CBT
For
Post Traumatic Stress
Disorder
(PTSD)
Leslie Sokol, Ph.D.
PTSD

About 5.2 million adults have PTSD
during a given year. This is a small
portion of people who have experienced
trauma.

Up to 60% of the U.S. population is
exposed to at least one traumatic event
in their lifetime.
PTSD
Lifetime prevalence of PTSD in U.S. if
approximately 8%
 For veterans of the Iraq and Afghanistan
wars, PTSD prevalence rate is
estimated to be 11-20%
 Women are twice as likely to develop
PTSD than men

 Note: women are more likely to report and
mostly interpersonal trauma (rape/abuse)
PTSD is associated with
higher odds for:
School dropout
 Teenage childbearing
 Marital instability
 Unemployment
 Suicide attempts
 Substance abuse
 Inpatient hospitalization

Type of Trauma
War trauma
 Domestic violence
 Rape
 Motor vehicle accident
 Witnessing a murder or other violent act
 Industrial accident
 Childhood abuse
 Natural disasters
 Traumatic grief
 Severe medical illness (HIV, Cancer)

DSM-5 Diagnostic Criteria
Released May 2013
 Includes changes to diagnostic criteria
for PTSD and Acute Stress Disorder
 Criteria was revised to take into account
data from scientific research and clinical
experience
 NIH may reject the DSM 5 and use the
RDOC tool instead

Major Revisions

PTSD (as well as Acute Stress Disorder)
were moved from class of anxiety
disorders to a new class: “TRAUMA and
STRESSOR –RELATED DISORDERS

All of the conditions in this classification
require exposure to a traumatic or
stressful event
Other changes

Symptoms were revised to clarify
symptom expression

Criterion A2 (requiring fear, helplessness
or horror happen right after the trauma)
was removed in DSM-5. Research
suggested that Criterion A2 did not
improve diagnostic accuracy
Criterion A: Stressor
(1 required)

1.
2.
The person was exposed to: death,
threatened death, actual or threatened
serious injury, or actual or threatened
sexual violence, as follows:
Direct exposure
Witnessing, in person
3. Indirectly, by learning that a close
relative or close friend was exposed to
trauma. (If death must be violent or
accidental)
4. Repeated or extreme indirect exposure
to aversive details of the event, usually
in the course of professional duties.
Does not include exposure through
media, tv, movies.

There a more opportunities to fit the
criteria so the concern is the diagnosis is
being watered down. However, the
problem must be debilitating to fit the
criteria.
Criterion B: Intrusion
(1 required)
Recurrent, involuntary and intrusive
memories.
2. Traumatic nightmares
3. Dissociative reactions
4. Intense prolonged distress after
exposure to reminders,
5. Marked physiologic reactivity
1.
Key Alterations
Note: mostly DSM-IV and 5 are same
 Now 4 clusters instead of 3

 Intrusion, avoidance, negative alterations in
cognitions and mood, and alternations in
arousal and reactivity
Criterion C: avoidance and numbing is now 2
criteria
Criteria C (avoidance) Criteria D (negative
alternations in cognitions and mood)
Criterion C: Avoidance
(1 required)
Persistent effortful avoidance of traumarelated stimuli:
1. Thoughts and feelings
2. External reminders (people, places,
conversations, activities, situations,
etc.)
NOTE avoidance makes patients very
difficult to treat.
new symptoms added
Criteria D is a new cluster
Criteria D: ( negative alternations in
cognitions and mood) 2 required
1. Inability to recall key features of event
2. Persistent negative beliefs about
oneself
3. Persistent distorted blame (self or
others) New symptom
4. Persistent negative emotions New
Symptom

Criterion D. Continued
5. Markedly diminished activities
6. Feeling alienated from others
7. Constricted affect
Criterion E: alterations in arousal and
reactivity (2 required)
Irritable or aggressive behavior
2. Self-destructive or reckless behavior
3. Hypervigilance
4. Exaggerated startle response
5. Concentration problems
6. Sleep disturbance
Note if sleep is the predominant symptom
in the first 30 days, high predictor (80%)
convert to PTSD
1.
Criterion F: duration
Persistence of symptoms
(in Criteria B, C, D and E)
for more than one month.
Criterion G: functional
significance
Significant symptomrelated distress or
functional impairment (e.g.,
social, occupational).
Criterion H: exclusion
Disturbance is not due to
medication, substance use,
or other illness.
Clinical Subtype Added
Specify if:

With dissociative symptoms
(depersonalization or derealization)
 This subtype is applicable to individuals who
meet the criteria for PTSD and experience
additional depersonalization and
derealization symptoms

1.Depersonalization: experience of being an outside
observer of or detached from oneself (e.g., feeling as if "this
is not happening to me" or one were in a dream).

2.Derealization: experience of unreality, distance, or
distortion (e.g., "things are not real").
Specify if: With delayed
expression.
Full diagnosis is not met
until at least 6 months after
the trauma(s), although
onset of symptoms may
occur immediately.
Children ages 6 and younger

Separate diagnostic Criteria
Prevalence Lower in DSM 5

Revision of Criterion A1 narrowed
qualifying traumatic events
 Unexpected death of family or friend due to
natural causes is no longer included
Splitting Criterion C in two required at least
one avoidance symptom
Pre-Traumatic Risk Factors
Gender: Women are at twice the risk.
Age: Higher risk under age 25.
Childhood trauma and/or adversity.
Prior psychiatric disorder (including a predisposed “ability” to dissociate under
duress).
 Additional adverse life events.
 Poor physical health; money problems.
 Family history of trauma (e.g., 2nd
generation Holocaust survivor); psychiatric
disorders.




25
Post-Traumatic Risk Factors
Poor social support.
 Development of Acute Stress Disorder?
(This is the subject of current research).
 Dissociation at (or just after) the time of
the trauma (also under investigation).
Note: Early dissociative responses have
been linked to persistent PTSD only in
non-sexual assault victims.

26
Overlap between PTSD and
other disorders
Many people with PTSD are misdiagnosed
because their presentation overlaps with
other disorders (e.g. GAD, OCD, specific
phobia, substance abuse, borderline
personality disorder)
 Can have both PTSD and one or more of the
above disorders
 PTSD treatment has been shown to diminish
symptoms of other disorders along with
PTSD

Overlap between PTSD and
other disorders
One could have trauma-related
difficulties without having full-blown
PTSD
 Hallmark of PTSD is: a constellation of
symptoms grouped into four general
clusters: intrusion, avoidance,
alterations in cognitions and mood, and
alterations in arousal and reactivity.
 May oscillate continuously between the
four or tend to be mostly “stuck” on one.

Typical Characteristics of PTSD (1)
Re-experiencing (“Reliving”)

Intrusive recollections and flashbacks.




Unwanted.
Sudden, unexpected, startling.
Can interfere with normal ideation.
Traumatic nightmares.
29
Typical Characteristics of PTSD (2)
Avoidance
Avoiding thoughts, feelings, activities,
places, and people related to the traumatic
event.
 “Psychogenic amnesia” for the traumatic
event.




Physiological reactions may still occur.
Vague sense of terror and doom may still occur.
Suppression of feelings.


Goal: self-protection.
“Side-effect”: Joy, humor, and love are muted.
30
Typical Characteristics of PTSD (3)
Hyperarousal
 Excessive physiological reactions.


Exaggerated startle reactions.
Poor concentration.
Insomnia.
 Irritability.

31
Typical Characteristics of PTSD (4)

The duration of the disturbance
(including symptoms of re-experiencing,
avoiding, and hyperarousal) is more
than one month.

