TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY FOR VETERANS AND MILITARY SERVICE MEMBERS WITH POSTTRAUMATIC STRESS DISORDER PDF Free Download
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TRAUMA-FOCUSED COGNITIVE BEHAVIORAL
THERAPY FOR VETERANS AND MILITARY SERVICE
MEMBERS WITH POSTTRAUMATIC STRESS
DISORDER
INSTRUCTOR
Scott H Waltman, PsyD, ABPP, is a clinician, international trainer, and practice-based
researcher. He currently works with veteran and military service members. His interests include
evidence-based psychotherapy practice, training, and implementation in systems that provide care
to underserved populations. He is certified as a qualified Cognitive Therapist and
Trainer/Consultant by the Academy of Cognitive & Behavioral Therapies. He also is board
certified in Behavioral and Cognitive Psychology from the American Board of Professional
Psychology. He is a board member for the International Association of Cognitive Psychotherapy.
More recently, Dr. Waltman, worked as a CBT trainer for one of Dr. Aaron Beck’s CBT
implementation teams in the Philadelphia public mental health system. He is the first author of the
book Socratic Questioning for Therapists and Counselors: Learn How to Think and Intervene like
a Cognitive Behavior Therapist.
SYLLABUS
Introduction
Military Culture
Terms and Acronyms
Values
Military Life and Seeking Care
PTSD in Military and Veteran Populations
VA/DoD Clinical Practice Guidelines for Treating PTSD
Cognitive Behavior Therapy for PTSD Overview
Cognitive Processing Therapy
Prolonged Exposure
Cultural Considerations
Treating Moral Injury in Military Populations
Summary
References
LEARNING OBJECTIVES
Upon completion of this course, the learner will be able to:
1. Identify critical elements of military culture.
2. Explain the theoretical underpinnings of CBT for PTSD.
3. Describe evidence-based approaches to treating PTSD.
4. Explain the application of technology aides in treating PTSD.
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5. Identify trauma-related stuck point cognitions in clients.
6. Describe how to conduct exposure to trauma memories.
7. Recognize moral injury in military populations.
INTRODUCTION
Cognitive Behavioral Therapy (CBT) is considered to be the “gold standard” in
psychotherapy (David et al., 2018; Hofmann, 2021). This does not mean that it is the only therapy
that works or that it works better than other therapy types; however, it does mean that CBT has a
proven track record in treating a wide variety of problems and presentations. In fact, Fordham and
colleagues (2021) recently conducted an empirical review analyzing 494 meta-analyses and
systematic reviews of CBT for various problems and presentations, in varied settings, and with
varied populations. Their research concluded that there is a preponderance of evidence supporting
CBT as generally effective at improving quality of life across problems, presentations, populations,
and settings (Fordham et al., 2021).
In recent years, body-focused or somatic therapies for trauma have gained in popularity.
Truisms like “the body keeps the score” (van der Kolk, 1996) highlight the mind-body connection
and ways the effects of trauma are observed in bodily distress. Therapy strategies such as Polyvagal
therapy have grown in popularity following this, as well (Porges, 2018). To date the outcome data
for polyvagal therapy is insufficient to determine its effectiveness at treating the effects of trauma,
and there is criticism from the scientific community with respect to the precise assumptions of
polyvagal theory (Liem, 2021). The future will reveal what the optimal therapy for treating trauma
is. Currently, the gold standard is CBT. Further, research on trauma-focused therapy reveals that
cognitive modification is likely the active ingredient in trauma-focused therapy. In other words,
changes in cognitive factors have been demonstrated to precede and predict changes in trauma-
reaction symptomology (Ehlers et al., 2021). This course is a review of the current state of the
science of CBT in the treatment of posttraumatic stress disorder (PTSD) in military and veteran
populations.
Beginning with a discussion on military culture, the course is an overview and illustration
of how to treat PTSD in veterans and military service members in a manner that is consistent with
the Clinical Practice Guidelines (CPG) of the Department of Defense and Veterans Health
Association. Although there are indeed unique cultural considerations to treating PTSD in military
populations and this course reviews relevant literature and recommendations, the main focus of
the course is the two CPG preferred treatment protocols for treating PTSD: prolonged exposure
and cognitive processing therapy. The course covers the underlying principles of these protocols,
which are further illustrated with case examples and dialogues.
MILITARY CULTURE
To work with military and veteran populations in a culturally responsive manner, a
clinician needs to develop a working knowledge of terms, common vernacular, acronyms, and
military culture.
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Terms and Acronyms
A comprehensive glossary of terms from the Department of Defense (DoD) dictionary is
freely available at http://www.jcs.mil/Doctrine/DOD-Terminology/). A quick summary tool is also
freely available at https://www.va.gov/vetsinworkplace/docs/em_termslingo.asp.
The term Service Member (abbreviated SM) refers to all military service members
(including veterans). Service members are further distinguished by their military branch; other
important terms to know are:
• Soldiers are members of the Army,
• Sailors are members of the Navy,
• Airmen are members of the Air Force,
• Coast Guardsmen are members of the Coast Guard,
• Marines are members of the Marine Corps,
• Guardsmen are members of the National Guard, and
• Reservists are members of the Reserve.
Some acronyms are pronounced phonetically (i.e., AWOL) and others are spelled out (i.e.,
CO or XO). Here, Table 1 presents some key acronyms, slang, and official terms.
Table 1. Military Acronyms, Slang, and Official Terms
ADSEP - Administrative Separation
CDR - Commander
IRT In reference to
ABU - Airman Battle Uniform
CO Commanding Officer
LIMDU -
Limited Duty
ACU - Army Combat Uniform
IAW - In accordance with
AFSC - Air Force Specialty Code
MEU - Marine Expeditionary Unit
AOR - Area of Responsibility
MOB/DEMOB - Mobilization/Demobilization
AWOL - Absent Without Leave
CONUS - Continental United States
CHU - Containerized Housing Unit
MST - Military Sexual Trauma
APO - Army Post Office
(overseas address)
COB - Close Of Business: the end of the day or
duty shift
HMMWV - (Humvee)
High Mobility Multi-purpose Wheeled
Vehicle
Garrison - A body of troops; the place where
such troops are stationed; any military post,
especially a permanent one
MEDEVAC - Medical Evacuation
Down Range - In a deployed combat setting
Inside the wire On base downrange
IBCT - Infantry Brigade Combat Team
OPTEMPO
Operating Tempo/Operations Tempo
TDY – Temporary
Duty Yonder
NEC - Naval Enlisted Classification
OCONUS - Outside the Continental United
States
PCS - Permanent change of station
(relocating)
Outside the wire - Off base down range
DD 214 - Certificate of release or discharge
from active-duty service
MEB/PEB - Medical Evaluation Board/Physical
Evaluation Board (components of being
medically retired from the service)
NCOIC - Non-Commissioned
Officer In Charge
IED/VBED - Improvised Explosive Device/
Vehicle Borne Explosive Device
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OPSEC - Operation Security
ROTC – Reserve Officer Training Corps
OIF - Operation Iraqi Freedom: official name used for the War in Iraq
OEF - Operation Enduring Freedom: official name used for the War in Afghanistan
V/R – Very Respectfully: used as an end greeting in written communication or email
XO - Executive Officer (the second officer in command)
POC - Point Of Contact
the person to liaise with
on a given matter
NCO - Non-Commissioned Officer: an enlisted person
with command responsibility over soldiers of lesser rank
MOS - Military Occupational Specialty: job or career specialty (e.g., infantryman,
intelligence analyst, operating room specialist, military police, etc.)
SM – Service member, a term used to refer to all active duty, reserve, guard, retired, or former
members of the armed forces
SOP – Standard Operating Procedure: the routine manner of handling a set situation
Theater – The geographical area for which a commander of a
geographic combatant command has been assigned responsibility
Shitbird - an insult for
someone who is deemed
undisciplined or useless
Rear-D – Rear Detachment
(A portion of a unit that did not deploy with everyone else,
usually due to medical problems)
UCMJ - Uniformed Code
of Military Justice (the
foundation of military law)
Values
Military SMs are perhaps more cohesive and concerned about the people they work with
than their civilian counterparts; in military culture there is a strong pull for camaraderie. The work
hours of SMs can be unpredictable and their guiding principle is always “mission first.” This means
that SMs are commonly task-oriented (which aligns well with a cognitive behavioral framework).
The orientation around missions includes personal sacrifice and, as such, SMs are never really “off
the clock” in the same way that their civilian counterparts might be. This can make it hard to have
a balanced lifestyle when the operating tempo (OPTEMPO) is high. This can strain relationships
if civilian family members have a hard time with SMs’ obligations to do whatever they are asked
whenever they are asked to do it. So, families are often making sacrifices as well.
The “mission first” principle dictates that SMs’ are assigned duties based on the needs of
the military. In the unfortunate event that SMs end up in a location or unit that is not a good fit, it
is likely that there is not an easy remedy. A SM may need to endure a potentially unfavorable
situation for as long as it lasts. There are avenues for addressing concerns with leadership (e.g.,
equal opportunity [EO], inspector general [IG], or open-door policies), though the hierarchy of
military is a cultural construct in, and of, itself.
Many SMs join the service out of a sense of duty or because the tight knit affiliation is
attractive to them. Others join because they are trying to leave a bad situation or do not see an
alternative career path. Providers should ask the SM they are treating why they joined the service
as part of their assessment. The context of the SM’s initial motivation can inform an understanding
of the trauma-related beliefs that are being targeted. There is often the most distress when the
camaraderie and trust of fellow service members is violated; this is best exemplified with military
sexual trauma (MST), which is an ongoing serious problem (Monteith et al., 2021).
Values are an integral part of the military system with each branch having their own unique
set of values and corresponding strengths. The Core Values of DoD and the Services are as follows:
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• DoD: Duty, integrity, ethics, honor, courage, and loyalty.
• Air Force: Integrity first, service before self, and excellence in all we do.
• Army: Loyalty, duty, respect, selfless service, honor, integrity, and personal courage.
• Coast Guard: Honor, respect, and devotion to duty.
• Navy and Marine Corps: Honor, courage, and commitment.
(Military Leadership Diversity Commission, 2009)
Military Life and Seeking Care
Service members enlist or commission into specific military jobs and this affects what they
do while uniformed. Combat arms such as infantry (i.e., soldiers who engage in close range
combat) may typify what someone who is naïve to the military imagines when they consider life
in the service. There are many other professions represented in the military including medics,
nurses, mechanics, cooks, chaplains and their assistants, psychology technicians, human resources,
logistics, and fuelers - to name only a few. Stress may occur when there is a mismatch between
what the service member thought their job would be and what it actually is. For example, a soldier
who is trained to be a veterinary technician may be tasked with rounding up and euthanizing stray
dogs while deployed or a chaplain’s assistant may spend large and unexpected amounts of time
with the deceased.
There are factors that make SMs more and less likely to seek all types of health care while
uniformed which can influence their relationship with the medical system. One factor that may be
an obstacle to seeking care include the risk of getting flagged and placed on a nondeployable or
limited duty status, which could limit a SM’s ability to deploy or participate in operations with
their team. An individual’s deployability (i.e., medical readiness) affects a unit’s deployability;
therefore, their command team is notified when SMs are put on a limited duty status. This is also
one of the unique aspects of confidentiality in the military healthcare system. Given the highly
cohesive culture of the military, being placed on a nondeployable status could result in the SM
feeling as though they are letting their team down. In addition, medical appointments typically
occur during the workday, meaning the SM is away from work for the duration of their
appointment. This can result in increased work for their teammates and make the SM feel guilty
for seeking care. In extreme cases, their teammates may call them a “shammer” or accuse them of
malingering to get out of work, which can be a barrier to seeking necessary medical care as the
SM may want to avoid the stigma associated with needing and receiving care. Service members
may further be concerned that seeking care will affect their career (i.e., being selected for special
duties that would make them more likely to receive promotions). Service members may seek “off-
post” services from someone in the non-military community in an effort to avoid stigma and
protect their privacy by keeping it off of their military healthcare record which is regularly
reviewed by clinicians who need to medically clear the SM for deployment or a special duty.
Factors that make it important to seek care include the processes for disability claims and
service connection (i.e., disability payment). Notably, the U.S. Department of Veterans Affairs
(VA) is actually three separate organizations: VA Health Care (VHA), VA Benefits (VBA), and
VA National Cemeteries; however, each of these organizations has a unique mission in providing
ongoing care for veterans. It is important for clinicians who provide services to veterans to
understand that the VBA is associated with the financial aspects (disability payments) of a PTSD
service connection, while the VHA administers or coordinates the treatment. For the purposes of
this course the overarching term VA will be used. It is important for a SM to have documentation
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in their chart of all their medical (and behavioral health conditions) so they can receive continuity
of care in the VA after leaving the service. It is advantageous for the SM for this documentation
to be completed while they are still active duty or on an active-duty status, because it is a more
difficult process to claim a condition as a veteran that was not observed (documented) while active
duty. There is also a financial aspect as well. Service members typically get a disability payment
called a service connection, which is a prorated amount of their regular pay while uniformed.
