________________________________________________________________________________
At this point in therapy we do 
not strongly challenge 
maladaptive statements

Principles of Socratic 
More important to help clarify 
thoughts and feelings Dialogue 

Work gently with assimilation 
(self‐blame & undoing) 

ASK

Therapist asks questions to assist in  • Question everything!
• Don’t assume
challenging the accuracy of thought processes  • You can ask anything if you ask right
and rectifying those that have kept the patient 
BE on their team
from recovering
• Helps to externalize thoughts
• Decreases defensiveness
Cornerstone of CPT practice
Think (NOT act) CRITICALLY about their logic
• Get non‐judgmentally into their head
• Be curious, not confrontational or argumentative
C = Clarify C = Clarify
• Assimilation
• “What were your expectations for that mission?”
A = Assumptions • “What did you know about that road? Was there 
any reason to think that your buddy was in more 
danger than usual?”
R = Real evidence • Over‐accommodation
• “Your thought is that no people can be trusted?”
• “When you say that you have poor judgment what 
D = Deeper beliefs do you mean?”

A = Assumptions A = Assumptions (continued)
• Assimilation (hindsight, happily ever  • Over‐accommodation
after, and just world biases)
• “Have you been out on patrol and nothing 
• “At that time, did you consider breaking 
bad happened?”
protocol? Why not?”
• “Did the insurgent know that you were  • “Have you (or someone else) had alcohol 
single and your friend was married?” without being attacked?”
• “Why do you assume you could have  • “What would have happened if you broke 
saved him?” the rules to cover your buddy and he was 
killed anyway?”
 R = Real evidence R = Real evidence (continued)
• Assimilation • Over‐accommodation
• “What is the evidence that you would have  • “Looking at the other people in your life, why 
saved your friend?” would this person’s actions mean that other 
• “Why were you sent to the other location?” people are less trustworthy?”
• Did the unit commander intend for your  • In what ways can you trust the other people in 
friend to be killed?  Did he know there was  your life?
going to be an explosion? • “When you say “I have bad judgment, are you 
• “Who actually has the fault, who intended  talking about in every aspect? What about as a 
the harm?” parent/spouse, etc?

Content
D = Deeper Beliefs (meaning making)
• Make assumptions
• Assimilation • Go after over‐accommodation before assimilation
• “What does it mean about you that this event 
happened to you?” Process
• “What does it mean about other people?” • Rhetorical questions
• Have to be a cogent line of questioning
• Over‐accommodation
• Too convincing
• “What would that mean if you didn’t have  • Impatience
complete control?” • Inadvertently validate stuck point
• “What if you got close to someone and they  • Create power struggle
died?” • Not maintained balance between validation and challenge
 Had no options
• “If only I had done x, the 
Were there event would not have 
options at the Hindsight bias happened. I should have 
time? Statement not true.  known that x would 
Was it an option Acceptance.  Wishful  happen”
at the time?
Had considered options.  thinking • “Something bad 
Go through choices and  happened so someone 
NO Outcome based 
Yes possible outcomes (not just  must be to blame.  
Alt. thought‐ reasoning (just world) Everything happens for 
fantasies).
“I couldn’t have 
a reason”
stopped X”
Why did you not  Failing to differentiate 
choose it? Is it possible  between guilt (intent),  • “It is my fault that the 
that outcome would 
responsibility (played a  IED exploded and my 
have been worse? (put  men were killed”
role), and the 
in context)
unforeseeable.

How does this feel? Different?

Your Role in the Traumatic Event: 
What are the Facts? 
Below are a list of questions to be used in helping you
challenge your maladaptive or problematic beliefs/stuck
No way to  points. Not all questions will be appropriate for the
Unforeseeable predict it would  Grief/sadness
happen belief/stuck point you choose to challenge. Answer as
many questions as you can for the belief/stuck point
Played a role in 
you have chosen to challenge below.
the event but 
Responsible didn’t intend 
Regret
Belief/Stuck Point:_________________________________________
outcome
1. What is the evidence for and against this idea?
2. Is your belief a habit or based on facts?
Intended harm;  3. In what ways is your Stuck Point not including all the
Fault/Blame intended the  Guilty
information?
outcome
4. Are you thinking in all-or-none terms?
5. Does the Stuck Point include words or phrases that
are extreme or exaggerated? (i.e., always, forever,
never, need, should, must, can’t and every time).
6. In what ways is your Stuck Point focused on just one
piece of the story? Therapist introduces 
Patient and therapist 
7. Where did this study point come from: Is this a Patterns of 
review Challenging 
Problematic Thinking 
dependable source of information on this stuck point? Questions Worksheets 
Sheet to see if there are 
8. How is your Stuck Point confusing something that is to question single 
typical patterns of 
possible with something that is likely? statements or beliefs
cognition
9. In what ways is your Stuck Point based on feelings
rather than facts?
10. In what ways is this Stuck Point focused on unrelated
parts of the story?