The disturbance causes clinically
significant impairment in social,
occupational, or other important areas of
functioning.
32
Alternative View of PTSD
PTSD can also be conceptualized as
a “normal” reaction to abnormal
circumstances, extending in time and
scope beyond its usefulness.
33
Cognitive Model of PTSD
Nature of
Trauma Memory
Negative Appraisals
Matching Triggers
Current Threat
Intrusions, Arousal and Emotions
Strategies Intended to Control Threat/Symptoms
Cognitive Model of PTSD:
Key Factors (1)
PTSD becomes persistent when individuals
process trauma in a way that leads to a
sense of serious, current threat.
 The above involves excessively negative
appraisals of the trauma and its sequelae.
 PTSD involves poor autobiographical recall,
poor elaboration, and poor contextualization,
but strong associations and perceptual
priming.

35
Cognitive Model of PTSD:
Key Factors (2)
Generalization of subjective sense of threat
leads to hyperarousal, hypervigilance, and
exhaustion.
 The person’s own physiology becomes a
source of fear.
 Therapeutic changes in the above are
hampered by the patient’s avoidance.

36
Cognitive Model of PTSD:
Key Factors (3)

Poor recall for positive memories (especially
evident in persons with Acute Stress
Disorder).

Impaired ability to draw upon past
experiences in order to problem-solve
current difficulties.
37
Heightened Appraisal of Threat
Sense of serious, current threat.
 External threat (e.g., the world is a
dangerous place).
 Internal threat (e.g., “I am not capable of
protecting myself.” “I’ll never get over this.”
“I’m dead inside.” “I am permanently
damaged”).
 Thought suppression makes it worse.

38
Acute Stress Disorder
Appeared in the DSM-IV in order…
To recognize the significant levels of
distress experienced in the initial month
following a traumatic experience.
 To foster early identification of those
trauma survivors in greatest distress.

39
Acute Stress Disorder: Caveats (1)
Clinicians should exercise caution in
making the diagnosis of ASD shortly
after a trauma, because the observed
distress may simply reflect a transient
response.
40
Acute Stress Disorder: Caveats (2)
The notion of treating all people who are
symptomatic in the acute trauma phase
is unjustified because of evidence that
most of these people recover without
formal intervention. This is why
mandatory treatment is problematic.
41
Acute Stress Disorder: Caveats (3)
Bear in mind that some of the apparent
psychological symptoms seen in
patients after they have experienced
trauma may in fact be medical
symptoms, such as a reaction to
morphine, the after-effects of head
trauma, and other such conditions.
42
When to Intervene?
Early interventions (e.g. debriefing) –
evidence not supportive and may be harmful
(e.g. Ehlers, Clark et al, 2003)
 A role for care and support in first days and
weeks, and ‘watchful waiting’
 Intervene when problem shows signs of
being chronic and not resolving itself (three
months?)

Critical Incident Stress Debriefing
Actually found to be associated with a
higher incidence of PTSD
 Different from Brief CBT for Acute Stress
Disorder which is associated with positive
outcomes

Treatment of PTSD
Psychotherapy – particularly CBT with
trauma exposures
Only effective treatment to date.
Psychopharm – prazosin (for nightmares),
SSRIs (probably), atypical antipychotics
No medication is endorsed as effective for
treating symptoms of PTSD
Elements of Cognitive-Behavioral
Therapies for PTSD
Psychoeducation
 Relaxation Training
 Exposure to anxiety-provoking situations
 Cognitive restructuring
 Behavioral experiments


The Key elements for PTSD thus far
appear to be exposure and cognitive
restructuring
There are several cognitivebehavioral therapies for PTSD
Prolonged Exposure Therapy (PE)
 Cognitive Processing Therapy (CPT)
 Stress Inoculation Training (SIT)
 Cognitive Therapy (CT)
 Eye Movement Desensitization and
Reprocessing (EMDR)

A word or two about EMDR




No evidence that eye movements reduce anxiety
EMDR just as effective without eye movements
Treatment effects no larger than exposure alone
General consensus among Behaviorist is that the eye
movements and tapping are inert additions to otherwise
effective treatments
Treatment for PTSD
Sample Treatment Goals
Prolonged Exposure Theapy
Based on:
Foa, E.B. Hembree, E. A., & Rothbaum,
B.O. (2007) Prolonged Exposure
Therapy for PTSD: Emotional
Processing of Traumatic Experiences.
New York: Oxford University Press.
PE
Based on 20 yrs of controlled studies
 International Consensus Group on
Depression and Anxiety selected
exposure therapy as treatment for PTSD
 “Model Program” by SAMHSA
(substance abuse and mental health
administration)

PE therapy effective in treatment of
PTSD and comorbid symptoms
 Appropriate for use across cultural
groups
 Effective in treating victims from a wide
range of traumas
 Effective in treating individuals who have
multiple traumas and patients who have
complex PTSD
 Progress maintained at follow-up (6
months or 1 year)

Prolonged Exposure Therapy:
Main Components
Education about PTSD and trauma
2. Repeated reliving of trauma memories
through imagination
3. Repeated in-vivo exposure to avoided
situations
1.
Prolonged Exposure Therapy
10=12 weekly or twice=weekly sessions
 Sessions are generally 90 minutes
 Therapy may take fewer or more than
10 sessions depending on number of
traumas and severity
 Sessions are audio-taped

Providing patients a rationale
It is difficult for clients to give up
avoidance and a good rationale helps
 PE focuses on addressing trauma
related fears and symptoms
 Sometimes memories get easier but
mostly trauma memories and symptoms
stay the same or get worse usually
because of avoidance

Prolonging Trauma Memories:
How Patients Avoid
Pushing away memories, thoughts, and
feelings
 Avoiding situations, places, or people
 The presence of unhelpful beliefs such
as: “The world is dangerous” “ I can’t
trust anyone” “I can’t get over this”

Why avoidance is a problem
When you avoid, you are giving yourself
the opportunity to work through the
memory or to think about it in a more
helpful way. It never gets better.
 Helpful to find out how each individual
patient’s avoidance behaviors
 Helpful if patients can recall a time they
overcame something they were avoidant
of.

2 Main procedures
Imaginal Exposure: repeatedly reliving
the traumatic event using imagination.
Confronting the memories allows for
processing of experiences and allows
for modifying unhelpful cognitions.
 In-Vivo Exposure: Repeatedly
approaching trauma related situations
out in real-life (usually for homework and
in between sessions)Target traumarelated situations that are safe, modifies
cognitions about danger.

PE has seven components
History, including most significant
trauma(s)
2. Psychoeducation
3. Formal assessment of PTSD severity
4. Relaxation training
5. Exposure hierarchy
6. In vivo exposures
7. Narrative exposures
1.
Contraindications for PE
If trauma just happened-exact amount of
time varies (Foa recommends 3 months)
PE has been shown to be equally
effective with old and new trauma even
decades past
 Imminent threat of suicide or serious
self-harm
 Psychosis
 Traumatic Brain injury (TBI)

Contraindications Continued
Still has a relationship with assailant
 Severe dissociation
 Current substance abuse with no
motivation to stop (abstinence is not
required but guidelines)
 Inadequate memory of the trauma

Under Engagement
Patient is “going through the motions”
 Little emotion
 Tell client what you observe
 Label it as PTSD avoidance
 Explore perceived consequences
 Help patient use their senses to get in
better touch with the event

Over Engagement
Too close to feeling as if it is really
happening (take a break and ground
them, tell them they are safe, play with
stress ball)
 Evidence of dissociating
 Regressive behaviors
 Physical movements that “replay”event
 Uncontrollable sobbing

Address Over Engagement
Can modify procedures to decrease
engagement
 Past tense
 Eyes open
 Write it out
 Take a time out
 More therapist involvement
 Grounding techniques

Session 1-12




Breathing re-training
Exposure Hierarchy- things not doing
and afraid of (sitting in restaurant with
back to door, talking to friend)
Face feared situations for 20 minutes
(regardless of whether SUDS
decrease/used to be 50%)
By session 3, narrative of trauma-no
cognitive work, restructure later
TIPS
Avoid cognitive work during the
exposure to the narrative-make sure
anxiety is not too high (person nauseas,
urge to urinate, defecate, dissociating,
confused, tunnel vision (sessions 4-9+)
 Make narrative exposure intense, use
first person, close eyes, focus on “hot
spots”, avoid analyzing
 Over time narratives are shorter
focusing on hot spots