They receive a higher rate for injuries that are caused by military service than for those that were
exacerbated by military service. Meaning a SM would likely receive a higher service rating
(disability payment) for PTSD resulting from military combat than for PTSD related to a traumatic
experience that occurred prior to joining the military.
It is critical, for civilian providers especially, to know that life in the service is a life of
service and sacrifice. As the phrase coined by Korean War Veteran Howard William Osterkamp
goes, “All gave some, some gave all.”
PTSD IN MILITARY AND VETERAN POPULATIONS
Research on the treatment of PTSD in military and veteran populations has expanded in
both quantity and quality over the past two decades. Much of the advancements to this knowledge
base has been driven an increased need for treatment secondary to military actions in the recent
wars in Iraq and Afghanistan. Veterans (i.e., individuals who have left the military) and military
SMs (i.e., those currently serving) are at increased risk for PTSD, particularly those who have
served in combat (Kessler et al., 1995; Prigerson et al., 2002). Though diagnostic criteria for PTSD
have shifted over the years (APA, 2013), rates of PTSD in Vietnam veterans range from 19 to 30%
(Dohrenwend et al., 2006). Similar rates are found in veterans who served in Iraq and Afghanistan
with prevalence rates ranging from 12 to 25% with variation due to military status (e.g., active
duty, National Guard, reserve), time-period, and location of military operations (Moore & Penk,
2019).
As noted by Moore and Penk (2019), the scientific evidence supporting all categories of
interventions for PTSD trails current knowledge regarding the development, course, and prognosis
of the condition. This became most apparent following the publication of a 2007 Institute of
Medicine (IOM) report, which reviewed the state of the evidence for effective treatments of PTSD
(Institute of Medicine, 2007). After reviewing 90 randomized controlled trials of
psychotherapeutic and pharmacological interventions, the IOM concluded that there was
insufficient evidence supporting the use of medications in the treatment of PTSD and exposure
therapy was the only psychotherapeutic intervention with adequate research support.
VA/DoD Clinical Practice Guidelines for Treating PTSD
Results from the more recent Department of Veterans Affairs/Department of Defense
(VA/DoD) Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and
Acute Stress Disorder (Department of Veterans Affairs and Department of Defense; VA/DoD,
2017) were similar. Trauma-focused, manualized psychotherapies such as Prolonged Exposure
(Foa & Kozak, 1986) and Cognitive Processing Therapy (CPT, Resick & Schnicke, 1992) were
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recommended as first-line interventions whereas pharmacotherapy (specifically sertraline,
paroxetine, fluoxetine, and venlafaxine) and manualized, non-trauma focused psychotherapies
(e.g., Stress Inoculation Training, Present-Centered Therapy) were recommended as second-line
interventions. Thus, trauma-focused psychotherapy is the preferred treatment for PTSD.
Previous versions of the clinical practice guidelines advocated for component-based
treatments of trauma focused therapy which were flexible. Meaning, as long as the clinician
included the appropriate components of treatment there was freedom and flexibility in how they
incorporated those elements. Those elements were trauma narrative, exposure therapy, cognitive
restructuring, relaxation training, and stress management skills (Moore et al., 2021). The guidance
from the current clinical practice guidelines is to follow the treatment manuals with fidelity
(VA/DoD, 2017). If there is not an expected treatment response, then the first recommendation
from the clinical practice guidelines is to assess treatment to ensure that fidelity to the manual is
present. This is a shift in how PTSD is being treated in the VA and DoD systems.
In recent years, there have been a number of advances in the psychotherapeutic treatment
of military-related PTSD. These include research on the pacing of treatment. For example, it was
found that ten sessions of prolonged exposure (PE) delivered in rapid context (i.e., a 2-week time
period) was non-inferior to the typical 8-week time period for this dose of treatment (Foa et al.,
2018). There are also findings that CPT can be delivered in a 2-week intensive timeline as well
(Bryan et al., 2018). Similarly, an archival study of Eye Movement Desensitization and
Reprocessing (EMDR) with military related PTSD found that twice daily sessions of EMDR
produced comparable results to weekly session (Hurley et al., 2018). Both dosages are effective at
treating PTSD and support the conclusion that an intensive dose of trauma-focused therapy can
produce comparable results to standard treatment in a shorter timeframe.
Notably, though the VA/DOD CPG recommend EMDR for the treatment of PTSD, much
less research has been done on EMDR in the VA and DOD than compared to PE or CPT (McLay
et al., 2016). To account for this, one study did an effectiveness study of EMDR with active duty
SMs. That study used a record review as the method and the researchers concluded that EMDR
outperformed treatment as usual with shorter courses of treatment and greater reductions in
symptoms. Methodologically, there are some problems with this study such that it is hard to make
generalizations from their findings, beyond echoing their main conclusion that a randomized
controlled trial is needed to further understand the clinical effects of EMDR with SMs (McLay et
al., 2016).
Additionally, a number of empirical reviews (i.e., meta-analyses) were recently conducted,
which updated current understandings of how to best treat PTSD in military populations. One
meta-analysis demonstrated the superiority of trauma-focused psychotherapy (e.g., PE, CPT, etc.)
over non-trauma focused therapies and pharmacological treatments for PTSD (Lee et al., 2016).
The developers of CPT conducted a randomized trial of CPT for PTSD in active-duty
populations at a military treatment facility (Resick et al., 2017). They found that individual therapy
outperformed group therapy. They report that even in individual therapy 50% of the SMs still had
PTSD at the end of treatment and that there is room for improvement (Resick et al., 2017). A
different small-scale study in the VA looked at treatment fidelity in CPT providers and concluded
that treatment fidelity was a predictor of clinical outcome (Holder et al., 2018), though this was a
study of only four VA therapists and nothing conclusive can be determined at this point. Generally,
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it has been recommended that providers should not have an overly rigid emphasis on fidelity of
treatment, with ‘flexibility within fidelity’ being a common recommendation (Kendall et al., 2008;
Waltman et al., 2017).
The use of virtual reality (VR) technology in psychotherapy is another area of innovation,
with a pilot trial of a new virtual reality therapy trauma management therapy (TMT) boasting a
65% PTSD remission rate (Beidel et al., 2019). Notably, these results have not been replicated,
and a small-scale randomized trial in a veteran population demonstrated the positive enduring
treatment effects of TMT, though it did not outperform standard VR exposure therapy for PTSD
(Beidel et al., 2019); in fact, the TMT PTSD remission rate dropped to 42% and traditional VR
exposure therapy had a 50% remission rate (Beidel et al, 2019). It is notable that a randomized
control trial comparing traditional PE and VR exposure therapy found that the innovation of VR
did not improve clinical outcomes over what is observed in traditional PE (Reger et al., 2016). In
fact, traditional PE outperformed VR at 3- and 6-month follow up (Reger et al., 2016).
The development of written exposure therapy (WET) is another development in the field;
a randomized trial with a mixed sample (veteran and non-veteran) found that 5 sessions of WET
was non-inferior to a full dose of CPT (Sloan et al., 2018). Treatment effects from WET have been
found to be enduring in a sample of veterans and nonveterans (Thompson-Hollands et al., 2018).
Non-trauma-focused mindfulness-based therapies have also been shown to have benefits
for military related PTSD in veteran populations (King et al., 2016), though these do not
outperform trauma-focused therapies (Lee et al., 2016). There was one randomized control trial in
a VA demonstrating the non-inferiority of non-trauma-focused mindfulness-based therapy
compared with PE (Nidich et al., 2018), though it was later pointed out that the PE effects observed
in that trial were substantially lower than what is typically observed (Tuerk et al., 2019).
The effectiveness of psychotherapy for PTSD in VA routine care was addressed by a
naturalistic archival doctoral dissertation (Rutt et al., 2017) that examined the charts of 750
veterans treated in 10 different states and found that PE and CPT were effective at treating PTSD
in the veterans who did not drop out of treatment; effectiveness was determined based on a
reduction in symptom inventory scores (i.e., PTSD checklist [PCL] scores) (Rutt et al., 2017). At
the final session, 65.5% of CPT patients and 60.8% of PE patients had total PCL scores below the
diagnostic threshold for PTSD; however, there is a caveat to these numbers - the percentage of
participants with a total PCL score below 50 before treatment was 19.6% for CPT and 17.2% for
PE. These results demonstrate that less than half of veterans who present for frontline PTSD
treatment with symptom severity significantly elevated on self-report measures will experience
clinically significant change (Jacobson & Truax, 1991); further, these results demonstrate that in
real world settings, observing symptom severity below clinical cutoffs does not necessarily
indicate an absence of distress or that there is no need for ongoing treatment.
Telepsychology is another area of treatment innovation (Waltman et al., 2020), with non-
inferiority trials demonstrating that telepsychology can be considered a suitable alternative to
traditional face-to-face therapy for PTSD in military populations (Acierno et al., 2016; Acierno et
al., 2017; Liu et al., 2019). A number of smartphone applications (app or apps) have been
developed for treating PTSD; these are ideally paired with professional care (Waltman et al.,
2020). For patients who are waiting for treatment, the use of these apps is superior to waitlist
control conditions, though these patients do not experience greater improvement after treatment is
complete (Ford et al., 2018). So, although these apps do not enhance outcomes, they can offer
relief while SMs wait for PTSD treatment. There are several free resources available from the “app
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store” Veterans Health Administration (https://mobile.va.gov/) with a specific section dedicated
to mental health.
A psychotherapy called accelerated resolution therapy is another recent development in the
treatment of PTSD (Waits et al., 2017). It has mostly been researched solely by one researcher and
there is only a single randomized control trial (where it outperformed an inert therapy in a treatment
sample that had mostly already received CPT or PE) (Kip et al., 2013). It is currently difficult to
make definitive statements about accelerated resolution therapy. Replications by independent
researchers and active treatment comparison groups are needed.
A significant advancement in the field of treating PTSD in military and veteran populations
is the Strong Star Consortium, which has been conducting novel research such as a trial of PE and
CPT on active-duty soldiers in the combat theatre to treat PTSD and target operational stress as it
develops (Peterson et al., 2020). This was a first look at the viability of this treatment option (n =
12); data was gathered between 2009 and 2013. The authors explain that it also might be the only
trial of its kind in the US military medical system because the research team designed to facilitate
research like this was disbanded years ago. “The Joint Combat Casualty Research Team, which
was established to facilitate U.S. military research in the combat theater, was disbanded with the
official end of the U.S. military conflict in Iraq in 2010 and Afghanistan in 2014. At the present
time, research in deployed U.S. military locations is no longer permitted” (Peterson et al., 2020;
p. 10-11). In the referenced study, both treatment conditions were associated with improvements,
though the improvements in the CPT condition were not statistically significant. Neither treatment
condition had follow-up data; also, one of the participants had increased symptoms. A larger
sample size is needed to better understand the effectiveness of treating PTSD in the combat theatre.
Long-term follow-up data is needed to understand if there are elevated risks for re-traumatization
when treatment is conducted in an active combat theatre. Further, a diagnosis of PTSD was not
officially established in the treatment sample. Rather, the operational diagnosis of combat
operational stress was used (this is a functional diagnosis used in military settings that could refer
to an acute stress reaction, PTSD, or subclinical/nonclinical stress reaction) which adds some
difficulty to the generalization of these findings to the treatment of PTSD.
In other developments, a randomized control trial found PE to be effective in treating PTSD
in an older adult (geriatric) veteran population, though treatment effects were only modest and
were mostly lost at follow up (Thorp et al., 2019). A new recent finding was that PE combined
with a cognitive behavioral substance abuse treatment protocol could be used to treat veterans who
had co-occurring PTSD and substance use disorders (Back et al., 2019). Positive results were also
found in a less exposure-based combined treatment for PTSD and substance use disorder in a
veteran population (Najavits et al., 2018). Similarly, a cognitive behavioral protocol for treating
co-occurring substance use disorders and PTSD in a veteran population, had positive outcomes,
but a high dropout rate (Capone et al., 2018). Notably, these three studies evaluated treatment
protocols with different emphases: exposure, coping skills, and group dynamics. Future research
will need to clarify optimal treatment ingredients for this comorbid population.
