Cognitive Restructuring and Trauma

Rationale

A body of literature suggests that traumatic events can dramatically alter basic beliefs about the self, the world, and other people. Characteristic for trauma survivors with PTSD are negative trauma-related thoughts and beliefs, such as “I am the one to blame for what happened,” “Other people are not to be trusted,” “Nowhere is safe,” and numerous other idiosyncratic beliefs. These negative interpretations or appraisals can negatively affect how events following the traumatic event are interpreted, interfere with successful processing of the traumatic memory, and prevent the realization that the trauma is a time-limited event from the past that no longer affects one's future. By perpetuating a sense of serious current threat, these negative appraisals can lead to the development and maintenance of emotional disorders, such as clinical depression or PTSD.

Core Procedures

CR involves reevaluating negative thinking patterns that maintain distorted beliefs about oneself, the world, and relating to others. As part of CR, the therapist may teach a trauma survivor to challenge his or her belief that the world is a dangerous place and nobody can be trusted by conducting a detailed examination of the evidence for and against these beliefs and consider alternative interpretations that are more balanced and realistic. This part of CR typically involves educating the client about common cognitive distortions (habitual negative patterns of thinking producing or exacerbating negative affect and maladaptive behaviors) and teaching him or her to identify and modify these distortions using thought records.

CR is explicitly featured in a number of CBT protocols, such as cognitive processing therapy (CPT) and cognitive therapy. These protocols differ in their exact procedures and emphasis on cognitive restructuring of thoughts and appraisals that occurred both during and after the event versus emphasis on fear reduction and habituation to feared stimuli during exposure. CPT, for instance, involves asking clients to prepare a detailed “impact statement” that describes their thoughts about the possible cause(s) of the event and its impact on themselves and other people, including how the event may have influenced their beliefs about themselves, others, and the world. Clients are instructed to read the story aloud repeatedly in and outside of session. With the help of CR, the therapist helps the patient to identify and address so-called “stuck-points,” such as conflicts between prior beliefs and experience of the traumatic event. Such stuck-points are often associated with negative interpretations and errors in thinking. CR aims to teach new and more realistic beliefs about a client's perceived ability to cope and about the safety of the world around him or her, particularly in situations that remind the client of the trauma. It is an explicitly collaborative effort, during which the client is asked to view negative thoughts and beliefs as hypotheses to be tested. In this way, client and therapist work together as a team collecting evidence for and against certain assumptions to determine whether a certain interpretation is accurate and useful to the client.

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