Continue narrative exposure in session
and listening to session (narrative) at
home
 Continue in vivo exposures outside of
session using breathing exercise
 Cognitive restructuring is done just like
CPT and CT (in repeated exposure to
narrative see how their reactions
change, situations unrelated to trauma
are no longer trigger, separate present
from past, mastery of memories)

Individualizing treament
PE is a manualized treatment but not
“cookie cutter”
 Homework is specifically tailored for
each patient’s unique avoidance
behaviors
 Patients therapy and life goals should be
elicited and re-iterate how PE is helping
to achieve those

Comorbidity
80% of PTSD patients also suffer from
depression, another anxiety disorder, or
a substance sue disorder
 May have a personality disorder
 Medical conditions can complicate
PTSD and can even be the index
trauma (HIV, Cancer)

Can still do PE with these groups
 May have to be more flexible with
treatment
 Address substance use or health issues
as needed
 Important to still focus on trauma as
main focus of treatment

Cognitive Processing Therapy
Process the trauma through writing out
details and reading repeatedly
 Systematically challenges unhelpful
“rules” related to self, others, world
 Addresses topics such as safety, trust,
intimacy, and power and control
 17 sessions
 https://cpt.musc.edu

Cognitive Processing Therapy
Strong Research Support
Focuses on distorted thinking about the trauma
 Contains an exposure component (written narrative)
 Can easily be done in group formats
 Manual freely available online
(http://cptforptsd.com/cpt-resources/)
 Goals of treatment
 To Recognize and modify old thoughts and feelings that may be
unhelpful
 To accept the reality of the event
 To change beliefs enough to accept it with going overboard
 To feel your emotions about the event


Cognitive Processing Therapy
Recommended for more complex PTSD
 Focuses on cognitive distortions made
during attempts to accommodate the
trauma

 Assimilation: altering information coming in
to fit with prior beliefs
 Over-accommodation: altering beliefs about
the world to the extreme in order to feel
safer and in more control
Goal

Accommodation – altering your beliefs
about the world enough to incorporate
the new information but in a balanced
and functional manner. Bad things
happen, but this is not the defining order
of the world in general.
EX: Car Jacking

Assimilation: my fault for being in bad
neighborhood, bad things don’t happen
to good people who are smart.

Over-Accommodation: you can’t trust
men, it’s kill or be killed in my
neighborhood
Goal: Accommodation
“The carjacking was a tragedy, but I am
grateful to have survived. It wasn’t my
fault. It’s not likely to ever happen
again.”
 OR
 In the case of a rape, “The rape was a
tragedy, but it wasn’t my husband that
raped me. He loves me and we can
enjoy sex with each other because it’s
safe and loving.”

CPT

The theory behind CPT is that the
patient with PTSD has been unable to
cognitively accommodate the trauma in
a healthy way. Accommodation (and
therefore recovery from trauma) requires
tolerating and processing complex and
conflicting thoughts and intense
emotions.

Instead, the person with PTSD engaged
in assimilation or over-accommodation
of the trauma, but assimilation and overaccommodation generally result in
persistent, negative views of the world,
the future, or oneself. The assimilated or
over-accommodated thoughts create
“stuck points” that prevent recovery
from PTSD.
CPT: Socratic dialogue
Clarifying by asking for more information
 Probing assumptions
 Probing reasons and evidence
 Questioning viewpoints and
perspectives
 Analyzing implications of beliefs
 Questions about questions (redirecting
questions asked by the patient back on
to the patient)

Key

Don’t argue with the patient.
Collaborate. If the patient isn’t ready to
examine a particular belief, note it, move
on, and come back to it later.
Cognitive Processing Therapy
12 weekly or twice-weekly sessions
 60-90 minute sessions
 Initially focuses on identifying and
evaluating assimilation errors, then on
identifying and evaluating overaccommodation errors. (guilt and blame
first, external blame second)
 Done in individual or group sessions

NOTE

PE does not work in groups and data
actually can make people worse
(retraumatized)

CP works in groups – especially in VA
where people have been through similar
traumas-vets trust another vet
CPT Session by Session
Session 1: Introduction and Education
Session 2: The Meaning of the Event
Session 2a: Traumatic Bereavement (Optional Session)
Session 3: Identification of Thoughts and Feelings
Session 4: Remembering the Traumatic Event
Session 5: Identification of Stuck Points
Session 6: Challenging Questions
Session 7: Patterns of Problematic Thinking
Session 8: Safety Issues
Session 9: Trust Issues
Session 10: Power/Control Issues
Session 11: Esteem Issues
Session 12: Intimacy Issues and Meaning of the Event
Impact statement
One page
 Handwritten
 Why person thinks trauma happened to
him
 How the trauma changed the person’s
view of the world, future, other people
and himself

Session 2
Read impact statement
 Socialize them to cognitive model
 Document stuck points
 ABC worksheet – activating event,
belief, consequences (are my thoughts
in B realistic and what can I tell myself in
the future on such occasions)

ABC worksheets
A-My platoon sergeant wouldn’t let me
help the wounded Iraqi child.
 B-Leaders are always insensitive jerks
who don’t understand what it’s like on
the ground. I am weak because I did not
disobey orders.
 C-Feel sad. Don’t trust authority. Can’t
be around own kids without feeling guilty
thinking about wounded Iraqi kids.

Reframe
Leader’s are not all insensitive
 Leader’s are human do make mistakes
 Not Weak to struggle with complex
issues.
 If I disobeyed orders and someone in
platoon got hurt, I would have felt
horrible.
 Leader was looking out for us.

Session 3
Trauma account
 Handwritten
 Several pages in length (Barad 35pgs)
 Full account of trauma and thoughts and
feeling experienced
 Want them to experience emotions but
not be overwhelmed, take breaks if need
to
 Read account daily after completing it
 Do ABC worksheets

Session 4
Read Trauma account out loud
 Allow affective displays
 Encourage them to describe the thoughts
and feelings they experienced during the
trauma –add in-add how feeling now in
parentheses. At the time I felt scarred and
sad (but right now I am angry)
 Note stuck points

 Places the patient stops writing or glossed over,
self-blame, judging the situation in hindsight.
Session 5-7

Evaluate the stuck points in and out of
session using the evaluating questions
worksheet.
Evaluating Questions Worksheet
Belief:____________
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 nothing terms?
5. Are you using words or phrases that
are extreme or exaggerated?
1.
Are you taking the situation 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 focused on irrelevant factors?
6.
Session7-11
Keep reading the trauma account and
work on one theme:
1. Safety
2. Trust
3. Power/control
4. Esteem
5. Intimacy

Patient thinks about how they viewed
themselves and others (in terms of each
theme) before the trauma, and how
these views changed after the trauma
 Use worksheet to evaluated beliefs
related to theme (homework and in
office)

Session 12
Review Evaluating Belief worksheets on
themes
 Review the new impact statement wrote
for homework (why thinks trauma
happened and how changed view) and
compare with original impact statement
 Review skills

References
US National Center for PTSD –
www.ptsd.va.gov
 APA Treatment Guidelines for PTSD –
www.psychiatryonline.com/praGuide/praGu
ideTopic_11.aspx
 Rothbaum, BO, Foa EB, Hembree EA.
Reclaiming Your Life From a Traumatic
Experience: Workbook. Oxford University
Press, 2007.
 Medical University of South Caralina, navy
Medicine. CPTWeb: A web-based learning
course for Cognitive Processing Therapy.
https://cpt.musc.edu/index