OVERVIEW OF COGNITIVE BEHAVIORAL THERAPY
FOR PTSD
There are two manualized cognitive behavioral treatments for PTSD that have been
designated as having strong research support by Division 12 of the American Psychological
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Association (Society Clinical Psychology, 2021) Prolonged Exposure (PE; Foa, 2007) and
Cognitive Processing Therapy (CPT; Resick, 1992). These are the same cognitive behavioral
treatments for PTSD that the VA/DOD CPG have recommended be used for treating PTSD in
military and veteran populations.
Notably, there are some indications that CPT may be better than PE at treating the guilt
that is often associated with PTSD (Resick et al., 2002). Cognitive behavioral treatments target the
mechanisms that are thought to maintain a problem (Butler et al., 2008; Ehlers et al., 2005; Foa,
2007; Resick; 1992). In the case of PTSD, it is theorized that symptoms are maintained by avoiding
cues and memories related to the trauma and maladaptive beliefs about what happened (Foa; 2007;
Resick, 1992). Avoidance is blocked through the use of exposure strategies and maladaptive
beliefs are addressed using Socratic questioning and cognitive restructuring (Waltman et al., 2020).
PE tends to emphasize the exposure piece, whereas CPT tends to emphasize the cognitive piece.
Cognitive Processing Therapy
CPT was originally developed for use with victims of rape (Resick, 1992; Resick, 1993),
and was later modified for combat-related trauma (Resick, 2007). The focus of CPT is modifying
beliefs about the meaning and implications of the traumatic event (Nishith et al., 2005; Resick et
al., 2008). This involves understanding how the event impacted a person’s set of beliefs (Sobel et
al., 2009).
Resick (1992; 2007) discusses the different ways that a person can respond to a traumatic
event. If the person interprets the event as being consistent with their previous assumptions, then
the individual will assimilate the event into their existing schemas. In contrast, if the occurrence is
counter to their previous learning, then a person will adjust their beliefs to accommodate this new
occurrence. Sometimes when an event is traumatic, the new learning is so poignant and unexpected
that a person may over-correct or over-accommodate their belief set. Over-accommodation often
involves a person over-generalizing trauma-based learning and developing beliefs such as, “The
world is dangerous,” or, “Other people are not to be trusted.” Over- accommodation is an over
correction like driving on the freeway, drifting into the next lane, and then jerking the wheel to
correct by pulling the care back into the intended lane. With trauma reactions over-accommodation
typically occurs after the shattering of a previous belief. A person responding to trauma with
assimilation is likely to experience guilt and self-blame and hold certain beliefs about the trauma
such as, “I should have known this was going to happen”. The goal of CPT is to foster adaptive
schematic accommodation. Typically, it is recommended to focus first on the stuck point beliefs
(described in greater detail later in the learning material) related to assimilation as they tend to be
more entrenched. This involves coming to terms with what happened and integrating this new
learning into the person’s belief set (Sobel et al., 2009).
Common fallacies that CPT addresses are that there is a just world and that good things
happen to good people and bad things happen to bad people (Resick, 1992;1993; 2007). People
who live their lives subscribing to these beliefs as a tacit contract with the universe experience
significant distress when they are involved in a traumatic event. The discrepancy between this
belief set and the reality of what has happened is often jarring and can lead to over-accommodation.
Due to the prevalence of this fallacy, it is typically directly inquired about and addressed (Resick,
2007). There often will be a trauma-related belief related to self-blame for the trauma, and the just
world fallacy often serves to reinforce that belief, which is why it needs to be targeted.
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Typical course of treatment
While a flexible approach to session lengths is recommended, the typical format of CPT is
the following 12 sessions which are elaborated and demonstrated below:
Session 1: Introduction and Education
Session 2: The Meaning of the Event
Session 2a: Traumatic Bereavement (Optional Session)
Session 3: Identifying Thoughts and Feelings
Session 4: Remembering the Traumatic Event
Session 5: Identifying 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
Cognitive modification of trauma-related beliefs (called stuck points) is the focus of CPT.
Skillful Socratic questioning (Waltman et al., 2020) predicts improved clinical outcomes when
CPT is used to treat individuals with PTSD (Farmer et al., 2017). In CPT, this Socratic process is
facilitated by an augmented and enhanced thought record called the Challenging Beliefs
Worksheet, which is functionally a number of thought records put together (Waltman et al., 2019).
When using CPT to treat PTSD in veteran and military populations, SMs are taught each
component of the Challenging Belief Worksheet one at a time. The full military version of the
CPT manual is freely available online (http://cptforptsd.com/cpt-resources/). A companion
smartphone app called CPT Coach is also freely available online (https://mobile.va.gov/app/cpt-
coach). CPT Coach has all the worksheets and handouts embedded in a free smartphone app that
can be used to facilitate treatment.
Service members are first taught how to use a basic rational-emotive therapy ABC
worksheet (Activating event, Belief, Consequence) and to ask themselves if their thoughts are
realistic and what they could alternatively tell themselves in the future. After the SM develops
proficiency with the ABC worksheet, they are introduced to the Challenging Questions Worksheet.
This is a list of questions to ask themselves about their stuck points. Next, they are introduced to
the Patterns of Problematic Thinking Worksheet that details common cognitive distortions and
thinking traps. Finally, all of that comes together in the Challenging Beliefs Worksheet. The goal
of a therapist using CPT is to work with the SM to identify their trauma-related stuck points (via
the impact statement described below). Then to incrementally and sequentially teach the
components of the Challenging Beliefs Worksheet with a focus on applying that thought record to
their stuck points. Originally, CPT also had a trauma narrative component that was mostly phased
out when it was found that outcomes without it were noninferior. There is a major caveat and
recommendation from the CPT treatment developers that this narrative component appears to still
be needed for SMs who are prone to trauma-response dissociation (Resick et al., 2016). What
follows is an illustrative case example of CPT for PTSD with a SM.
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Case Example: Cognitive Processing Therapy
Sergeant F (SGT F; a pseudo-client) is a 35-year-old married, Latino, cisgender man. SGT
F grew up in active war zone before immigrating to the US as a teenager. He joined the military
in a combat role as a young adult. Over the course of a decade of service, he combat deployed to
the wars in Iraq (OIF) and Afghanistan (OEF) and was promoted to the rank of a senior
noncommissioned officer. During his deployments he has abundant exposure to combat and death;
he also sustains several head injuries. He is later diagnosed with a Mild Neurocognitive Disorder
Due to Traumatic Brain Injury; his main impairments are attentional deficits and memory
impairments. SGT F seeks behavioral health services for assistance with difficulties sleeping.
His intake assessment and clinical interview reveals that he meets full criteria for PTSD.
The PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) scores in the clinical range with a
score of 65. Though SGT F has been exposed to multiple traumas, he is most distressed by the
death of one of closest friends. This friend volunteered for a dangerous mission and SGT F felt
guilty for not having successfully dissuaded his friend from going. He believes that his friend’s
death is his fault. SGT F has stuck points related to the world being dangerous. These are
preexisting beliefs from growing up in a war zone, and his trauma-related experiences have been
assimilated into these belief structures, causing a strengthening of his beliefs. SGT F holds the
assumption (i.e., schema) that the world is imminently dangerous and that he has to be on guard
at all times. “Every time you let your guard down, that’s when things happen.” Based on this
assumption he engages in a number of safety behaviors including constantly being on-guard,
taking on the role of sentry at his home, minimizing his interactions with the outside world, and
routinely checking on his family from the perspective that he is ensuring their safety. These
behaviors lead to strained marital and family relationships as there is also a corresponding
decrease in relationship-building behaviors. Along with the sleep disturbances, the lack of
intimacy with his family is the functional impairment he finds most distressing.
SGT F’s safety behaviors (subtle avoidances) serve to maintain his problems. He is so
fixated on perceptions of danger (hypervigilance) and his corresponding safety behaviors that he
is unable to attend to corrective experiences. This also leads to misattributions that his safety
behaviors are what keeps him, and his family, safe. Therefore, to facilitate cognitive modification,
his safety behaviors become targets of treatment.
Creating an Impact Statement and Stuck Point Log
As is the case in any course of CBT, the first step in CPT for PTSD is psychoeducation.
There are excellent psychoeducation materials embedded in the CPT coach app. Clicking on the
tab that looks like a book will reveal a number of resources. Specifically recommended materials
to review in session together with a SM include: ‘recovery versus non recovery from PTSD
symptoms’ and ‘stuck points - what are they.’ After the SM is oriented to what the cognitive
behavioral understanding of PTSD is and why treatment will involve cognitive strategies, the
therapy then moves into creating an impact statement to identify stuck points for the creation of a
stuck point log.
The impact statement is a written (preferably by hand) description of the impacts of the
trauma on the SM’s life. They are explicitly directed not to write a trauma narrative (i.e., what
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happened) but rather to write about the impacts and effects of the trauma. The exact written prompt
for the impact statement is contained in the CPT Coach app (it can be found by clicking on the
icon that looks like gears). Clinicians should ask SMs to write specifically about
• what they think was the cause of the trauma,
• how the trauma affected them,
• how it affected their beliefs, and
• how it affected them across a number of common domains such as trust, intimacy,
safety, and control.
An obstacle occurs early in treatment with SGT F. He does not complete the assignment to
write the initial impact statement. In discussing this with SGT F, the therapist frames this obstacle
as common, consistent with the model for PTSD, and as an example of avoidance. Adhering to the
CPT manual, this avoidance is blocked, by the therapist asking SGT F to say out loud the impact
statement and directing him to later write it out again as homework.
Notably, sometimes a SM will write out a trauma narrative instead of the impact statement;
although, this is a valuable exercise, the therapist and SM still work together in session to create
an impact statement. The impact statement reveals stuck points when reviewed for assimilation
and over-accommodation.
SGT F’s impact statement reveals a number of stuck points. He reports three main parts of
his life are affected by his PTSD: memories and thoughts of his fallen friend, emotional distance
from his family, and increased frustration at work. He is most distressed by the loss of connection
to his family and feelings related to losing fellow soldiers who were close to him. The most
distressing beliefs are related to the notion that the world is dangerous and that, “Just when you
let your guard down is when something happens.” These identified stuck points, specifically the
idea that when you let your guard down is when something happens is logged onto his stuck point
log.
This particular stuck point relating to bad things happen when someone lets their guard
down results in hypervigilance and over-prediction of danger (i.e., catastrophizing; Waltman &
Palermo, 2019), and can result in any number of safety behaviors including SGT F’s checking and
sentry-like behaviors. The stuck point log is found in the CPT coach app under the tab that looks
like gears. A user must have a stuck point log in order to use the full functionality of the app.
ABC Worksheet
The next step in CPT is teaching the client basic cognitive restructuring skills that are
typically applied to more peripheral thoughts; once the client is more adept at using these skills,
key stuck points become treatment targets.
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SGT F is taught to use the standard CPT thought record, the ABC worksheet (Activating
Event, Belief, Consequence) initially applying it to thoughts that he has let his wife down. He is
reasonably able to understand the skill and is asked to practice filling out some ABC worksheets
on his own as the action plan (i.e., homework). At the next session, SGT F reports difficulty doing
the ABC worksheets on his own. Namely, he is convinced the identified cognitions are, indeed,
true. Upon further inspection, it becomes clear that the thoughts he identified are relevant to his
stuck points and, due to his safety behaviors, he has a limited amount of disconfirming evidence
to draw from; thus, he is under the impression that these thoughts are true.
Therapist
OK, SGT F, you did a great job trying out the ABC worksheet on your own. Can we
talk about how it went?
Client
Yeah, I did it. But I don't know if I did it right.
Therapist
How so?
Client
Well, I wrote down the B and the C, but it seemed like my thought was accurate and
that didn't make me feel any better.
Therapist
It is possible that the thought was true. The point of the ABC worksheet isn't to say
that all of our thoughts are incorrect or irrational. Can we take a look at it together?
Client
Yes.
Therapist
Excellent, why don't you tell me a little bit about what was happening? Just so I can
have the background information.
Client
Well, I was at home, and I was waiting for my wife to be back from work, and I was
worried that something might have happened to her and so I texted her to make sure
that she was OK.
Therapist
That sounds like it was pretty worrisome for you.
Client
It was.
Therapist
So, the activating event was you were at home waiting for your wife to get home.
Client
Yes.
Therapist
And how were you feeling in this situation?
Client
I was nervous.
Therapist
OK, so nervous or anxiety goes down in the C or consequence column. And what did
you do when you felt nervous?
Client
I started texting her to see where she was.
Therapist
So, you were checking on her - sort of like an accountability kind of thing - I'm sure
you knew where she was.
Client
Yes.
Therapist
OK this behavior is also a consequence so put this in the C column as well.
Client
OK.
Therapist
Now, what were you telling yourself that made you nervous and made you start
texting her.
Client
I was afraid that something happened.
Therapist
So, you had a thought that something had happened.