Listed below are several types of patterns of problematic 
thinking that people use in different life situations.   3.  Ignoring important parts of a situation
These patterns often become automatic, habitual  4.  Oversimplifying things as good/bad or right/wrong
thoughts that cause us to engage in self‐defeating  5.  Over‐generalizing from a single incident (a 
behavior. Considering your own stuck points, find  negative event is seen as a never‐ending pattern)
examples for each of the patterns.  Write in the stuck 
point under the appropriate pattern and describe how it  6.  Mind‐reading (you assume people are thinking 
fits that pattern.  Think about how that pattern affects  negatively of you when there is no definite evidence 
you. for this).
7.  Emotional reasoning (using emotions as proof, 
1.  Jumping to conclusions  or predicting the future? e.g., “I feel fear so I must be in danger”)
2.  Exaggerating or minimizing a situation (blowing 
things way out of proportion or shrinking their 
importance inappropriately).
 Challenging Beliefs Worksheet

A. Situation B. Thought/ D. Challenging Thoughts E. Problematic patterns F. Alternative Thought

Stuck Point

Describe the Write thought/Stuck Use Challenging Use the Problematic What else can I say instead
event, thought or Point related to Questions to examine Thinking Patterns of Column B?
belief leading to Column A. your automatic thoughts sheet to decide if this How else can I interpret
the unpleasant Rate belief in each from Column B. is one of your the event instead of
emotion(s). thought/stuck point problematic patterns of Column B?
below from 0-100% Consider if the thought is thinking. Rate belief in alternative
(How much do you balanced thought(s) from 0-100%
believe this thought?)

Evidence For? Jumping to conclusions

Evidence Against?
Exaggerating or minimizing
Patient and therapist  Therapist introduces  Habit or Fact?
Ignoring important parts
review Patterns of  Challenging Beliefs  Not including all information?

Problematic Thinking Worksheets All or none? Oversimplifying

G. Re-rate how much you now
Extreme or exaggerated? believe the thought/Stuck Point
Overgeneralizing in Column B from 0-100%
Focused on just one piece?
C. Emotion(s)
Specify sad, angry, etc., Source dependable? Mind reading
and rate how strongly you
feel each emotion from 0-
100% Confusing possible with likely? H. Emotion(s)
Emotional reasoning Now what do you feel? 0-100%

Based on feelings or facts?

Focused on unrelated parts?

Challenging
ChallengingBeliefs
BeliefsWorksheet
Worksheet
CBW Worksheet Date:__________________Patient:_________________________ A. Situation B. Thought/ D. Challenging E. Problematic patterns F. Alternative Thought
stuck point Thoughts
Describe the Write thought/stuck Use Challenging Use the Problematic What else can I say
A D E event, thought point related to Column Questions to Thinking Patterns instead of Column B?
or belief leading A. examine your sheet to decide if this is How else can I interpret
Activating Event Challenging Questions New Belief
to the Rate belief in each automatic thoughts one of your problematic the event instead of
"Something happens"
unpleasant thought below from 0- from Column B. Is patterns of thinking. Column B?
Evidence for the stuck point? What can I tell myself in the emotion(s). 100% the thought Rate belief in alternative
future? (How much do you balanced and factual thought(s) from 0-100%
believe this thought?) or extreme?
B Evidence For? Jumping to conclusions
Belief/Stuck point Evidence against the stuck point?
"I tell myself something" Evidence Against?
Alternatives
Habit or Fact?
Exaggerating or minimizing

Is the stuck point out of context? Not including all ABC

Ignoring important parts
information?

All or none? Oversimplifying

G. Re-rate how much you now

C
Is the stuck point extreme or
F
Challenging Extreme or exaggerated?
Overgeneralizing
believe the thought/stuck
point in Column B from 0-
exaggerated?
Focused on just one 100%
Consequence New Consequence C. Emotion(s) piece?
How does the stuck point make me How does the new belief make me Specify sad, angry, etc., Mind reading
feel? feel? and rate how strongly you Source dependable?
feel each emotion from 0-
Is the stuck point based on 100%
feelings rather than all the facts? Confusing possible with Emotional reasoning H. Emotion(s)
likely? Now what do you feel? 0-
100%

Based on feelings or
facts?

Focused on unrelated 85
parts?
 Beliefs Related to Self Beliefs Related to Others
• Belief about dangerousness of other 
• Belief you can protect yourself from harm  people and expectancies about the 
and have some control over events.
intent of others to cause harm, injury, 
• Associated symptoms include anxiety, 
intrusive thoughts about danger, irritability, 
or loss.
startle responses, intense fears about future  • Symptoms include avoidant or phobic 
dangers. responses, social withdrawal.

Use the Challenging Beliefs 
Worksheet throughout the rest of 
therapy. 

Each theme can relate to beliefs 
about self or others

Challenging should help clients 
move from extreme statements 
to balanced statement.