Research






Ehlers, A.& Clark, DM. (2000) A cognitive model of
PTSD. Behaviour Research and Therapy 38
Ehlers et al, (2003) A RCT of CT, a self-help booklet,
and repeated assessments as early interventions for
PTSD
Ehlers et al (2005) CT for PTSD: Development and
evaluation. Behaviour Research and Therapy, 43
Ehlers et al (in prep) A RCT of intensive and weekly
cognitive therapy versus emotion focussed supportive
therapy
Gillespie et al (2002). Community based CT in the
treatment of PTSD following the Omagh bomb.
Behaviour Research and Therapy, 40
Duffy et al (2007) PTSD in the context of terrorism and
other civil conflict in Northern Ireland: RCT. British
Medical Journal, 334
This CBT treatment lines up really well with the Mind over Mood Curriculum
A BRIEF LOOK AT CPT
CPT Session by Session
Session 1 - Introduction and Education: Symptoms of PTSD;
explanation of symptoms (cognitive theory); description of therapy.
Practice assignment: Write Impact Statement.
 Session 2 - The Meaning of the Event*: Patient reads Impact
Statement. Therapist and patient discuss meaning of trauma. Begin
to identify stuck points and problematic areas. Review symptoms of
PTSD and theory. Introduction of A-B-C Worksheets with
explanation of relationship between thoughts, feelings, and
behavior. Practice assignment: Complete 1 A-B-C sheet each day,
including at least one on the worst trauma.
 Session 3 - Identification of Thoughts and Feelings: Review AB-C practice assignment. Discuss stuck points with a focus on
assimilation. Review the event with regard to any acceptance or
self-blame issues. Begin Socratic questioning regarding stuck
points. Practice assignment: Reassign A-B-C Worksheets. Assign
written trauma account.

CPT Session by Session
Session 4 - Remembering Traumatic Events: Have patient read
full trauma account aloud with affective expression. Identify stuck
points. Start to help patient challenge self-blame or assimilation
with Socratic questions. Explain difference between responsibility
and blame. Practice assignment: Rewrite trauma account, read full
written trauma account on a daily basis, complete A-B-C sheets
daily.
 Session 5 - Identification of Stuck Points: Have patient read
second written trauma account aloud. Identify differences between
first and second account. Help patient challenge self-blame or
assimilation with Socratic questions. Introduce Challenging
Questions Worksheet to help patient challenge stuck points.
Practice assignment: Challenge one stuck point per day using the
Challenging Questions Worksheet, continue to work on trauma
account if not finished, read trauma account daily.

CPT Session by Session
Session 6: Challenging Questions - Review practice assignment. Review
Challenging Questions Worksheet. Continue cognitive therapy regarding
stuck points. Introduce Patterns of Problematic Thinking Worksheet. Teach
patient to use the new worksheet to challenge his cognitions regarding the
trauma(s). Practice assignment: Identify stuck points and complete Patterns of
Problematic Thinking worksheets for each. Look for patterns in thinking.
Continue to read trauma account if still having strong emotions about it.
 Session 7 - Patterns of Problematic Thinking: Review Patterns of
Problematic Thinking Worksheets to address trauma-related stuck points.
Introduce Challenging Beliefs Worksheet with a trauma example. Introduce
Safety Module. Discuss how previous beliefs regarding safety might have
been disrupted or seemingly confirmed by the index event. Use Challenging
Beliefs Worksheet to challenge safety beliefs. Practice assignment: Daily
identification of stuck points, including one on safety using the Challenging
Beliefs Worksheet. Read Safety Module. Continue to read trauma account if
still having strong emotions about it.

CPT Session by Session
Session 8 - Safety Issues: Review Challenging Beliefs
Worksheets and help patient to challenge problematic beliefs they
were unable to complete successfully on their own. Introduce Trust
Module. Pick out any stuck points on self-trust or other-trust.
Practice assignment: Read Trust Module and complete at least one
Challenging Beliefs Worksheet on trust. Continue to challenge
stuck points on a daily basis using Challenging Beliefs Worksheets.
Continue reading trauma account if still having strong emotions
about it.
 Session 9 - Trust Issues: Review Challenging Beliefs Worksheets.
Introduce module on Power/Control. Discuss how prior beliefs were
affected by the trauma. Practice assignment: Read Power/Control
Module and complete at least one Challenging Beliefs Worksheet
on Power/Control issues. Continue to challenge stuck points on a
daily basis using Challenging Beliefs Worksheets. Continue to read
trauma account if still having strong emotions about it.

CPT Session by Session


Session 10 - Power/Control Issues: Review Challenging Beliefs
Worksheets. Introduce module on Esteem (self-esteem and regard for
others). Practice assignment: Read module and complete Challenging
Beliefs Worksheets on esteem, as well as assignments regarding giving
and receiving compliments and doing nice things for self. Continue to
challenge stuck points on a daily basis using Challenging Beliefs
Worksheets. Continue to read trauma account if still having strong
emotions about it.
Session 11 - Esteem Issues: Review Challenging Beliefs Worksheets.
Discuss reactions to two behavioral assignments – giving and receiving
compliments and engaging in a pleasant activity. Introduce final module
on Intimacy. Practice assignment: Continue giving and receiving
compliments, read Intimacy Module and complete Challenging Beliefs
Worksheets on stuck points regarding intimacy. Continue to read
trauma account if still having strong emotions about it. Final
assignment: Write final Impact Statement.
CPT Session by Session

Session 12 - Intimacy Issues and Meaning of the Event: Go
over the Challenging Beliefs Worksheets. Have patient read the
final Impact Statement. Therapist reads the first Impact Statement
and then compares the differences. Discuss any intimacy stuck
points. Review the entire therapy and identify any remaining issues
the patient may need to continue to work on. Encourage the patient
to continue with behavioral assignments regarding compliments
and doing nice things for self. Remind patient that he is taking over
as therapist now and should continue to use skills he has learned.