Client
Yes.
Therapist
And what is it that you thought happened?
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Client
I don't know.
Therapist
What were you afraid might have happened?
Client
Maybe she was injured or something bad happened.
Therapist
So maybe she was in danger or hurt?
Client
Yes.
Therapist
OK, we're doing a good job with the form so far. So, A - activating event - you were
at home waiting for your wife to get home. B - belief - you had a thought that
something bad might have happened to her. C - consequence- you felt anxious and
started texting her to make sure she was OK.
Client
Yes.
Therapist
Now there are two questions in the form. Let's practice going over those questions.
First question is are my thoughts from B realistic? So, was the thought that something
happened to your wife realistic?
Client
Well, something could have happened.
Therapist
True, and at the same time is it realistic that something did happen?
Client
Stuff happens all the time, you never know, maybe something did happen.
Therapist
It's true that you don't know, and I don't know. But it sounds like the amount of anxiety
you had was not that something could happen, but more that something did happen.
Client
Yes, that's true.
Therapist
So maybe it's realistic that something could happen but was it realistic to assume that
something did happen?
Client
Maybe not.
Therapist
Maybe not. I want to acknowledge that this thought lines up with your stuck point
really well. And so, getting movement on this is often an incremental thing. Moving
from something probably did happen to maybe something happen would be
incremental progress. Is there a difference in the amount of anxiety you feel when
you tell yourself something might have happened versus something probably did
happen?
Client
Yeah, both make me feel nervous, but something might have happened isn't as bad or
something probably did happen. But I don't like not knowing I want to know that she's
OK.
Therapist
And how does she respond with you constantly texting her to make sure she's OK?
Client
She hates it.
Therapist
I imagine she does. Does she ever stop responding because she's bothered by you?
Client
Yes! And we fight about that a lot!
Therapist
So, this is one of the ways that your PTSD has negatively impacted the relationship.
Client
Yes.
Therapist
And, I know you were saying that you were really motivated to improve the
relationship and that's one of the reasons you came in for treatment.
Client
Yeah, I have lost so much my life I don't want to lose this.
Therapist
It sounds like you really care about her.
Client
I do.
Therapist
The next question on the worksheet asks what can you tell yourself on such occasions
in the future? So…. what’s something you can tell yourself in the future that will help
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you feel a little less anxious, but also not respond in a way that's going to be damaging
to your relationship?
Client
I don't know.
Therapist
When you argue with her about the texting what does she tell you then?
Client
She says that I should just trust that things are OK if there isn't any major reason to
think otherwise.
Therapist
Is that something you could tell yourself next time? Could you tell yourself things are
probably OK and there's not a major reason to think otherwise?
Client
I could.
Therapist
Would you believe it?
Client
Yes, and I would be afraid it's not true.
Therapist
That's part of what the PTSD is - your brain is stuck in survival mode such that you're
more likely to think that something is dangerous when it's not actually dangerous. If
you were to tell yourself that things are probably OK and there's not a reason to think
otherwise would that make it easier to not text her in the same way that you have
been, the way that really irritates her?
Client
Yeah, I think so.
Therapist
Does that make it worth it?
Client
I think so.
Therapist
OK, so little by little we're making progress worksheet by worksheet we're getting
there. Let's write down this new thought on this ABC worksheet and let's keep
practicing.
There is flexibility in the CPT protocol. The goal is to build up to the full Challenging
Beliefs Worksheet, but the clinician has to go at the pace of the SM. Usually, several weeks are
spent on the ABC worksheet given that it is a foundational component of the treatment. Such self-
awareness skills as identifying thoughts and emotions are also requirements that may require
additional attention before moving on.
Challenging Questions Worksheet
When the SM is able to do a number of ABC worksheets well and seems like they are
getting the hang of it, the clinician folds in additional elements to make the process more robust.
If a clinician is following the protocol this typically occurs around session 5. Below is an example
of how the clinician introduced and applied the challenging questions worksheet with SGT F.
Therapist
SGT F you’re really getting the hang of the ABC worksheet, so I want to fold in the
next piece. Essentially, we’re going to add on a few more things to make a more
elaborate ABC worksheet. Today we are adding in the challenging questions
worksheet. This is a list of questions to ask yourself to help when you're looking to
find a more realistic B for the ABC worksheet. The idea is that you'll use this
challenging question worksheet when you're filling out an ABC worksheet to
evaluate the thoughts and the situation. To help you get more accustomed to the form
why don't we go over it together. Let's apply it to the stuck point we've been targeting.
Remember, this is an incremental process and part of this is also just me learning
more about you and you helping me understand where you're coming from more as
well. Is that OK?
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Client
Yes, sir that'll be fine.
Therapist
Great. The stuck point we've been looking at is this idea that the world is dangerous
and if you put your guard down something bad is going to happen specifically
something physically dangerous. The first question in the challenging questions
worksheet is ‘what is the evidence for this stuck point?’ So, what is the evidence that
if you put your guard down something physically damaging and dangerous is going
to happen?
Client
Well, my buddy died when I least expected it.
Therapist
That's true. Is there other evidence that this stuck point is true?
Client
You know how I grew up. It was a dangerous place and people got hurt all the time,
so you had to be on guard to make sure nothing bad was going to happen.
Therapist
So, in the war zone you grew up in and when you were downrange in both these
settings things that were dangerous unexpectedly happened.
Client
Yes.
Therapist
OK, let's write that down. Now the next question on the challenging questions
worksheet is ‘what is the evidence against this stuck point?’ So, what is the evidence
against the idea that if you put your guard down something dangerous is going to
happen?
Client
I don't know.
Therapist
Well, has anything dangerous happened since you’ve been back stateside?
Client
No, but that might just be because I'm always on guard to make sure nothing bad
happens.
Therapist
So, nothing bad has happened since you've been back but there's a thought that
maybe nothing bad has happened because of your hypervigilance?
Client
Yes.
Therapist
OK, that's good information for me to have. As we continue working on this let's
write that down. I think we're getting good information. The next question on the
challenging questions worksheet is ‘is your stuck point a habit or based on facts?’
So - is it a habit to assume that something bad is going to happen at any moment?
Or is it a fact that something bad is going to happen at any moment?
Client
That I don't know. It is a habit to expect the worst-case scenario and I also don't
know that it's not true. Something bad could happen at any moment.
Therapist
True, and we've talked about this, right? There's a distinction between the idea that
something could happen and something is likely to happen and even something will
happen. Is the anxiety you feel more in line with the idea that something could
happen or more in line with the idea that something will happen?
Client
My anxiety is more like something will happen.
Therapist
And is the idea that something will happen based on a habit or based on facts?
Client
It's a habit.
Therapist
It's a difficult habit to break - I can see that. Let's write that down - it's a habit and
it's a hard habit to break because you don't know if something is going to happen,
kind of ever, in life.
Client
Yeah, I don't like that. Like, if I knew something bad is going to happen, it might be
easier than not knowing if something bad is going to happen, because then at least I
could respond to it.
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Therapist
Uncertainty often breeds anxiety for people. Sometimes service members even say
that they feel less anxious when they're down range because at least there they know
they're in danger, and so they paradoxically feel less anxious in that environment
sometimes.
Client
I get that. It's scary to be there but at least you know you're in danger so you can
take steps to try and keep yourself safe. Here I don't know if I'm in danger and that’s
what really scares me.
Therapist
Let me write that down, that sounds important. OK, the next question on the
challenging questions worksheet is ‘in what ways is your stuck point not including
all of the information?’ So, in what ways is your idea that something bad is going to
happen when you least expect it not including all of the information?
Client
Well like you said nothing bad has happened yet since I've been back.
Therapist
I hear the yet there.
Client
Yes. Nothing bad has happened yet. I don't know that nothing bad is going to happen.
That's why I have to be ready.
Therapist
So, there's two pieces that aren't accounted for with your stuck point. One: nothing
has happened the whole time you've been back. Two: you're not psychic - you can't
predict what's going to happen and that is scary in itself
Client
Yes.
Therapist
OK, let's write that down as well. Now, the next question on the challenging
questions worksheet is’ does your stuck point include all or none terms?’ Does your
stuck point that something bad is going to happen when you least expect it include
all or none terms?
Client
I'm not sure what you mean by that.
Therapist
Well, all or none or all or nothing terms would refer to seeing things in absolutes or
over generalized ways. If you think that there's a chance that something could
happen at some point, are you generalizing that specific something could happen at
any point or all points? Meaning are you thinking if a specific hypothetical danger
exists then you're completely vulnerable all the time?
Client
Yes.
Therapist
Yes to?
Client
Yes, I think my anxiety that something bad will happen is all or nothing in that I'm
afraid something bad will happen all the time.
Therapist
OK, I'll write that down, and this is something we can continue to work on as well.
The next question in the challenging questions worksheet is’ does your stuck point
include words or phrases that are extreme or exaggerated like always, forever,
never, need, should, must, can't, and every time?’
Client
I don't think so.
Therapist
The way we wrote it down it doesn't have any of those words in it. That's true. Maybe
there's an implied always or every time to the situation?
Client
Yes, I can see that.
Therapist
I’ll write ‘maybe’?
Client
Yes.
Therapist
We're doing a great job with this! The next question on the challenging questions
worksheet is ‘in what ways is your stuck point focused on just one piece of the event?’
Now, not every question is going to apply to every stuck point. This question seems
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like it might be more related to the self-blame you have related to the death of your
buddy. Where you blame yourself for not volunteering for the mission that he
volunteered for. I'll make a note to talk about this question for the next time we talk
about that stuck point. But I'm curious, do you think that this stuck point that
something bad might happen is focused on just one piece of the traumatic events?
Client
Well - I'm mostly focusing on when something bad happened not when something
bad didn't happen.
Therapist
You're getting good at noticing that pattern.
Client
Well, I'm good at noticing that you notice it.
Therapist
I do and it's something we will continue to work on.
Client
I know, I think it will help.
Therapist
I hope so. OK - let's look at the next question on the challenging questions worksheet
‘where did this stuck point come from? Is this a dependable source of information
on this stuck point?’ So, where did this stuck point that something bad could happen
at any moment come from and is it a reliable source?
Client
I'm not sure I understand this question either.
Therapist
Well, the treatment is designed for a broad base and different types of traumas so
not every question is going to be relevant. The way that I see this as being potentially
relevant is a question of the environment in which these stuck points developed? And
how well do those environments match the current environment that you're in? Are
those dangerous environments that you grew up in and that you deployed in reliable
predictors of how life is here while you're in garrison?
Client
Oh, yeah – I get that. Well, those were very dangerous places. Bad stuff does happen
here too.
Therapist
I know that bad stuff happens here definitely. Is here as dangerous as there?
Client
No.
Therapist
So are the rules for survival there reliable predictors of how to survive here?
Client
I guess not but that makes me nervous to put my guard down.
Therapist
I totally get that. I think anyone who grew up where you grew up and who served
where you served would feel uneasy putting their guard down. It's a different set of
assumptions and someone who grew up in the suburbs and had a very quiet life. So,
it makes perfect sense that you have these ideas that it's very dangerous. And is the
environment that those ideas developed in a reliable predictor of your current
situation?
Client
No.
Therapist
OK, let's write that down. Now, the next question on the challenging questions
worksheet is ‘how is your stuck point confusing something that is possible with
something that is likely?’ This one seems to be very relevant. How is your stuck point
that something bad could happen confusing with the possibility that something is
very likely to happen?
Client
This is something you talk with me about a lot. So, it's relevant. We talk about how
there is a possibility that something could happen but that doesn't mean that there's
a likelihood that something will happen.
Therapist
And what does that mean?
Client
It means that something could happen but that doesn't mean that I should be
expecting something to happen or assuming something will happen.
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Therapist
Why not?
Client
Because when I'm always assuming something bad is going to happen then those
assumptions cause me to feel anxious which causes me to not want to go places, be
irritable and frustrated with my family, be really controlling of my family, and just
be miserable.
Therapist
Exactly, and you have had too much of that anxiety and exhaustion your life and it's
taking too much of a toll on you and your family it's time to let go and be at ease.
Client
I know.
Therapist
You're working so hard on it in here. I really appreciate it and I'm so impressed by
how all that you're doing to deal with this.
Client
I am so tired of this PTSD. I really need some relief from it.
Therapist
I know, I'm glad we're working on it. And you're doing such a good job working on
it that we're moving on to the next level of CPT which is this challenging questions
worksheet. The next question on this worksheet is ‘in what ways is your stuck point
based on feelings rather than facts?’ So, in what ways is your stuck point that
something bad is going to happen if you put your guard down based on feelings and
not facts?
Client
It's a fact that sometimes I have feelings that something bad is going to happen.
