Norman Cotterell, Ph.D.
Beck Institute for Cognitive Behavior Therapy
Beck and Gellatly (2016) propose that catastrophic thinking is a central feature in psychopathology. Such thinking magnifies both the immediate and eventual consequences of any perceived threat. A variety of disorders can be conceptualized as such: Clients magnify external threats (accidents, attacks, arson) but most notably misinterpret and magnify perceived internal threats. Sensations, thoughts, and emotions are seen as signs of immediate physical or psychological catastrophe.
- Panic — immediate catastrophic consequences of an unexpected physical sensation: “If my heart races, I’m dying.” “If I feel lightheaded, I’m about to faint.”
- Social Phobia — catastrophic misinterpretations of the social consequences of anxiety: “If people see me sweat, I’ll be judged, shunned, rejected or shamed.”
- Agoraphobia — catastrophic beliefs about the consequences of anxiety: “If I panic, I’ll be trapped.”
- Specific phobias — catastrophic beliefs about a feared object or situation: “If I get on an airplane, I won’t be able to handle the anxiety.”
- Health anxiety — catastrophic consequences of an unexpected physical sensation, or image: “If my chest hurts, I have heart, lung, or infectious disease. If the doctor sends me for tests, it means I’m seriously ill.”
- Obsessive compulsive disorder — Catastrophic misinterpretation of an intrusive thought: “If I think something unacceptable, it means I myself am unacceptable. Thinking it is as bad as doing it.”
- Posttraumatic Stress Disorder — Catastrophic beliefs about the reoccurrence of danger: “If it happened before, it’s likely to happen to me again.” “Flashbacks mean danger.”
- Pain — Catastrophic beliefs about pain and its consequences: “If I’m in pain, it is unsafe to move, and I must stop my activities.”
- Traumatic Brain injury — Catastrophic misinterpretations of post concussive symptoms: “If I have a headache, my brain injury is getting worse.”
Beck and Gellatly regard such thinking as an essential ingredient in the development and maintenance of these anxiety disorders. They identify 6 essential ingredients of a cycle that fuels them: Catastrophic Beliefs (“I’m having a heart attack, I’m dying,”) triggered by a Precipitating Event (heart palpitations) results in both Anxiety Symptoms (shortness of breath, dizziness, feeling out of control) and an Interpretive Bias (“If my chest hurts, I’m having a heart attack”). These, in turn trigger an Attentional Fixation (“There’s no other way to look at this!”) and an Attentional Bias (“I really need to pay close attention to my chest.”) And these attentional factors serve to refuel the anxiety, the interpretative bias, the catastrophic beliefs and each other.
Beck and Gellatly propose taking catastrophizing into account would be useful in the diagnosis, prediction, prevention, and treatment of psychopathology. Future research and exploration will answer such questions as: Which catastrophic beliefs differentiate which conditions? Who is susceptible to developing such beliefs? How do we educate people to promote resiliency against such beliefs? What interventions will best enable clients to counter these beliefs?
Although they point to catastrophic beliefs as the key essential factor, other factors may serve as points of interventions. Decatastrophizing enables clients to test the validity of catastrophic beliefs through exposure to the sensations. Therapists use panic inductions, for example, to alter the misinterpretation of symptoms. Other techniques, such as cognitive reappraisal, may ameliorate attentional fixation by providing more plausible ways to account for symptoms. Various in-office procedures may modify attentional bias by directing focus to breathing, to objects in the office, or to sounds inside and outside the building. This model may serve as a way to conceptualize the problem and identify where interventions work.
Beck, A.T. & Gellatly, R. Catastrophic Thinking: A Transdiagnostic Process Across Psychiatric Disorders. Cognitive Therapy and Research, 2016, pp. 1-12.
Worried about their reputation and career prospects, returning service members with PTSD may avoid seeking treatment. In a randomized controlled trial, the authors examined engagement in treatment and symptoms among veterans with PTSD who received a brief phone-based intervention to discuss why they had avoided treatment. Veterans who received a call entered treatment sooner and experienced more immediate reductions in PTSD symptoms than veterans who received usual care. By six months, differences between the two groups had faded, suggesting that adding a second phone call might be warranted.
Many service members do not seek care for mental health and addiction problems, often with serious consequences for them, their families, and their communities. This study tested the effectiveness of a brief, telephone-based, cognitive-behavioral intervention designed to improve treatment engagement among returning service members who screened positive for posttraumatic stress disorder (PTSD).
Service members who had served in Operation Enduring Freedom or Operation Iraqi Freedom who screened positive for PTSD but had not engaged in PTSD treatment were recruited (N=300), randomly assigned to either control or intervention conditions, and administered a baseline interview. Intervention participants received a brief cognitive-behavioral therapy intervention; participants in the control condition had access to usual services. All participants received follow-up phone calls at months 1, 3, and 6 to assess symptoms and service utilization.
Participants in both conditions had comparable rates of treatment engagement and PTSD symptom reduction over the course of the six-month trial, but receiving the telephone-based intervention accelerated service utilization (treatment engagement and number of sessions) and PTSD symptom reduction.
A one-time brief telephone intervention can engage service members in PTSD treatment earlier than conventional methods and can lead to immediate symptom reduction. There were no differences at longer-term follow-up, suggesting the need for additional intervention to build upon initial gains.
Stecker, T., McHugo, G., Xie, H., Whyman, K., & Jones, M. (January 01, 2014). RCT of a brief phone-based CBT intervention to improve PTSD treatment utilization by returning service members. Psychiatric Services (washington, D.c.), 65, 10, 1232-7.