A modified protocol (CPT-C) is available for individual who refuse to
write the trauma narrative
CBT
For
ANGER
STEPS
1. A should rule is broken
(Perceived wrong)
Examples:
“People should listen to me, and they don’t.”
“I should have total control over this situation, and I
don’t.”
112
2. Meaning: What hurts or scares you the most?
(Hurt or Fear?) Feeling Diminished? Victimized?
(Categorical thinking, recalled grievances through
selective attention)
113
Examples:
“They are diminishing me.”
“People are rude and insensitive, they don’t
care.”
“I’ll be made the victim.”
“He’s going to leave me.”
114
3. Hot Thoughts/Ruminations on Grievances
(Anger driven thoughts)
Examples:
“How dare he?”
“How stupid can she be?”
“Poor me, they are always blaming me.”
115
4. Anger (Arousal/Anxiety)
Physical/emotional symptoms
Examples:
Muscles tension
Anxiety
116
5. Moral Disengagement: Permission-giving
beliefs
(Mobilize for action)
Examples:
“He deserves it.”
“I just want them to hurt the way I have been
hurt.”
117
6. Extort validation: Passive
Aggression/Aggression/Violence
(Strike) (Dysfunctional Behaviors)
Examples:
Acts aggressively and ignores the rights of other
people
Violence
118
7. Resentment, Guilt, Shame
(Outcome)
Examples:
Views every anger episode as a self-perpetuating
failure, as a set back
Views anger as proof of being helpless,
powerless, weak
119
Each step represents a point of intervention or
choice point
One can choose to intervene at each step, cool
down and break the pattern
OR
Continue down the destructive path
120
STEP
1. A SHOULD RULE IS
BROKEN.
INTERVENTION
ACCEPT REALITY (THAT YOU
HAVE 0% CONTROL OVER
OTHER PEOPLE’S BEHAVIOR
AND 100% CONTROL OVER
YOUR CHOICES)
CHOOSE A DIRECTION BASED
ON YOUR VALUES:
SHOULD RULES OFTEN
REFLECT DEEPER VALUES AND
PRINCIPLES.
TAKE CONSTRUCTIVE ACTION
IN THAT DIRECTION.
121
INTERVENTION
Facts are that people don’t listen, they do get
in our way, and we cannot control their
behavior. We can learn to accept the
circumstance as given, accept them as reality.
Ask yourself:
122
Intervention
•
•
What do I want in the long run?
What constructive steps can I take in that
direction?
When people do ignore my wishes and
intrude, I can tell myself I wish it were
different but accept the reality.
What Should Rule Was
Broken?
Example:
Bill is at his friend’s house cleaning and another
friend shows up to use the computer.
Bill thinks, “He should know not to come in while
I am cleaning.” “ Doesn’t he see my car and
realize I am here?” “ He should be more
considerate.”
Response to Broken Should
Example:
“ I have 100% control over me and 0% control
over the rest of the world. If would be nice if
the world followed my rules but I cannot
demand they see the world I do.”
“My expectations and rules are not the same as
his and I have to accept people are always
going to break my rules since they are not
their rules, too.”
STEP
2. Meaning: What hurts or scares you the most?
(Hurt or Fear?)
Feeling Diminished? Victimized?
126
INTERVENTION
Toll: What’s the effect of my thinking?
What are the costs/benefits of thinking this way?
127
INTERVENTION
Ask “What really hurts here?” Maybe they are
trying to help me, not control me. Maybe I can
see myself not as a victim but a person getting
assistance. It’s not helping me to think about
it this way, its possible they would act that way
no matter who it was.
128
Ask, what does it mean to me or
about me that they did not meet
my expectation?
Example:
“The audacity!” “Am I supposed to
accommodate him, this is so inconsiderate.”
“My time does not matter.” The world
revolves around him.” “I have no control.”
“I’m powerless.”
129
Examine the thoughts.
Is the meaning true or just an
emotional perception?
Example:
Alternative View: Consider this a nervous guy
who was driven by anxiety and agitation to
get on the computer and not driven by his
brain. He is an impaired person who is just
trying to cope with his problems. He did not
intentionally set out to inconvenience me. I
could be sympathetic and be gracious or I
could assertively ask him to come back later.
130
Feeling Subside
Example:
Feelings of being annoyed, angry and pissed-off
subside.
131
STEP
3. Hot thoughts/Ruminations on Grievances
INTERVENTION
Answer them with cooling responses.
Practice using role plays.
132
Examples:
“How dare he.”
“How stupid can she be.”
“Poor me, they are always blaming me.”
133
INTERVENTION
Find more level headed thoughts, like
“I think he is trying to help me.”
“She’s human.”
“I guess I did make a mistake, or I did overreact.”
134
New Conclusion
Example: The guy did not use the computer to
intentionally annoy me, he just did not think and
instead was just trying to cope with his anxiety.
135
STEP
4. Anger (Arousal/Anxiety)
Physical/emotional symptoms
136
Examples:
Muscles tension
Anxiety
137
INTERVENTION
Learn and practice different form of
relaxation therapy (progressive relaxation,
visualization, music).
Learn to relax muscles and focus attention
away from anger inducing stimuli.
See the anger as energy for constructive
action.
Remind oneself that just as Martin Luther
King was angry at racism and Mother
Theresa was angry at poverty, I can turn
anger into positive action.
138
STEP
5. Moral Disengagement: Permission-giving
beliefs
(Mobilize for action)
139
INTERVENTION
Reconnect with morals and values: “Do unto others
as you would have them do unto you.” Respond
to the ways you rationalize or minimize
aggression.
140
Examples:
“I just want them to hurt the way I have been
hurt.”
“I have to teach them a lesson.”
“I am not going to let them have one up on
me.”
“This is the only way I can get my point
across.”
“He deserves it.”
141
INTERVENTION
Examine the beliefs that turn anger into
dysfunctional action. Help them recognize
these ideas are con artistry. They con the
person into throwing aside their morals and
engaging in threats, sarcasm, demands and
blame. Have them remind themselves of the
cost of such strategies, and the benefits of
remaining calm and fair.
142
STEP
6. Extort validation: Passive
Aggression/Aggression/Violence
(Strike) (Dysfunctional Behaviors)
143
INTERVENTION
Time out
Empathy
Assertiveness (Being Fair to yourself and fair to
others):
DEAL
Describe the situation – just the facts
Express feelings – without blame
Ask for changes in the relationship – no
demands
List the benefits of those changes
144
INTERVENTION
Put yourself in the other person’s shoes and
empathize. Imagine what they are thinking and
feeling and work to understand their perspective.
145
Action or No Action
Cleaning Example:
Confronting this guy would have probably resulted in a man
crying. It could have snow balled and my anger would
have gotten the best of me. The better choice was to
leave the computer room not cleaned and left the house
as soon as possible.
KEY: Take Appropriate Action.
146
STEP
7. Resentment, Guilt, Shame
(Outcome)
147
INTERVENTION
Relapse prevention: Turn guilt or resentment into
constructive action. Break episode into points of
intervention. Review what you can do at each
step.
148
EXAMPLES
•
Views every anger episode as a self-perpetuating
failure, as a set back
•
Views anger as proof of being helpless,
powerless, weak
149
INTERVENTION
Reduce resentment and guilt.
Learn to see each episode as a success, so
long as you are examining the triggering should
statements, the angering beliefs, the automatic
thoughts, the anger arousal, the permission
giving beliefs, and the strategies you engage in.
The episodes can be fewer and further between
and less intense.
150
Strategies





Stop
Take a Breath
Observe
Pull Back (get some
perspective)
Practice what works
Coping Card
Patient with chronic anger
Anger comes from your should rule being
broken.
“She should not have done what she did!”
HURT comes from me believing it was
because I wasn’t good enough, special
enough, or valued enough.
Coping Card
RECOVERY come from:
1. Accepting you cannot control the world. You
cannot make what happened not happen. You
can wish it but not demand it. Accept that it
did happen.
Coping Card
2.
To help you accept remind yourself that the
marriage had problems and at that time the
circumstances presented themselves to
make what happened happen. BUT, it never
happened again and it will never happen
again.
This woman loves you and is committed to you!
The goal is not to forget but to Accept!
Situation
Husband leaves a pile of dirty clothing sitting
on floor.
155
Thinks
Why do you have to leave a pile of dirty clothing
on the floor?
I told you explicitly not to do this.
He should put his clothing in the laundry.
156
You do it purposely to get me upset.
You’re trying to push my buttons.
You don’t care about me.
157
Feels
Angry
Frustrated
Hurt
158
Alternative Response
He does care. He calls me during the day. He
asks about my day and is genuinely interested.
He talks to me. We are good friends. We are
lovers.
It is not that he doesn’t care, he is not
purposely trying to hurt me. It is just the way he
is. Born slob. He has been a slob his whole life.
159
Alternative Response Cont.
This is the negative side of who he is, but the
positive side is a lot longer. He is smart, kind, a
good friend, responsible, reliable, attractive and
my good friend and lover.
He is not going to change so there is no benefit
in shouting and demanding he do so.
160
Alternative Response Cont.
I am the one suffering. he just laughs it off.
Instead of shouting and demanding he should do
what I want, I can wish it, desire it, or prefer it and
maybe even let him know in these words.
161
Conclude
I can accept his mess if I remind myself this is
about him not about me. He is not purposely
trying to hurt me, he cares about me too much.
He is not going to change but his strengths
outweigh such an unimportant deficit.
162
Coping Cards
Step 1
Anger comes from broken should rules, identify
the should rule that has been broken .
Step 2
Recognize the world does not operate on
imperatives: should, ought, have to, must.
163
Step 3
Replace the imperative with a preference: wish,
like, prefer, it would nice.
Step 4
What does it mean to you that your should rule
was broken? What does it mean about you
or what does it mean about them?
Look for the Hurt or Fear under the anger and
the thoughts that drive those feelings.
164
Step 5
Examine the validity of the thoughts that are
connected to the hurt or fear.
Step 6
Recognize the answer is not in changing others
but in changing how you think, taking
appropriate action, and modifying your
external circumstances if that is what is
necessary.
165
HOMEWORK
Look for the should.
Replace the should with prefer.
Look for the thoughts connected to hurt or fear.
Evaluate your thoughts.
Take appropriate action.
166
Trigger: 2 year old son is
being difficult
Should Rules:
He should be cooperative.
He should be patient.
He should be satisfied.
Should Rules for all of his kids:
They should be able to self-entertain.
They should be able to play nicely.
They should be less crazy, be calm, be patient.
167
Ask is that Demand valid?
These are not valid demands. The kids are
young and they cannot control their impulses.
My kids have learning issues and that makes it
even harder for them. Their 2 and 4 year old
brains are not fully developed, give them time.
It is difficult if not impossible for most 2 and 4
year olds to have patience. Patience is even
more compromised when disability makes
things frustrated. Even adults have difficulty
with this.
168
Replace the Should
It would be nice if my kids…
I would prefer if the kids…
I would like…
It would be better if…
Remember, replace the should, must, ought,
have to or anger and frustration will remain.
169
Trigger: Daughter is not
practicing the Piano
“ For all we spent, she should be practicing!”
SHOULD RULE is broken.
But, it is reasonable to expect her to practice
since she wanted to do this.
Acknowledge the frustration.
BUT, Demanding her cooperation is not an
answer.
170
You cannot force her to practice. In the shortrun you may be able to, but in the long run, it
is up to her. Since you cannot effectively
force her, you can only help convince her to
choose to practice. She has to choose to
make it happen.
You can remind her. You can encourage her.
You can help her see the advantages and
sell it. You can set rules and impose
consequences.
Tolerate sharing the power.
171
Feeling Frustrated and Angry
and Starts Yelling
Look out for the escalation of upset.
Your gut warns you.
Stop the aggressive yelling before it escalates.
Force yourself to communicate in a soft, slow
voice. (This will have a natural calming effect
and the facts will be heard and not your yells.)
Yelling leads to more upset and forces people
to defend themselves and be less likely to
hear you.
172
Be Assertive
Use a soft voice.
Engage them by asking questions that lead
them to see your point. Don’t ask why
questions, but rather questions that help them
see practicing will get them closer to their
goals.
Recognize that demands makes us more
powerless even though we do it to try and get
more power.
173
State the facts.
Let them know how it made you feel.
Let them know what you wish for or would like.
Ask what they want and hear them.
Compromise.
174
Venting