Therapist
That is very true. And are those feelings that something bad is going to happen the
same thing as having evidence or facts to support the idea that something bad is
definitely going to happen?
Client
No, that's not the same.
Therapist
OK, let's write that down and the final question on the worksheet is ‘in what ways is
this stuck point focused on unrelated parts of the event?' Now this is another question
that I think is more relevant to other stuck points. Like where your friend volunteers
is more focused on the fact that you didn't volunteer and less focused on the fact that
they volunteered before you had an opportunity to volunteer. So, this is another
question that can be helpful, but might not apply it to all the stuck points. Now I want
to check-in with you we just went through a lot of questions. Do you think these
questions will help you be more effective with your ABC worksheets?
Client
I think so. I'm not sure how I remember them though there's a lot of them.
Therapist
Oh, let me show you where these are in the apps that way you don't have to memorize
them you can just read them.
Client
Too easy.
Therapist
Now, this coming week I want you to keep doing your ABC worksheets and I want
you to also use this challenging questions worksheet to evaluate the belief in your
ABC worksheet so we can keep making progress and building up this ABC worksheet
skill. Is that OK?
Client
Yes, I can do that.
Therapist
Excellent, we will go over it next time we meet.
Patterns of Problematic Thinking Worksheet
The patterns of problematic thinking worksheet is similar to the challenging questions
worksheet. It is an additional component to add to the ABC worksheet. Eventually, it all becomes
a part of the combined challenging beliefs worksheet. When the SM develops a grasp of how to
use the challenging questions worksheet, the patterns of problematic thinking worksheet is
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introduced. Typically, this does not take large amounts of time and is commonly done during the
following session. Though, if the SM has difficulty using the challenging questions worksheet the
clinician should spend as many sessions as it takes for the client to become skilled at the
challenging questions worksheet because the clinician should not work faster than the SM is able
to. Below is an example of how the patterns of problematic thinking worksheet is introduced and
applied with SGT F.
Therapist
We’re making good progress. I want to introduce the next piece today. The next piece
is called the patterns of problematic thinking worksheet. This is a list of common
pitfalls and mental traps we can fall into. It can help us identify patterns of thinking
that might be problematic. Are you ok with me going over this with you?
Client
If you think it will help.
Therapist
I do think it will help. There are seven different patterns to go over. It can be easier
to go over these patterns if we apply them to a specific situation. So will you tell me
about the most recent ABC worksheet that you did?
Client
Yes, let me pull it up in the app.
Therapist
Excellent.
Client
OK, I woke up in the middle of the night and I was afraid that someone was in the
house. So, I felt anxious and I got up and checked and no one was there.
Therapist
That's scary. To wake up and think someone was there. Now leaning on questions
from the challenging questions worksheet was there any evidence or reason to think
that someone was in the house?
Client
No, it was just a feeling that I often have when I wake up.
Therapist
And the belief you wrote down was someone's in the house?
Client
Yes.
Therapist
Can we use this as the example when we go through this new worksheet?
Client
Yes.
Therapist
Good. This will be a good example. OK, the first pattern of problematic thinking that
we humans are prone to is something called jumping to conclusions. This is when
we make assumptions when there isn't evidence to support those assumptions. In this
situation when you woke up and you had a thought that someone was in the house is
it possible that you were jumping to conclusions?
Client
Yes, I think so.
Therapist
I think so too. I see how you get there. I know with the history you have it makes
sense that these thoughts come up for you. And this is still a potentially problematic
pattern of thinking - because if you jump to conclusions you are going to have
emotional and behavioral consequences that don't fit the facts.
Client
I often have that.
Therapist
I know, and I'm glad we're working on that. The next pattern of thinking that we're
all prone to is either exaggerating or minimizing a situation. So, either blowing
things out of proportion or really downplaying the importance of something. With
this situation in the ABC worksheet do you think it's possible that you were either
exaggerating or minimizing the situation?
Client
I don't think I was exaggerating if somebody was there, I would want to check. I
wouldn't want someone to be there and have me not check.
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Therapist
True, if someone was there you would want to check. Were you exaggerating the
likelihood that someone was there?
Client
Oh, yes.
Therapist
OK I'll write that down. The next pattern of thinking that we might fall into is
disregarding important aspects of a situation. Is it possible you were disregarding
important aspects of the situation?
Client
Maybe.
Therapist
What aspects do you think you might have been disregarding?
Client
Um, I guess the fact that the house is locked and I didn't hear anybody.
Therapist
That seems like important information to have in mind if you're trying to determine
if there is a good reason to think that someone's in the house. So, we're saying that
maybe you disregarded some important information with this one?
Client
Yes.
Therapist
Alright. I'll write that down. Now the next pattern of thinking that we can get us into
trouble is something called oversimplifying. This means seeing things as all good or
all bad period or maybe in this case all safe or all dangerous. Another pattern of
thinking is over-generalizing where an isolated incident is seen as a never-ending
pattern. Do you think you might have been oversimplifying or over-generalizing
things in this situation?
Client
I don't think so.
Therapist
Yeah, I'll agree on that. I think with the other stuck point related to your friend's
death. I think you oversimplify that sometimes. This one seems to not be an
oversimplification or over-generalization. The next pattern of problematic thinking
to talk about is mind reading this is where we assume we know what other people
are thinking. Do you think there was any mind reading going on in this situation?
Client
No, I don't think so.
Therapist
I agree - I don't think that there was someone else we're interacting with. This pattern
might be more relevant to more interpersonal interactions. Now the final pattern of
problematic thinking on this worksheet is emotional reasoning. This is where we have
a feeling about something and assume if we feel like things are dangerous then things
must be dangerous. Now normally we if we're in danger we feel anxious - people
with anxiety and PTSD often think if I feel anxious there must be danger. Does that
make sense?
Client
I think so.
Therapist
Do you think there was any emotional reasoning going on?
Client
I'm not sure.
Therapist
So, you woke up and had a feeling that someone might be in the house and based on
that feeling you made an assumption that it might be true. Does that sound like
emotional reasoning?
Client
I guess so.
Therapist
Yeah - I think it could be. Again, these are all things for us to continue working on.
The main question though is after we go through these seven patterns of thinking
does this affect the new belief you come to with your ABC worksheet?
Client
Well, it helps highlight that I was afraid someone was in the house, but it wasn't
really necessarily factual. I had a hunch or feeling something was wrong, but I didn't
have any facts.
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Therapist
Do you think that looking for these seven patterns of thinking in your future ABC
worksheets will help you find more helpful ways of looking at situations that are
better for you and your family?
Client
I hope so. I'll have to try and see.
Therapist
That's fair. Are you willing to try it out this week and we can see how it goes and
make a decision then?
Client
Yes, I'll do that.
Therapist
Excellent. We're making good progress. I'm interested to see how this goes this week.
Challenging Beliefs Worksheet
When the SM develops proficiency at identifying problematic patterns of thinking and
using the challenging questions worksheet, the therapist can work to put it all together into the
challenging beliefs worksheet. The challenging beliefs worksheet is meant to be flexible or
adaptable, rather than rigid in its application. Therapists are encouraged to use Socratic questioning
to make the process engaging and individualized (Farmer et al., 2017). Below is an example of
how the challenging beliefs worksheet was used with SGT F.
Therapist
SGT F we have been making great progress. How has the ABC worksheets been
going on your own?
Client
Not bad. I'm not sure I'm doing right sometimes.
Therapist
It's a process to learn this. I appreciate how hard you're working. Let's continue
doing them together. So, did any situations come up this week that relate to the stuck
points we have been focusing on?
Client
Well, I've been wanting to start getting out of the house more - like we've talked
about. My wife wanted me to take the kids to the park down the street. But I was
afraid that something might happen and so I didn't go.
Therapist
That sounds like it could be a good situation to focus on. So, the situation is your
wife wanted you to take the kids to the park? This is all in the context of what you've
been trying to do - face your fears and get out of the house more as well, correct?
Client
Yes, sir.
Therapist
When your wife suggested going to the park what was the thought or prediction that
you had about what was going to happen?
Client
I was afraid that something could happen.
Therapist
Now, we've talked about this before. I'm curious - were you afraid that something
might happen or were you thinking that something would happen?
Client
I was thinking something would happen.
Therapist
That's a scary thought. What was the consequence of that thought?
Client
I felt afraid and didn't want to go.
Therapist
If we were to rate how much you believed something bad was going to happen and
how much anxiety you felt what kind of percentages would you put on these?
Client
I'd say maybe 80% I thought something was going to happen and 100% I felt anxious.
Therapist
Let me write this down here on this worksheet so we can both keep track of it. Alright,
we've been doing this for a few weeks now. What's the next step?
Client
Well, we start going through the questions.
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Therapist
Awesome! That's exactly right. So, was there any evidence that something was going
to happen?
Client
Well no. But I was afraid something could happen. I've seen teenagers at the park
before. I remember some cars were vandalized last year. I just didn't know what was
going to happen.
Therapist
So, a possibility existed. And there have been teens, perhaps troublemakers, in the
area. Now to help me understand, were these gang members?
Client
I don't know.
Therapist
Last year when the cars were vandalized was anyone injured?
Client
I don't know.
Therapist
If someone had been injured at the park by teenagers, do you think you would have
heard about it?
Client
Well, yes. It probably would have been on the news. And my wife would have heard
from the neighbors as well.
Therapist
Did that happen? Did you see anything on the news or did you hear from the
neighbors about someone being physically attacked at the park?
Client
No.
Therapist
So, was there evidence to support this thought that something would happen?
Client
No, but something could always happen - you never know.
Therapist
That is true that - you do never know. Though the thought we’re evaluating is the
fear that something would happen. If the thought was something might happen and
you never know is that a different level of anxiety? Different than 100%?
Client
Yeah, that's less bad. Scary still. Scary in a different way.
Therapist
I agree. I think that's an entirely different challenging beliefs worksheet though. I'm
going to make a note of that. It might be that there's a third stuck point related to
tolerating the uncertainty of not knowing. Let's stay with the one we've been looking
at though. Is that OK?
Client
Yes, sir.
Therapist
Is there any evidence against the stuck point that something was going to happen?
Client
Well, like we just talked about. Nothing has happened, like in a violent way, that I
know of.
Therapist
Is that evidence against the thought that something was going to happen?
Client
I think so.
Therapist
I'll write that down. Now is this thought that something was going to happen is this
a habit or is this based on the facts?
Client
It's a habit. I always think this is going to happen.
Therapist
Yes. And this is the habit we're working on together right now. So, you're actively
working on changing this habit. And you're working hard at it.
Client
I'm really trying.
Therapist
I can see that. I appreciate it. Now our next question - does your stuck point include
all or none terms?
Client
I don't know.
Therapist
In that moment were you thinking all parks are dangerous? Or all teenagers are
dangerous? Anything like that?
Client
No.
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Therapist
OK. I'll write that down. Now the next question - does this thought that something
was going to happen include phrases that are extreme or exaggerated like always,
forever, never, need, should, must, can't, and every time?
Client
I don't think so.
Therapist
Yeah, I think that perhaps there might be some of those are related to that other stuck
point we’ve identified. This idea that if there is a possible risk, I need to know it. This
tolerating uncertainty, perhaps there is some of that going on here. Though that's
not what we're evaluating right now. I'll just make a note and when we get to that
we can talk about it more.
Now, in what way is your thought that something was going to happen focus on just
one piece of the event or one piece of the facts?
Client
I guess, I was just focusing on the times that there have been teenagers around or
those cars that were vandalized and not on all the other times that nothing happened.
Therapist
Good job recognizing this. Let me write that down. OK next question, where did this
thought that something was going to happen come from? Is this a dependable source
of information for the stuck point?
Client
I'm not sure I understand this one.
Therapist
I think this one might be less relevant to the one we're working on right now. Why
don't we move on to the next question? How is your stuck point confusing something
that is possible with something that is likely?
Client
This is the one you keep talking with me about. Yes. It is possible that something
could happen. But that doesn't mean that it is likely that something would happen.
Therapist
Why do we keep focusing on that one?
Client
Because I keep acting like if something could happen then I should plan on it
happening. Which is kind of how I was trained. Hope for the best but expect the
worst.
Therapist
And what happens when you literally expect the worst from an emotional
perspective?
Client
Well, I'm agitated and anxious and I can't sleep and I’ve pushed my family away.
Therapist
It's exhausting. Also, that rule of hope for the best but expect the worse is designed
to keep you safe in a more austere environment. People aren't deployed indefinitely.
You can't keep that up forever.
Client
That's true.
Therapist
So, I'll write this down. This seems to be a very important question for you to ask
yourself, especially when you're feeling anxious about what might happen.
Client
I think so too.