Use of the full continuum of 
thoughts and emotions
 Challenging safety is primarily 
Assess symptoms about putting actual probabilities 
into perspective (e.g., if someone is 
Review module and worksheets and assist as  deployed twice and doesn’t die, that 
doesn’t mean he will die the third 
consultant (client takes on a greater role) time). 
Focus on individual stuck points as well as the theme 
for the sessions
Do traumas happen daily, 
weekly, monthly, yearly? Are 
Introduce the new theme and module they actually connected or is 
the patient connecting only 
some of the ‘dots’ (leaving out 
Other specific assignments for sessions 11 & 12 all the good and neutral 
events)? 

Go over the module briefly regarding self and other  Trust with regard to what?
trust. Generate a list of different types of trust and put on a 
continuum.
Look at the Stuck Point Log, clarify the wording on any  + +
trust stuck points and assign them for the next session. Loan money

+ secrets

Patient should continue to work on any other 
No information
assimilated stuck points from the log.
-
Don’t be surprised if they test your trustworthiness  - -
with new information or misbehavior. Emotional support
Many PTSD patients believe that 
they should begin from a position  Again, control with regard to what? 
of complete trust or complete  Control of emotions, control over other 
distrust.   people’s actions, control over urges, 
control over future events?
They need to learn to start with “I 
If the client says he/she is helpless or 
have no information” and collect  has no control, ask them to list all of the 
data from there. decisions they made that day.

People make mistakes and it is  Traumas sometimes follow choices and 
important to give people second  decisions but that doesn’t mean that the 
chances.  You can learn to trust more  choice was a bad decision (outcome 
when they don’t repeat mistakes.  They  based reasoning).
have changed for you.

GIVING POWER TAKING POWER
1. Being altruistic  1. Being assertive
2. Helping others in need or crisis 2. Setting limits and boundaries 

POSITIVE
with others
3. Sharing yourself with another 
Other control is concerned with authority,  person as part of the give and  3. Being honest with yourself 
the idea that other people are trying to  take in relationships and others
control you, or that it is always bad when 
other people are in positions of authority  1. Basing your behaviors solely on  1. Giving ultimatums
the reactions you expect from 
and can tell you what to do. 2. Testing limits
NEGATIVE

others
3. Intentionally upsetting 
2. Always placing the needs of 
others for personal gain
others above your own
4. Behaving aggressively
3. Allowing others to easily access 
your “buttons” 
Beliefs related to Self Beliefs related to 
Others
Being understood,  Beliefs about other people  Examples:
respected, and taken  that match the reality of  • People are uncaring, indifferent, 
Belief in your own 
seriously is basic to  the other person and are  selfish
worth.  • People are bad, evil, or 
the development of  revised as new  malicious
self‐esteem. information is received.

• Have them interacting  • Start reengaging in 
more with other  previously enjoyed 
people and focusing  activities (approach 
their attention  Do at least one  behavior)
outward (giving 
Giving and  compliments is a fairly  nice thing for  • Depression relapse 
Receiving  prevention
safe interaction) themselves every  • Building of self‐
Compliments • Listening to what  day (not earned,  esteem (“Because 
other people say to 
them without filtering  noncontingent) I’m worth it”)
and distorting • If they are not going 
Purposes are to:
Purposes are to:  • Considering other  to be spending much 
sources of information  of their time on their 
about them PTSD symptoms, 
• Help dispute stuck  what are they going 
points about self to be doing?
 •Ability to be alone 
without feeling lonely, 
Patient and therapist review  empty or anxious
esteem issues and other  •Being comfortable in 
Challenging Beliefs Worksheets. Beliefs related to  your own skin
•Enjoying your own 

Patient and therapist review other  Self company

•Knowing what you like 
practice. Self‐intimacy is the ability to  and don’t like and how 
you want to spend your 
self‐soothe time
Therapist introduces Intimacy  Self‐intimacy is more than  •Not needing other 
peoples’ approval
Module. self‐esteem. It is about your  •It is an ongoing process 
relationship with yourself the  (developmental 
ability to calm oneself considerations)

Patient and therapist review 
• Need for intimacy,  Challenging Beliefs Worksheets on 
connection, and 
closeness is a basic  intimacy.
human need. 
• This can be damaged  Patient reads new Impact 
Beliefs related  through insensitive, 
hurtful, or non‐
empathic responses 
Statement.

to Others from others.
• Other intimacy 
includes the full range 
Patient and therapist review 
course of therapy and skills 
of relationships from  learned.
acquaintances, to 
deep friendships, and  Patient and therapist identify 
intimate partners.  
future goals and issues which still 
need attention.
The first 12 sessions are conducted exactly the 
If the patient still has PTSD at 11th session the 
same. therapist should review items on the PCL as well as 
If someone responds early (<19 on PCL), the  the Stuck Point log and discuss continuing for a few 
therapist and client discuss whether he/she is  more sessions.
finished with goals.  If they decide to stop 
early, therapist assigns final impact statement  Do not assign the impact statement, but have them 
and they have one more session. continue the two behavioral assignments.
At final session, they go over the changes in 
meaning of event, content of session, and  Sessions are based on completing CBWs on the 
future goals.  remaining stuck points. Continue doing CPT.