Research dating back to at least the 80s
has shown that venting is generally not
helpful and tends to increase anger
Insomnia
Sleep Hygiene

Keep bed for sleep and sex. Don't use it for watching television, using computer etc.









Get the TV out of the bedroom
Get some regular exercise during the day. Try some regular swimming or
walking. Avoid exercise late in the evening.
Cut down on caffeine (tea, coffee, some soft drinks) in the evening. Try a milky drink
instead.
Don’t drink a lot of alcohol. It may help you fall asleep, but you will almost certainly
wake up during the night.
Don’t eat or drink a lot late at night. Try to have your evening meal early rather than
late.
If you’ve had a bad night, resist the temptation to sleep the next day – it will make it
harder to get off to sleep the following night.
If something is troubling you and there is nothing you can do about it right away, try
writing it down before going to bed and then tell yourself to deal with it tomorrow.
If you can’t sleep, don’t lie there worrying about it. Get up and do something you find
relaxing. After a while you should feel tired enough to go to bed again.
Avoid clock watching when in bed
CBT
For
Psychosis
Highlights
Evidence for CBT for
Schizophrenia
Improvements in positive symptoms
 Improvements in negative symptoms
 Improvements in ability to cope with
voices
 At follow-up may demonstrate increased
improvement

Focus in Patients’ Assets
From Aaron T. Beck, M.D.
Patients have healthy, accessible attitudes that
can be tapped to neutralize or moderate
disturbing symptoms
 Through self-reflection and correction of
distressing beliefs, they can modify
neurocircuitry (neuro-plasticity)
 The symptoms can be understood in terms of
universal psychological problems
 Even patients with severe deficits can benefit
from psychotherapy

Problems Exacerbated By Illness
From Aaron T. Beck, M.D.
Estrangement/Stigmatization
 Withdrawal
 Anxiety
 Hopelessness
 Depression
 Suicidal
 Passivity

Cognitive Therapy Approach

For all presenting problems Thinking influences emotion and behavior
○ Interpretation of experience key
 Beliefs are possibilities, hypotheses, not
facts

Approach can be applied to beliefs
associated with hallucinations and
delusions
Strategies/Principles
From Aaron T. Beck, M.D.
Forming working relationship
 Provide structure
 Guided discovery
 Collaborative empiricism
 Improve reality testing
 Case formulation
 Normalizing rationale
 Activate questionable mode

Specific Tasks in CBT for
Psychosis
Establish therapeutic alliance
Assess & Formulate problems
Construct a ‘problem list’
Explore catastrophic (non psychotic)
beliefs about symptoms & experiences
(normalising).
5. Explore patient’s problems – including
positive symptoms.
6. Evaluate ‘problematic’ beliefs – develop
‘benign’ alternatives, look for evidence
for/against the alternatives, behavioral
expts.
7. Schema Level Work
1.
2.
3.
4.
184
Engaging and Rapport Building

Empathy, warmth, unconditional acceptance
and respect

Genuineness

Find a balance between non-confrontation and
non-collusion

If patient insists s/he is right then need to
agree to differ

If emotional climate become too intense then
tactical withdrawal is advised
185
Purpose of CBT for Psychosis

Decrease distress
 If patient reports no distress:
○ Try to understand why
○ Respect his or her wishes
 It’s not the symptom that is the problem, it is
the emotional behavioral consequences

Patient may have other issues to bring
forth
 Can do therapy without tackling delusions
and hallucinations
Cognitive Model of Schizophrenia
Bizarre Beliefs
 Information-processing biases contribute
to development
 Overestimate coincidences, “jump to
conclusions”, engage in self-serving
biases, or threat-related stimuli biases
 Maintained by recruiting supporting
evidence and ignoring or minimizing
disconfirming evidence
Therapeutic Process
Assessment
Engagement
Trace origins of beliefs/hallucination
Elicit beliefs about the mechanisms underlying delusions/hallucinations
Normalize symptoms and discuss alternative mechanisms
Reattribute
hallucinations and
discuss content
Inference chain resistant
delusions
Specific techniques for negative symptoms, etc.
Hallucinations
The Cognitive Model
Behaviour
Event
THOUGHT
Feelings
Physiology
190
Event
Thoughts
Affect
I’m going mad
Hearing
Voices that no
one else
claims to hear
I’ve got
schizophrenia
I’ll lose my job
People will be
frightened of me
Fear
Despair
Hopeless
My life is ruined
I’m going to be
locked away
191
Triggers and Maintenance
Stressful Life Events
Psychotic Episode
Increased Arousal
Catastrophic
Interpretation of
Events
192
Event
Thoughts
Affect
This is a reaction to
all the stress I’ve
been under
Hearing
Voices that no
one else
claims to hear
If I take my
medication or get
the stress under
control then these
symptoms should
go away
Relief
Hope
I can get my life
under control again
193
Cognitive Biases in Patients with
Delusions
Use less information and more likely to jump
to conclusions
 More likely to look for confirmatory data
 Less likely to have alternative beliefs
available.
 Theory of mind deficits – less likely to be
able to determine others’ intentions and
feelings.