Therapist
Maybe we should find a way to write this down somewhere so you can see this
question more often or maybe even create a symbol that would queue you to ask
yourself am I confusing likely with possible? Something for us to think about after
the worksheet. Now, the next question in what ways is your thought that something
was going to happen based on feelings rather than facts?
Client
I had a feeling something bad was going to happen and I treated that as evidence
that something bad was going to happen.
Therapist
Excellent job recognizing that. Let me write that down for both of us. And the last of
our challenging questions - in what ways is this thought that something bad was
going to happen focus on unrelated parts of the event?
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Client
Well, I guess I was focused on things that had happened which weren't related to
what was going on right now, maybe.
Therapist
Maybe. I think perhaps this question is less geared towards the current situation.
Though I guess it is important to note that focusing on those other things, like the
incidents of vandalism, might not be entirely relevant to your worries about whether
or not you and your children would be attacked at the park.
Client
That's true.
Therapist
After we finish the challenging questions, we what do we look at next?
Client
We move on to look at the problematic patterns.
Therapist
Great, let's go down the list and see if there were any of these problematic patterns.
Do you see any problematic patterns that you think might have been coming up for
you this time?
Client
This one is always hard for me.
Therapist
Then, let's just do this one at a time. If you open up the app in your phone. And click
on the worksheets that's the tab that looks like the pen on paper. You can see the one
that says patterns of problematic thinking worksheet. At the bottom click where it
says all patterns - that gives us a description of all the different patterns. Let's read
through these and see which ones we think might be related.
Client
Oh, that helps. I think sometimes I forget what the different patterns are.
Therapist
These descriptions are in the challenging beliefs worksheet as well. There's just a lot
of stuff in that worksheet as well. So, this first one, jumping to conclusions is it
possible some of that was going on with this stuck point that we're looking at?
Client
I think so.
Therapist
How so?
Client
Well, I was jumping to the conclusion that something bad was going to happen even
though there wasn't any reason to think that something bad would happen this time.
Therapist
That's really good. Let me write that down. Now was there any exaggerating or
minimizing going on?
Client
I guess I could be exaggerating the dangerousness of the neighborhood.
Therapist
I wondered that. I know that we've talked about your neighborhood before. And it
sounds like you deliberately sought out an area that was pretty safe. So, maybe there
was some exaggerating about how dangerous the neighborhood is.
Client
Yes.
Therapist
Was there any disregard for important aspects of the situation occurring?
Client
Well, I was disregarding that nothing violent had happened in the area at least in
recent years.
Therapist
That seems important. I'll write that down. Was there any oversimplifying going on?
Client
I don't think so.
Therapist
Yeah, I don't think so either. How about overgeneralizing?
Client
I don't know about this one.
Therapist
Hmmmm, you did say that a few things had happened over the years with vandalism
at the park. Were you overgeneralizing from those few incidents to think that the
park overall was dangerous place?
Client
Oh, I get it. Yes. Yes, I was
Therapist
I’ll write that down. Now was there any mind reading going on?
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Client
I don't think so. I mean I could tell my wife was upset I mean.
Therapist
She might have been, but that seems like a different worksheet than the current one
we're working on.
Client
True.
Therapist
It seems like there wasn't an interpersonal component to this current fear. Now, the
last pattern of problematic thinking to examine is emotional reasoning. Were you
reasoning that because it felt like it would be dangerous that you thought it would
be dangerous?
Client
Yes, sir. I think so.
Therapist
I'll write that down. That was the last question! So, what do we do after we finish
going through the questions?
Client
We come up with an alternate thought.
Therapist
Excellent. What else could you say to yourself next time instead of this thought that
something bad was going to happen?
Client
I suppose I could say I'm afraid that something is going to happen but that I don't
know that something bad is going to happen.
Therapist
May I suggest an addition?
Client
Yes.
Therapist
I'm afraid that something is going to happen but I don't know if it will and, at the
same time, there are no current indicators to think something is going to happen.
How does that sit with you?
Client
Oh, I get it. I don't know if something bad is going to happen but there isn't any sign
that something bad is going to happen.
Therapist
Do you believe that though?
Client
Yes, it makes me nervous not knowing, but I do believe that there are no signs that
something is going to happen.
Therapist
How much do you believe that thought to be true?
Client
Maybe 80%.
Therapist
It's OK, if you don't believe this. I'm not trying to tell you what I think the right
answer is. I'm trying to summarize what we have on the challenging beliefs
worksheet. Is there something that I'm missing?
Client
No. I think it's at least 80% true. It just makes me a little nervous not knowing what's
going to happen.
Therapist
And that might be another challenging beliefs worksheet to do related to I must know
what's going to happen or I can't tolerate not knowing.
Client
I think so.
Therapist
OK, so with this new thought that we have, does that change how much you believe
the initial thought that something was going to happen?
Client
Yes, I believe it less.
Therapist
How much do you believe it right now?
Client
Maybe 30%.
Therapist
That's a big jump. Help me understand what's most helpful for you. Which question
was the most meaningful to you on this particular stuck point?
Client
I think it's the possibility versus likelihood thing that we keep talking about.
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Therapist
It seems like that's a pretty important one for you. That's important for us to know.
And helpful for you to know what's the question you can have in your back pocket
that might make the biggest impact in the moment. Now, this new perspective that
we have, how does that change the amount of anxiety you would feel in the situation?
Client
I'd feel less anxious. Maybe like a 40%.
Therapist
That's a pretty big difference. Now, you were saying that you weren't sure you were
doing it right. Was there something that we did together that is different than how
you've been doing it on your own?
Client
I think so. You had some elaborations on the questions that help me think about them
differently.
Therapist
How do you think I've gotten to the place where I know what to ask to elaborate on
the questions?
Client
I don't know, maybe they teach you this in therapist school.
Therapist
I've done a lot of CPT with people. The upside is the more that we do this together,
the more you'll start to think about what the questions mean and how to flexibly apply
them to the situation.
Client
I hope so.
Therapist
But the only way to get there is keeping at it. Are you on board with continuing to
use these challenging beliefs worksheets to work on the thoughts and situations
which are related to your stuck points?
Client
Yes.
Treatment will continue for as long as necessary following this format. In their impact
statement, the SM should be directed to note how the trauma affected them in such domains as
power, control, intimacy, and safety; the manual suggests spending at least one session applying a
challenging beliefs worksheet to each of the domains. If complicated grief is an important part of
the presentation, an optional bereavement session usually happens around session two or three.
The logistics of this session would not be different from traditional grief work. Though, the
therapist might note information from the bereavement session that might be useful for future
cognitive strategies. In this case SGT F’s close buddy who died had volunteered for a dangerous
mission as they were eager to get their Combat Patch (the Shoulder Sleeve Insignia called the
“Combat Patch” is a highly desired patch worn on the right shoulder of SMs who were in combat;
it is a visible representation of sacrifice and service and can be a status symbol as well). It may be
helpful to consider elements of the impact statement from the position of the deceased; for
example, “do you think that your friend would have blamed you for their death?” For SMs who
are receiving CPT, and have a tendency towards trauma related disassociations, it is recommended
to include a course of trauma narration, this is different from a prolonged trauma narration which
is detailed below in the section on prolonged exposure. In CPT, this is done with a written narrative
component. Of note, the CPT coach app will help facilitate the entire treatment process. When the
SM is first beginning with the app, it asks them if they are doing traditional cognitive processing
therapy (CPT) or cognitive processing therapy—cognitive only (CPT-C); CPT-C is the version
that does not have the exposure component and CPT is the version with the exposure component.
The clinician needs to guide the SM in this process to ensure a smooth course of therapy.
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Prolonged Exposure
Prolonged exposure (PE) is the other CBT for PTSD strongly recommended by the
DoD/VA CPG (Moore et al., 2021). Prolonged exposure has seven components:
• history, including most significant trauma(s);
• psychoeducation;
• formal assessment of PTSD severity;
• relaxation training;
• exposure hierarchy;
• in vivo exposures; and,
• narrative exposures.
The basic premise of PE is that repeated exposure to trauma-related thoughts, feelings, and
situations helps reduce the power they have to cause distress. This is accomplished through the use
of imaginal exposures, which recount the traumatic memory and process the revisiting experience,
and in vivo exposures, in which the client repeatedly confronts trauma-related stimuli that were
safe but previously avoided. Prolonged exposure typically last 8-15 sessions. The dosing of PE
can be done intensively or weekly (Foa et al., 2018). For SMs who have co-occurring borderline
personality disorder there is a protocol for dialectical behavior therapy (DBT) and PE that has been
developed (Harned et al., 2021).
Case Example: Prolonged Exposure
Senior Airmen J (SrA J – Pseudo client) is 24-year-old cisgender bisexual Latina woman
working as a medic in the Air Force. She was groomed and then sexually assaulted by her
commanding officer. She reported the assault, and the officer was subsequently court martialed
and dishonorably discharged from the military. This MST led to the development of a chronic
PTSD.
The elements of PE such as psychoeducation, gathering of trauma history, and are not
unique to a PTSD diagnosis. Consequently, the treatment course for SrA J, presented below,
focuses on the unique treatment elements of PE including relaxation training, in vivo exposure,
and imaginal exposure. Similar to CPT, the VA has a free smartphone app called PE Coach that
facilitates PE treatment.
Relaxation Training
Relaxation training in PE is typically accomplished with breath retraining. Paced breathing
teaches clients to slow their breathing, which decreases anxiety (Foa et al., 2007). Most SMs are
taught some breathing strategies when they're undergoing range training as well. This typically
includes strategies on ways to slow and control their breathing. A clinician may inquire from the
SM whether or not they previously underwent this training. If they have, it might be a suitable
option for relaxation training. There is another smartphone app from the VA called PTSD coach
(see Ford et al., 2018). This app does not facilitate exposure therapy, but does have a number of
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relaxation and stress management skills embedded within it. These skills include common PTSD
related coping skills such as grounding, progressive muscle relaxation, positive imagery, ambient
noise, and meditation. If the SM does not find breathing retraining to be helpful for them, the
clinician can consider other relaxation strategies and the PTSD coach app may help facilitate those
skills. Below is an example of how the clinician taught SrA J relaxation skills with help of the PE
Coach app.
Therapist
SrA J, I wanted to talk with you a little bit about breathing strategies. Have you
ever done any breathing training or learned any breathing skills before?
Client
Not formally.
Therapist
That's pretty common. Let's talk a little bit about ways to breathe that might be
helpful with managing your PTSD symptoms. First, it can be helpful to understand
what happens when we get anxious and our body goes into survival mode. When
we're in survival mode our fight or flight response is triggered and we breath as if
we are running for our life or fighting for our life. This often involves the diaphragm
tightening up and our body taking rapid shallow breaths. We do diaphragmatic
breathing to stimulate the parasympathetic nervous system, or the rest and digest
system - which is the opposite of the fight or flight system. This involves taking
deeper breaths. Put a hand on your navel and a hand on your breastbone and notice
which one moves more when you're breathing. Often, when we're anxious, we're a
little bit holding our breath and our bottom hand won't move as much. So, when
we're trying to do diaphragmatic breathing, we take almost belly breaths where you
really try to pull a lot of oxygen into your lungs expand them to their capacity. When
you do this, you'll notice that your bottom hand will move more than your top hand.
So that's a good deep breath. But the most important thing is actually the pace of
the breath. There is a pitfall where people try to use breathing to calm down but if
you're breathing rapidly because you're anxious and deeply because you're trying
to calm down you might over breathe or get too much oxygen. Too much oxygen
causes us to feel dizzy which can make it seem like the anxiety is getting worse.
Although a good deep breath is good, a slow breath is even better. Does that make
sense?
Client
I think so.
Therapist
Let me demonstrate this for you so you can see what it looks like
(therapist demonstrates for the client). Can you see how slowly I'm breathing and
how deeply I'm breathing?
Client
Yes, sir.
Therapist
Will you try doing it with me? Can we try breathing slowly and deeply together?
Client
Yes.
Therapist
(Breathing at the same time as client) How was that?
Client
It was kind of relaxing.
Therapist
OK, I'm glad. And if it wasn't - that's OK as well. Sometimes people find breathing
can remind them of things and it can be counterproductive. If breathing strategies
aren’t so helpful for you, there are other strategies we could do as well. The goal
is just to personalize this to make it work best for you.
Client
I appreciate that.
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Therapist
The thing about breathing strategies is this won't work really well at first. Often
times, people will wait until they are in the middle of a flashback or really anxious
about something to try breathing. It definitely won't work in those moments because
you aren't good at it yet. What needs to happen is the person needs to practice this
skill a lot, so they get good at it. And if they get good at it, they can use it when they
really need it. It's like learning to drive. You can't learn to drive on the freeway.
You start in the parking lot and then go to the neighborhoods and eventually move
to more difficult steps.
Client
That makes sense.
Therapist
To help you practice and get good at this there is actually a handy resource in that
PE coach app that I had you download. When you click on the menu, do you see
where it says breathing tool?
Client
Yes.
Therapist
Excellent. This is a place where you can practice your breathing. Let's click practice
and just watch it to see what it does and then we can try breathing along with it.
(watching and breathing along together)
What do you think?
Client
I like it, but it seems a little fast for me.
Therapist
That can happen everyone's lungs are a little different and so finding the optimal
pace can take a little bit of trial and error. Let's try out the other app that I had you
download PTSD coach - do you have that?
Client
Yeah, the one with the Red Star?
Therapist
Exactly. Open that up and click on manage symptoms. Then at the top there's three
columns. Click on tools. Scroll down to deep breathing. Here it will ask you how
distressed you are initially, and if you can, to rate your anxiety before and after to
see if the breathing is helpful. If you can’t rate your anxiety, you can just hit skip.
It tells you what breathing is in case you're exploring around. Then if you hit
continue and hit play it will guide you through what to do.
(watching and breathing along together)
How was that one compared to the PE coach one?
Client
I like that one more.
Therapist
I find different people like different things more, so it's helpful to find what works
best for you. If neither of these were helpful there's other apps we can use - there is
one called breathe2relax that’s another DoD free app, it lets you customize the
breathing intervals if you find the pace isn’t comfortable for you. Otherwise, we can
always look for YouTube clips or we could even make an audio recording of us
counting through the breathing together. As we try these out, just let me know how
it's going so we can personalize and modify these tools to make them work best for
you. How does that sound?
Client
I appreciate that.
Therapist
Excellent! What I want you to do is practice this at least twice a day every day until
I see you again. I want you to track how this affects your mood. And I also want you
to track if there are any parts of it that seem to be less helpful for you so we can see
if we need to make adjustments. Is that a plan?
Client
Yes, sir.
Therapist
Excellent, we're making good progress. Thanks for your hard work today.
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Although breath retraining is the typical relaxation strategy found in the PE manual and PE
coach app, the clinician should be flexible and find strategies that work well for the client. The
goal is to help manage symptoms in general, and to develop skills to help facilitate exposure
therapy. Imaginal exposure to the trauma narrative is, by definition, an anxiety provoking activity.
It is important for the clinician to equip the SM with coping skills to help weather this process.
The PTSD coach app and breathe2relax app are helpful tools for this. In addition, the clinician can
also look to incorporate other religious or cultural practices that might be relaxing and facilitate
exposure.
In-Vivo Exposure
In vivo exposure is exposure to real life stimuli that are anxiety provoking. Often what
happens when someone develops PTSD is their life becomes smaller as they start avoiding people
and places that remind them of the trauma. For example, SMs with combat related PTSD may
avoid going places that are crowded or not operationally secure. For these SMs in vivo exposure
commonly involves going to places that are crowded or where they cannot have eyes on everyone
around them. Optimally, in vivo exposure is both exposure and response prevention. The response
prevention piece addresses the limiting or minimizing of false safety behaviors. For example, a
SM may avoid going places that are crowded, but when they do go to these places, they may
engage in safety behaviors such as pre-planning their route around the store or only shopping
during off hours when it is less crowded. The clinician should directly ask the SM what things they
do to try and minimize the anxiety they feel to learn more about what safety behaviors may need
to be addressed. Coping skills that help the SM engage in the exposures such as deep breathing
can be helpful. Alternatively, strategies to reduce distress such as use of alcohol or other avoidance
strategies are viewed as dampening the positive benefits of exposure therapy. So, a SM with
combat related PTSD who typically avoids going to the store and when they do go to the store
approach it with a mission like precision should be encouraged to not preplan their route and
linger/browse around the store so that the exposure is both to the environment and to not using the
safety behaviors. This makes for a more potent exposure (Foa et al., 2007).
It is critical for clinicians to understand that, by definition, exposure therapy is exposure to
situations that are anxiety provoking but not actually dangerous. It would be irresponsible and
unethical to expose the SMs to situations that are actually dangerous. In vivo exposure is usually
done by first creating a fear hierarchy, making a subjective units of distress scale (SUDS)
anchoring, and planning where to start on the hierarchy. Newer research shows that exposure does
not need to be done with a rigid hierarchy (Craske et al., 2014).
Sometimes, SMs are unable to avoid the trauma-cues they would normally try to avoid.
This might include the sounds of artillery shelling from ongoing training operations or, in the case
of SrA J, it is being surrounded by male officers. In order for exposure to work it must be done
willingly. It is not uncommon for a SM to have ongoing trauma reminders that they have not
habituated to. Adding these elements to the hierarchy and approaching them in a deliberate manner
can be helpful.
In creating SUDS “anchors”, the PE method is to create a rating scale of SUDS which are
connected (i.e., anchored) to historical adverse or stressful events because past stress levels won't
change. For example, if going to a crowded supermarket was an 8 out of 10 level of anxiety at the
start of treatment, the idea is that after continued exposure the distress rating would reduce to a
lower number on the SUDS scale. However, anchoring an 8 as grocery store would not be ideal as
the scale would not be consistent nor set to previous levels of distress. Anchoring the scale using
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previous experiences would be consistent. For example, the amount of anxiety they felt, in the
past, about specific trips to the grocery store (e.g., a trip to the grocery store the day before
Thanksgiving) could serve as an anchor. An example anchored SUDS scale is presented below to
illustrate the idea of specific past stressors being the anchors for current treatment.
10
The time my attacker showed up at my work unexpectedly.
9
The time I was in an elevator with someone I didn’t know, and it got stuck.
8
7
Talking with the victims advocate for the first time.
6
5
Grocery shopping the day before Thanksgiving.
4
3
When I had to call the power company about a billing error.
2
1
0
When I got my new puppy.
The rationale for creating an anchored system is that change is typically incremental. In a
technical sense, habituation is staying in the presence of the exposure stimuli until the distress has
decreased by half. In order to track this, there needs to be a relatively reliable scaling system (Foa
et al., 2007). After a scale is made and suitable exposure items have been identified, then the
clinician and SM can go about planning exposure.
Typically, an optimal exposure is one that ranks as a 6 to 8 level of distress (Foa et al.,
2007); though, the clinician may have to work with what they are able to negotiate. Sometimes it
can be helpful to link some of the exposure tasks to things that the SM values (Thompson et al.,
2013). Often, a SM may state that they simply are not interested in going anywhere, possibly due
to anxiety. These SMs are often motivated to improve their relationships with their spouses and
children; the clinician may assess what activities they are not doing with their spouses or children
because of their PTSD symptoms. Personal sacrifice for the benefit of others is a core value of
military SMs. For example, a SM may be willing to go to a crowded restaurant they might typically
avoid if it's something that they think their family might enjoy. Below is an example of how the
clinician may have addressed these issues with SrA J.
Therapist
SrA J part of this treatment involves going out and re-engaging in aspects of your
life you have been avoiding. Often times, as the result of PTSD, people stop going
places and doing things which remind them of the trauma. As they start avoiding
things the anxiety, paradoxically, gets worse. A goal of prolonged exposure is to
face your fear head on, to decrease the anxiety and PTSD response that you're
having. As we talked about before, this will involve talking about the trauma. This
also has to include going out and going places and doing things that you have been
avoiding doing. So, let's make a list of places that you have been avoiding going to
due to your PTSD.
Client
I typically avoid going places that are crowded and have a lot of people.
Therapist
OK. I'll write that down. Now are some places worse than others?
Client
Yes. Places where it's crowded and there are a lot of men is scarier for me.
Therapist
I imagine there's a lot of places like that around here.
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Client
Yes. The gym. I used to go to, but I stopped going there because it was so crowded
with men who were looking at me.
Therapist
So, your old gym - let me write that down. Where are other places that you've
avoided going?
Client
Well, I won't go out to a bar anymore. It's just not my scene. Also, it’s just scary.
Therapist
So, out to a bar. Are there other places you stopped going?
Client
Yeah, I often don't go grocery shopping anymore.
Therapist
Are some stores more difficult than others?
Client
Yes, there's the super store right by base and that is usually full of people in uniform.
Therapist
Is that better or worse for you?
Client
Worse, much worse.
Therapist
So, shopping goes on the list and shopping at places where there's a lot of people
in uniform is even worse.
Client
Yes.
Therapist
Are there things that you used to do like hobbies or recreation, places you stopped
going like that?
Client
Oh, yeah. I used to like to go to the beach a lot with my friends, but it just makes me
kind of nervous to be out with people when they're drinking.
Therapist
Is it more about the beach or more about them drinking?
Client
Them drinking.
Therapist
In general, is it frightening to be around people who are drinking?
Client
Yes, I really don't like it.
Therapist
I remember that was an element from when you were attacked that he had been
drinking and that was a piece that the investigators had focused on. Now to help
me understand - is it being around people who are drinking at all or being around
people who are intoxicated?
Client
Both, but people who are really drunk is scarier. I won't do that.
Therapist
That's good information. Let me write that down. Now are there things you avoid
looking at or other things you avoid being around?
Client
Not really. I mean, there's like pictures from that time in my life that I don't really
look at but that's just because they remind me of what happened.
Therapist
I get that. So, pictures from that time in your life are reminders as well. Are there
other things from that time in your life that you avoid? Music? Activities?
Client
Well yeah, when he was grooming me he was teaching me different skills like stuff
related to basic mechanics and other kind of handy things like that. I thought it was
really helpful at the time. Like a father figure. But when I have to do something that
is handy in a way I don't want to do it - it reminds me of that.
Therapist
That sounds like an important exposure task as well. Also, it sounds like a really
difficult thing to do and the carryover is probably pretty unpleasant. I'm sorry
you've had to deal with that. OK, so we have a list of some things to start with. How
this goes is, as we get started, we get more information, and that new information
helps us make a better plan. So, we'll just be flexible and see how it goes and try to
make good decisions in the moment.
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After a hierarchy is made and anchors are set, it is time to plan out the exposure. Below is
an example of how that could be done.
Therapist
We made a list of things that you have been avoiding due to your PTSD and we
have a goal of gradually and incrementally exposing yourself to these situations
which are anxiety provoking, but not dangerous, to help facilitate a reduction in
your PTSD symptoms. For the first one, we want to find something that is kind of
middle of the road anxiety provoking. If we think of an analogy, like physical
therapy, the idea is to find something that's going to be uncomfortable to do but it's
not going to be too difficult—a stretch but not an over-stretch. So, what on our list
is something that would be more than you typically do but still doable?
Client
I guess going grocery shopping. I'm almost out of food.
Therapist
OK, grocery shopping could be good. I imagine there are things that you normally
do because you're anxious about going grocery shopping that are designed to make
it as minimally anxiety provoking as possible. For example, people often go to the
store at times when it's less crowded or they preplan out what they're going to get
and where it is so they're in the store for the least amount of time. Do you do
anything like that?
Client
How did you know?
Therapist
Oh, it's just really common. The trouble with these safety behaviors, as they are
called, is that often you attribute your success to the safety behavior and not to
yourself. Someone might go to the store when it's less crowded, plan where and how
they're going to get the things they want, and then afterwards tell themselves “oh,
that only worked because I went when it wasn't crowded or because I preplanned”.
I want you to build confidence in yourself and not confidence in any of your safety
behaviors. Do you want to see if we can either shelf or minimize the safety
behaviors? So, you're going to go to the store this week. Are there ways we can
make that a little bit more intense than it normally is?
Client
Oh, that's scary.
Therapist
Is it too scary?
Client
I don't like it, but if this is what I have to do then I can do it.
Therapist
Well, let's shoot for a stretch but not an over-stretch. When we were making anchors
for a 7 we said that the time you were first preparing for your upcoming promotion
board and your staff sergeant said that you could practice with them, it activated
your social anxiety and made you feel really anxious. That was something that was
a lot of anxiety, but not an unbearable amount of anxiety, correct?
Client
Yes.
Therapist
And how did you feel after practicing with their staff sergeant? Was your anxiety
still 7 out of 10?
Client
No, it was better after.
Therapist
And if you consistently did stuff that was around a 7 how do you think that would
affect your overall ability to do things that are scary?
Client
I think it would get easier, it would be hard, but I remember before all this happened
and I used to do scary things and I was good at it.
Therapist
So, part of this is taking your confidence back then.
Client
I hope so.
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Therapist
If we wanted to take this upcoming trip to the grocery store and try to titrate it to
around 7 out of 10, how could we make it a little bit more intense than it normally
is?
Client
I don't want to go to the one by the base that's too scary.
Therapist
That's totally fine. A key part of this is that everything has to be voluntary. So, you're
going to go to the one you typically go to, the one that's a little bit further away.