194
The Cognitive Model
Behaviour
Event
THOUGHT
Feelings
Physiology
195
Cognitive Model of Delusions
A
B
Activating
Belief
Event:
Anomalous
Experience
Delusion
C
Consequences:
Affect
Behaviour
Physiology
196
Cognitive Assessment of Delusions
Delusion
Situation/
Antecedent
Belief
Emotional/
Behavior
Consequences
Paranoid
People heard
speaking
outside house
“they’ve come
to harm me”
Fear/ Escape
house
Though
broadcast
Hears man ask My thoughts are Fear/Escape
for bus ticket
being passed to
just as he was
others
thinking “I need
a ticket”
Reference
Plane passes
overhead
WW III is
starting
Anxiety/
Helplessness
Somatic
Develops skin
rash
I’ve got AIDS
Terror/
Hopelessness
CBT Techniques for Delusions






Peripheral questioning
Socratic questioning
Graded reality testing
Tackling emotional/behavioural
investment
Inference chaining and schema level
work
Maintaining a collaborative set
Focus on Specific Beliefs Related to:

Voice’s identity

Purpose of voices

Perceived power/omnipotence

Perceived consequences of
obedience/disobedience
Exploring Beliefs
 Explore beliefs using a gentle non-interrogative
Socratic style.
 Is there some truth in the ‘delusional’ belief? Be aware
of your own cognitive biases - don’t jump to
conclusions but take comments at face value.
 Even if belief isn’t factually true it is very real to the
patient as is the associated affect.
 Don’t try to do too much but keep the flow of
discussion going
 Aim for sessions to be positive, even enjoyable,
experiences as far as its reasonable to do so.
200
Origins of Beliefs
How did he/she come to this belief?
 What was happening at that time?
 Stress?
 Personal History?
 Why that conclusion?

Understanding Beliefs
Give context to beliefs
 An attempt to make sense of an unusual
or confusion circumstance?
 Jumped to conclusions?
 Need for closure?

Mechanisms

What evidence have they collected that
that this is the case?

What evidence have they seen that this
may not be the case?
Weakening Delusional Beliefs

What makes person think this?

May need to review evidence for belief and not
belief itself
○ E.g “the car did a U-turn – it must have been following me”
○ Are there any other reasons for cars to do U-turns?

Generation of Alternatives
○ Consider impact of beliefs on self esteem, mood etc.
○ Consequences of alternative being true?
 Identify other sources of self esteem if belief weakened
204
Verbal challenge

Generating Alternatives
 Recognizing other possibilities
 Direct confrontation avoided
 Columbo, not Dirty Harry
 Collaborative, not forceful style
○ “What are some other possibilities?”
○ “Hypothetically . . .”
○ IF someone told you _____, what would you
say?”
Components of Verbal Challenge
Inconsistencies pointed out (gently)
 Alternative explanation discussed

 Ideally from client, can be offered by
therapist

Which explanation most likely, given
evidence
Thought Record
Example of patient with Paranoid Schizophrenia
Event
Seeing a red
car
Automatic
Thoughts
They are trying to
tell me something
Realistic
Thoughts
There are lots of
red cars
They want me to do Color of car
something
doesn’t
determine who
They can control me is inside
My illness makes
me overreact to
a situation
“I didn’t really look at it as accepting, but that’s
probably what it was—accepting. And I
suppose once you accept it, it’s easier for you
to look at ways of coping. Because when
you’re fighting it, you’re just scared.”
--Quote from a participant in person-based cognitive therapy (PBCT) for distressing
voices; Goodliffe et al., 2010
CBT for Schizophrenia:
Treatment Considerations
Standard treatment always includes
psychotropic medication and case
management.
 CBTp for Sz would be in addition to standard
treatment.
 Risk for suicide and self-harm is high and is
harder to detect; careful, direct, and frequent
monitoring is important.
 The focus of CBTp is in helping individuals
cope with and manage (versus “cure”)
schizophrenia.

CBT for Schizophrenia:
Clinical Strategies

Engagement and establishment of a therapeutic
relationship



Importance of establishing rapport is heightened
at beginning of treatment when clients may be
particularly paranoid, etc.
Assessment and CBT case formulation including an
understanding of client’s beliefs regarding their psychotic
symptoms
Intervention Strategies
CBT for Schizophrenia:
Highlighted Intervention Strategies



Attention Switching

It is not the goal, nor is it necessary, to eliminate
delusions/hallucinations, just attend less or respond differently
to them.
Reattribution

“It may seem like a real voice, but it is [or could be] my own
thoughts.”
Awareness training

Decentered awareness; ACCEPT experiences without having to
react to them.

Attend to (be mindful of) form and characteristics of thoughts
and perceptions versus the content.

Goal: increase the client’s scientific curiosity into their
symptoms and sx patterns.
CBT for Schizophrenia:
Highlighted Intervention Strategies


Behavior change is probably the best way to produce cognitive
change.

Behavioral experiments and reality testing.

Clients may tend toward biased interpretation and confirming
beliefs; therapist can help by [gently] suggesting alternative
interpretations.
Enhancing self-efficacy in client’s ability to cope

Self-efficacy can be the highest when the client is experiencing
delusions, hallucinations or other symptoms. (The good news in
the bad news.)

Again, the goal does not have to be “getting rid” of symptoms.
Schizophrenia:
Diagnostic Criteria
Positive Symptoms: excess or distortion of normal functioning
(e.g., hallucinations, delusions)
Negative Symptoms: decrease in or loss of normal functioning
(e.g., restricted affect, alogia, avolition)
The Role of Defeatist Beliefs
(Rector, Beck, & Stolar, 2005)
Negative Expectancy
Appraisals
negative
symptoms
Low selfefficacy
(success)
Low
satisfaction
(pleasure)
Low
acceptance
Low available
resources
Affective
flattening
If I show my
feelings, others
will see my
inadequacy.
I don’t feel the
way I used to.
My face appears
stiff and
contorted to
others.
I don’t have the
ability to
express my
feelings.
Alogia
I’m not going to
find the right
words to
express myself.
I take so long to
get my point
across that it’s
boring.
I’m going to
sound weird,
stupid, or
strange.
It takes too
much effort to
talk.
Avolition
Why bother, I’m
just going to
fail.
It’s more
trouble than it’s
worth.
It’s best not to
get involved.
It takes too
much effort to
try.
(Rector, Beck, & Stolar, 2005)
Core Elements
Therapeutic alliance a priority
 Collaborative approach in exploring
symptoms
 Acceptance of patient’s subjective
experience
 Symptoms not directly confronted
 Try to reduce distress related to
symptoms
 Reduce stigma related to illness

Overall purpose of CBT for
Hallucination and Delusions

To reduce distress and disability
(Reducing delusions and hallucination is
simply a means to that end)
Useful Texts

Beck, A.T., Rector, N.A., Stolar, N.,
Grant, P. Schizophrenia: Cognitive
theory, research and therapy (2008).
New York: Guilford
Useful Texts
Kingdon, D. and Turkington, D. (1994).
Cognitive behavioural therapy of
schizophrenia. New York: Guilford.
Fowler, D., Garety, P., and Kuipers, E. (1995).
Cognitive behaviour for psychosis: Theory
and practice. New York: Wiley.
Chadwick, P.D.J., Birchwood, M., and Trower,
P. (1996). Cognitive therapy for delusions,
voices, and paranoia, New York: Wiley.
Working with Difficult Clients
Awareness

What are your automatic thoughts about
working with people who have a
personality disorder?
Same Principles Apply





We’re looking at the contingencies that maintain a
behavior set
We’re looking at cognitive distortions that maintain a
behavior set
We’re maintaining an empirical mindset
We’re utilizing experiments to test assumptions and
beliefs
We’re valuing skill generalization, and using logs
and homework to track “real world” behavior change
Conceptualizing









Describe the patient in behavioral terms
What is their learning history?
How did these behaviors develop?
What is the function of these behaviors?
How are they maintained by the environment?
What cognitive distortions are present?
How did they develop?
How are they maintained? / How are they not disconfirmed?
How will these thoughts and behaviors interact with treatment?
Avoidance Paradigm
(Lynch & Cheavens, 2007)
Key Diagnostic Terms