Can we plan for you to go there at a time that's a little bit busier and go there in a
way where you're there a little bit longer?
Client
Yeah, I can do that.
Therapist
So, what's the plan?
Client
I normally go really early on a Sunday morning because everyone is either in
church or hungover.
Therapist
So, what's the time period that's going to be a little bit more crowded than Sunday
morning? The busiest times are usually going to be right after work. So, what is
something in between the least crowded and the most crowded that might be
doable?
Client
Oh, yeah, you're right. I've gone right after work and it's a nightmare. I just leave
the store. I abandon my shopping cart.
Therapist
So, do you want to shoot for later in the evening on a weekday or a different time
during the weekend?
Client
I'll go on a weekday evening not right after work, but after traffic and dinner time.
Therapist
You might be most motivated to do that today right after meeting with me. So, do
you want to go tonight?
Client
Yes.
Therapist
What can we do to make you stay there a little bit longer than usual?
Client
Oh, that's hard. I guess I could walk the entire store instead of just directly heading
to the few things that I'm going to get.
Therapist
That sounds reasonable. Does this trip or plan sound like a 7 out of 10 to you?
Client
Yes, around there.
Therapist
Excellent. The goal of this is to go and do something that is scary but not dangerous
and do it long enough until the anxiety comes down on its own. This is to help you
see that you don't need to avoid things. So, the goal is to go to the store. You will
definitely feel anxious, and you're going to do it anyways because you're not letting
the anxiety be in control. Does that make sense?
Client
I think so.
Therapist
If you go and you get really anxious and you do it anyways, is that a failure?
Client
I don't think so.
Therapist
Exactly, that's a success. My goal is to get you to go and do things that you're afraid
to do and have you do them anyways, so you learn to be less afraid while doing
them. Now, is there anything that might come up that might get in the way of doing
the exposure today?
Client
Only if I forget.
Therapist
How are you going to make sure you don't forget?
Client
Well, I'm going to do it today. And I'll put a reminder in my phone
Therapist
Sounds good.
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In debriefing the in vivo exposure, the clinician will assess how it went, problem solve
any barriers that came up, and consolidate learning. Often, clients will be more focused on how
anxious they felt instead of how able they were to do it. Below is an example of how this presents
with SrA J.
Therapist
SrA J, I'm happy to see you again! First, I want to know how did the exposure of
going to the store go?
Client
I don't think I did it right.
Therapist
Oh, I'm sorry to hear that. What happened?
Client
I went like we planned and I just got so scared.
Therapist
That sounds scary. How anxious were you on our SUDS scale?
Client
Like an 8 or 9.
Therapist
So really anxious then. What happened? Did you go grocery shopping or did you
go home?
Client
Oh, I went shopping still and I walked the whole store like we planned, but I just
got so anxious.
Therapist
So, you went, you got really anxious, and you went shopping anyways. Which is the
part you think you didn't do right?
Client
Oh, I just got too anxious.
Therapist
It sounds like this was more intense than we thought it was going to be. You kind of
ended up a little bit more in the deep end than we had anticipated. And at the same
time, you still did the exposure. You did something even harder than we planned.
From your perspective what was the goal of the exposure?
Client
To go to the store even though I was afraid.
Therapist
You went to the store even though you were afraid and you were actually more
afraid than we thought you would be. Is that a success or a failure?
Client
Oh, I guess a success.
Therapist
Yeah. I agree. If anything, this was even more of a success because it was even more
difficult than we thought it would be. Now, if you were to continue doing this, do
you think it would get easier overtime?
Client
I think so. It was really scary. And I wouldn't want to do it again. But I could do it
again.
Therapist
And if you kept doing it?
Client
It would get less scary.
Therapist
Yes. And that's the basic idea of this treatment. We're going to do things that are
difficult and scary on purpose. And, as you keep doing them, they will become easier
to do. And as they become easier to do you will have more freedom in your life and
your PTSD symptoms will come down.
Narrative Exposures
The narrative exposure of PE is the heart of the treatment. It is relatively straightforward.
A common question that clients or clinicians will ask is, “What if there is more than one trauma?”
The general approach when there is more than one trauma is to start with the most distressing one
(Foa et al, 2007). Although addressing the most severe trauma may generalize to the other less
distressing traumas, this is not always the case. The clinician should not cycle through traumas,
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but should stay with the main trauma until there is habituation. During the trauma narration the
SM should describe the trauma in present terms (as if it is happening right now). The clinician
should avoid processing or evaluating what happened during the trauma narration. Cognitive
restructuring is not officially a part of PE. As PE progresses, the trauma narration shifts to focusing
on the “hot spots” or more distressing elements of the trauma narrative. The trauma narration in
session should be audio recorded. The PE coach app has a built-in encrypted voice recorder that
will store the file in a protected folder. The trauma narration audio is then listened to daily as
homework for the SM. Periodically during the trauma narration the clinician will check in with the
SM to gauge their SUDS. Ideally, the session will last long enough for habituation to occur.
Initially, this will typically take longer than a 55-minute clinical hour. Studies have shown that
habituation does not need to occur in session and can be effective as long as it occurs in between
sessions (Craske et al., 2014).
During the PE process the therapist’s task is to ensure that the SM is engaged in the process.
A sample explanation to use in session is presented below.
Now we're moving into the imaginal exposure component of prolonged exposure. During
this phase of treatment, we will be doing exposure to the memories of what happened. This is best
accomplished if you can talk both of us through what happened as if it is happening right now.
Meaning use present term language. I will periodically interrupt you to check in with your SUDS.
This will help me track how you are doing. This will also help us track habituation. We will go
through the trauma narrative over and over in today's session. I might interrupt you to ask a
question to get you to elaborate on a certain part of the narrative. We will record today's session
so you can listen to this and the trauma narrative during the week as homework. As we keep doing
this together, and you keep doing this on your own, reactivity to the trauma memory decreases and
distress comes down as well.
If the SM is under-engaged (not distressed) by the trauma narration the therapist should
assess for dissociation, distraction, or other avoidance strategies. It is also possible that important
elements of the trauma narrative are being omitted. If the SM is over-engaged (i.e., SUDS = 10/10)
then the therapist can facilitate some down regulation strategies such as the breathing training. An
ideal exposure is one where the target distress is around a seven or eight out of 10. The length of
the course of treatment is dependent upon the individual’s habituation to the trauma narration
process.
CULTURAL CONSIDERATIONS
The current Clinical Practice Guidelines (CPG) call for culturally-sensitive care but does
not give directions on how to do this. In fact, the CPG do not contain such common words related
to this topic as diversity, race, ethnicity, or multiculturalism.
While these guidelines are broadly recommended, their
implementation is intended to be patient-centered. Thus, treatment
and care should take into account a patient’s needs and preferences.
Good communication between healthcare professionals and the
patient is essential and should be supported by evidence-based
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information tailored to the patient’s needs. Use of an empathetic and
non-judgmental approach facilitates discussions sensitive to gender,
culture, ethnic, and other differences. The information that patients
are given about treatment and care should be culturally appropriate
and available to people with limited literacy skills. It should also be
accessible to people with additional needs such as physical, sensory,
or learning disabilities. Family involvement should be considered,
if appropriate. (p. 16)
Later the CPG cautions against modifying treatments and recommends fidelity to the
treatment manual.
The Work Group does not recommend adding or removing
components from evidence-based psychotherapy protocols. If
modifications to an established protocol (e.g., PE, CPT, EMDR) are
clinically necessary, the modifications should be empirically and
theoretically guided, and with understanding of the core components
of trauma-focused psychotherapies considered most therapeutically
active. (p. 21)
This leaves providers who are attempting the follow the CPG without guidance on how to
proceed. Further, evidence exists to demonstrate a need for modifications to practice as usual.
Recent research demonstrates that health disparities are present both inside and outside of the
military health system (Gross et al., 2021; Spoont et al., 2020). African American veterans are
more likely to develop PTSD than their Caucasian counterparts (Gross et al., 2021). Further, they
experience a reduced benefit from trauma-focused therapy in the VA system (Gross et al., 2021).
This also includes increases symptom re-occurrence rates following treatment. The researchers
hypothesize that this is due to increased levels of stress, possibly stemming from discrimination
(Gross et al., 2021).
While the CPG do not give clear guidance, there are three course of action that are
reasonable:
1. incorporate elements of the patient’s cultural strengths into the treatment process in a
manner that is consistent with the core components of trauma-focused therapy (i.e.,
relaxation training, stress management training, narrative exposure, and cognitive
restructuring);
2. Provide larger doses of care and increased relapse prevention. Trauma-focused therapy
has been found to be an effective treatment for subclinical symptoms of PTSD and so
it is thought that an additional dose of therapy might help treat residual symptoms of
PTSD (Larsen et al., 2019); and,
3. Work to address such systemic issues as discrimination and institutionalized racism
that contribute to distress, which is thought to attenuate the benefits of treatment.
The social worker framework for social justice and micro, mezzo, and macro level
interventions is a useful framework to consider.
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TREATING MORAL INJURY IN MILITARY POPULATIONS
Moral Injury is a relatively recent construct (Griffin et al., 2019). The idea of a moral injury
is that a traumatic event can also injure a person’s moral, spiritual, or sense of self – in other words,
the details of the trauma violate a moral code. For combat veterans, the injury might not just be
connected to how they almost died, but also if and under what circumstances they blame
themselves for killing someone (as is seen with the example of SGT F above). There are things a
human will do that make sense in the heat of the moment but may be a weight to carry afterwards.
SMs may feel guilty and ashamed of their actions or some of the things they experienced while
deployed.
From the perspective of CPT, moral injury can be viewed as over accommodation. Many
SMs join the military with ideas and values related to service and protecting freedom; yet, when
they are exposed to the horrors of war and in the face of great suffering these ideas and values may
be shattered (Frankfurt & Frazier, 2016). Further moral injury may occur with this type of
disillusionment. For example, SMs who joined the military with the ideas of bringing freedom to
other countries or removing weapons of mass destruction may find themselves wondering whether
it was all worth it or why they sacrificed so much.
There is some data that CPT is a preferred treatment for working with inappropriate guilt
following a traumatic event (Resick et al., 2002). Clinicians treating a SM with PTSD who has
moral injury may consider using a CPT approach. Further, because there is a spiritual or moral
component to this, clinicians commonly seek to involve spiritual leaders from the SM’s faith
tradition in the treatment. Every military unit has a chaplain who is able to provide some spiritual
counseling as well. It has been pointed out that in some rare cases of serious misconduct, there
may be confidentiality issues associated in treating moral injury (Williamson et al., 2021)— (in
some settings war crimes are a mandated reporting issue, though there is no data to support the
idea that this is a common clinical problem).
Clinically, there is a difference between working with unjustified guilt and shame and
justified guilt and shame (Linehan, 1993). It is not up to the therapist to decide if the SM’s wartime
behavior was right or wrong, but it is instead up to the SM to decide their own code of morality.
This may be an existential, spiritual, or philosophical course of self-discovery. Again, it may be
helpful to involve spiritual leaders or encourage outside spiritual readings or teachings in this
process. If the SM has committed transgressions which are not in keeping with their values, then
there is a question of how to make repairs (i.e., is there a path to redemption?). Most religions have
a path towards repentance or forgiveness. Although a therapist is not a spiritual advisor, culturally
humble and competent clinicians can walk along (or learn to walk along) that path with their
clients. Under the advisement of, and in collaboration with, spiritual leaders a therapist can be a
meaningful team member on a path towards psychological-spiritual healing.
In instances where the moral injury is based on unjustified guilt or shame, meaning the SM
did not violate their code of ethics, traditional cognitive-, behavior-, and emotion-focused change
strategies can be effective. For example, what is the emotional meaning of the supposed
transgression? If the SM views themselves now as being a monster, Socratic questioning can be
used to define the construct of monster (see Waltman et al., 2020). The therapy can then evaluate
how well the SM fits that description and may help illustrate for the SM that they are, in fact, not
a monster. In these instances, referencing the context within which the behavior occurred is
essential. Treating moral injury can help lead to a reduction in distress and facilitate healing.
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However, there remains more to learn about moral injury and further research on the topic is
needed (Griffin et al., 2019; Frankfurt & Frazier, 2016).
SUMMARY
Post-traumatic stress disorder is a major clinical concern among active duty SMs and
veterans. Effective treatment of PTSD in these populations requires a clinician to be familiar with
the VA/DoD CPG and the unique cultural strengths and experiences of SMs. CPT and PE are the
two therapies for PTSD in SM populations that are recommended by the clinical practice
guidelines. Clinicians new to trauma focused therapy or new to working with military populations
may consider seeking outside consultation or supervision.
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