Enduring maladaptive patterns of behavior
Exhibited across many contexts
These patterns develop early, are inflexible and are
associated with significant distress or disability
What’s the theme?
 Pervasiveness
This is something we are likely to see “in the room with us”
AXIS II BELIEFS AND STRATEGIES
Personality
Disorder
Avoidant
Dependent
Core Belief
Belief about
about the Self Others
I’m unlovable.
I’m helpless.
Other people
will evaluate
me
negatively.
Other people
should take
care of me.
Assumptions
If people know
the real me,
they’ll reject
me.
If I put on a
façade, they
may accept
me.
If I rely on
myself, I’ll fail.
If I depend on
others, I’ll
survive.
Behavioral
Strategy
Avoid intimacy
Rely on other
people
Obsessive
Compulsive
Paranoid
Antisocial
My world can
go out of
control.
I’m vulnerable.
I’m vulnerable.
Other people
can be
irresponsible.
If I’m not totally
responsible,
Control others
my world will
rigidly
fall apart.
Other people
are malicious.
If I impose rigid
rules and
structure,
things will turn
out okay.
If I trust other
people, they
Be overly
will harm me,
suspicious
Other people
are potentially
exploitative.
If I am on my
guard, I can
protect myself.
If I don’t act
first, I can be
hurt.
If I can exploit
first, I can be
on top.
Exploit others
Narcissistic
I’m inferior.
(The manifest
compensatory
belief is I’m
superior.)
Histrionic
I’m nothing.
Other people
are superior.
If others
regard me in a Demand
non-special
special
way, it means treatment
they consider
me inferior.
(The manifest
compensatory
belief is others
are inferior.)
If I achieve my
entitlements, it
shows I am
special.
Other people
will not value
me for myself
alone.
If I am not
entertaining,
others won’t
be attracted to
me.
If I am
dramatic, I’ll
get others’
attention and
approval.
Entertain
Schizoid
I’m a social
misfit.
Other people
have nothing to
offer me.
If I keep my distance Distance self
from others, I’ll
from others
make out better.
If I try to have
relationships, they
won’t work out.
Schizotypal
I am defective.
Other people
If I sense that others Assume
are threatening. are feeling
hidden
negatively toward
motives
me, it must be true.
If I’m wary of others,
I can divine their
true intentions.
Borderline
Personality
Disorder
I’m defective.
Other people
I’m helpless.
will abandon
I’m vulnerable. me.
I’m bad.
People can’t be
trusted.
If I depend on
myself, I won’t
survive.
If I trust others,
they’ll abandon me.
If I depend on
others, I’ll survive
but ultimately be
abandoned.
Vacillate in
extremes of
behavior
TYPICAL OVERDEVELOPED and
UNDERDEVELOPED STRATEGIES
Personality Disorder
Overdeveloped
Strategy
Control
Responsibility
Systematization
Underdeveloped
Strategy
Spontaneity
Impulsivity
Dependent
Help-Seeking
Clinging
Self-sufficiency
Mobility
Passive-Aggressive
Autonomy
Resistance
Passivity
Sabotage
Intimacy
Assertiveness
Activity
Cooperativeness
ObsessiveCompulsive
Personality Disorder
Overdeveloped
Strategy
Underdeveloped
Strategy
Paranoid
Vigilance
Mistrust
Serenity
Trust
Narcissistic
Self-aggrandizement Sharing
Competitiveness
Empathy
Encouragement
Antisocial
Attacking
Deprive others
Exploit
Empathy
Reciprocity
Social sensitivity
Schizoid
Autonomy
Withdrawal
Intimacy
Reciprocity
Avoidant
Avoidance
Inhibition
Self-assertion
Gregariousness
Histrionic
Exhibitionism
Expressiveness
Impressionistic
Self-discipline
Control
Systematization
Adapted from Beck, A.T. Freeman, A. & Associates, Cognitive Therapy of Personality Disorders, 2004
When Client (and Therapist) Behaviors Interfere
with Treatment
What things do your clients do that
make it difficult to work with them?
 Anyone brave enough to talk about
things that they do that impacts
treatment?

 For some this can be avoidance of the real
issues
Emotions too high or too low



New learning is
not occurring
when emotions
are extremely
high
Hard to do good
work without
accessing
emotions
Want to shoot for
a moderate level
of emotion
Ever feel like this?
Basic Strategy for Working with
TIBs
1.
2.
Call it out
Highlight how behavior is not serving their
goals and how it affects your relationship

3.
4.
5.
It’s probably related to problems outside of
session
Get buy-in to work on it by relating in
session problematic behaviors to out of
session problematic behaviors
Get explicit permission to target it
Make TIB a focus of treatment
Saying I don’t know a lot
Differential: Hypotheses
 They don’t actually know (how they’re
feeling)
 They don’t want to talk about it
 They are afraid of how they’ll feel if they
talk about what your asking
 Other ideas?

Other Common TIBs
Missing sessions
 Consistently not doing the homework
 Being Hostile towards the therapist
 Constantly being in crisis
 Too Much Talking about Peripheral
Issues

What are your beliefs about interrupting a patient?
INTERRUPTING
SOOTHING VS. THERAPEUTIC
• Most of the clients we work with live extremely
stressful, painful, and chaotic lives
• While we certainly want to be emphatic and
validating
• The most compassionate thing we can do is
work with them to build a better life
• This invariably includes: interrupting people,
sticking to an agenda, and making goals
Dissociation: Strategy
Grounding

Grounding is a set of simple strategies
to detach from emotional pain (for
example, drug cravings, self-harm
impulses, anger, sadness). Distraction
works by focusing outward on the
external world-- rather than inward
toward the self. You can also think of it
as “distraction,” “centering,” “a safe
place,” “looking outward,” or “healthy
detachment.”
Mental Grounding




Describe your environment in detail using all your senses.
For example, “The walls are white, there are five pink chairs,
there is a wooden bookshelf against the wall...” Describe
objects, sounds, textures, colors, smells, shapes, numbers,
and temperature. You can do this anywhere.
Play a “categories” game with yourself. Try to think of “types
of dogs”, “jazz musicians”, “states that begin with ‘A’”, “cars”,
“TV shows”, “writers”, “sports”, “songs”, “European cities.”
Say a safety statement. “My name is ____; I am safe right
now. I am in the present, not the past. I am located in _____;
the date is _____.”
Read something, saying each word to yourself. Or read
each letter backwards so that you focus on the letters and
not on the meaning of words.
Physical Grounding






Grab tightly onto your chair as hard as you can.
Touch various objects around you: a pen, keys, your clothing, the
table, the walls. Notice textures, colors, materials, weight,
temperature. Compare objects you touch: Is one colder? Lighter?
Dig your heels into the floor-- literally “grounding” them! Notice the
tension centered in your heels as you do this. Remind yourself that
you are connected to the ground.
Carry a grounding object in your pocket-- a small object (a small
rock, clay, ring, piece of cloth or yarn) that you can touch whenever
you feel triggered.
Walk slowly, noticing each footstep, saying “left” “right” with each
step.
Focus on your breathing, noticing each inhale and exhale. Repeat
a pleasant word
Soothing Grounding





Think of favorites. Think of your favorite color, animal,
season, food, time of day, TV show.
Picture people you care about (e.g., your children; and
look at photographs of them).
Remember the words to an inspiring song, quotation, or
poem that makes you feel better (e.g., the Serenity
Prayer).
Remember a safe place. Describe a place that you find
very soothing (perhaps the beach or mountains, or a
favorite room); focus on everything about that place-- the
sounds, colors, shapes, objects, textures.
Say a coping statement. “I can handle this”, “This feeling
will pass.”
LET’S PRACTICE
Does
anyone have a difficult client?
Practice
Forming
Conceptualizing
a compassionate
conceptualization
Identifying the contingencies
Individualized treatment plan
Role-plays
Yes,
let’s do this
Your Homework:

Watch a YouTube video of a good CBT
session
Questions & Answers