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a widely used treatment model for trauma-exposed children and adolescents (Cohen, Mannarino, & Deblinger, 2006). The Healthy Coping Program (HCP) was a multi-site community based intervention carried out in a diverse Canadian city. A randomized, waitlist-control design was used to evaluate the effectiveness of TF-CBT with trauma-exposed school-aged children (Muller & DiPaolo, 2008). A total of 113 children referred for clinical services and their caregivers completed the Trauma Symptom Checklist for Children (Briere, 1996) and the Trauma Symptom Checklist for Young Children (Briere, 2005). Data were collected pre-waitlist, pre-assessment, pre-therapy, post-therapy, and six months after the completion of TF-CBT. The passage of time alone in the absence of clinical services was ineffective in reducing children’s posttraumatic symptoms. In contrast, children and caregivers reported significant reductions in children’s posttraumatic stress (PTS) following assessment and treatment. The reduction in PTS was maintained at six month follow-up. Findings of the current study support the use of the TF-CBT model in community-based settings in a diverse metropolis. Clinical implications are discussed.
Konanur S., Muller R. T., Cinamon J.S., Thornback K. & Zorzella K. P. (2015). Effectiveness of Trauma-Focused Cognitive Behavioral Therapy in a ommunity-based program. Child Abuse Negl. 2015 Aug 25. pii: S0145-2134(15)00242-2. doi: 10.1016/j.chiabu.2015.07.013.
Amanda, a recent graduate of University of Michigan (but a Spartans fan!) attended the Beck Institute CBT for a PTSD workshop, taught by Dr. Aaron Brinen. She traveled from Michigan with 8 other trainees from Henry Ford Health System. At HFHS, Amanda is a clinical therapist for adults and teenagers; she also runs a substance abuse group.
The group from HFHS had the opportunity to travel to Philadelphia and attend training at Beck Institute, because their organization recently learned that they will be providing services to first responders in the Detroit area. The CBT for PTSD workshop was the perfect fit.
When she learned she would have the opportunity to attend a workshop at Beck Institute, Amanda was thrilled because she learned and loved CBT in graduate school. “And let’s be honest, the Beck Institute is prestigious.” Other than meeting Dr. Aaron Beck, and learning more about prolonged exposure therapy, Amanda most appreciated that “Dr. Brinen is amazing with talking about difficult topics and keeping us engaged.”
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria for posttraumatic stress disorder (PTSD) incorporate trauma-related cognitions. This adaptation of the criteria has consequences for the treatment of PTSD. Until now, comprehensive information about the effect of psychotherapy on trauma-related cognitions has been lacking. Therefore, the goal of our meta-analysis was to determine which psychotherapy most effectively reduces trauma-related cognitions.
Our literature search for randomized controlled trials resulted in 16 studies with data from 994 participants. We found significant effect sizes favoring trauma-focused cognitive-behavioral therapy as compared to nonactive or active nontrauma-focused control conditions of Hedges’ g = 1.21, 95% CI [0.69, 1.72], p < .001 and g = 0.36, 95% CI [0.09, 0.63], p = .009, respectively. Treatment conditions with elements of cognitive restructuring and treatment conditions with elements of exposure, but no cognitive restructuring reduced trauma-related cognitions almost to the same degree. Treatments with cognitive restructuring had small advantages over treatments without cognitive restructuring.
We concluded that trauma-focused cognitive-behavioral therapy effectively reduces trauma-related cognitions. Treatments comprising either combinations of cognitive restructuring and imaginal exposure and in vivo exposure, or imaginal exposure and in vivo exposure alone showed the largest effects.
Diehle, J., Schmitt, K., Daams, J.G., Boer, F., & Lindauer, R.J. (2014). Effects of psychotherapy on trauma-related cognitions in posttraumatic stress disorder: a meta-analysis. Journal of Traumatic Stress, 27(3), 257-264. doi: 10.1002/jts.21924.
Posttraumatic Stress Disorder (PTSD) refers to a problematic and prolonged response to traumatic events. Ehlers and Clark (2000) note its puzzling nature, identified by both inattention and hyper-arousal, by memories that won’t go away and others that cannot be found, and by both recklessness and an excessive desire for safety. Rothbaum (2006) describes it as a failure of natural recovery.
Mike, a 49 year old production packer, was involved in an accident and suffered 3rd degree burns on the back of his right hand. He is right handed. He remembers watching the machine coming down on his hand. He remembers in vivid detail the smell of burning flesh.
Mike’s initial response is matter-of-fact. He tells his wife, “Everything is fine.” He makes it through surgeries and skin grafts without much overt difficulty. But he doesn’t own up to any emotional distress. So he misses out on the emotional support that could have helped him process the trauma. Why does he fail to reveal his feelings? One key belief he holds is, “If I reveal any vulnerability, people will lose faith in me and view me as weak.”
Shortly after the medical procedures are finished, Mike experiences cognitive intrusions: flashbacks and nightmares. While these intrusions are distressing, what is more distressing is the special meaning he puts to them. “[They show] I can’t control my own mind.” Dissociative amnesia is further evidence to Mike of his loss of control.
His perceived loss of control leads to Mike’s experiencing intense and distressing negative emotions. He feels highly anxious, sad, and ashamed. “I should be able to cope. I’m weak.” The experience of negative emotion, too, leads Mike to feel out of control. His core beliefs — “I’m out of control. I’m helpless. I’m weak. I can’t function” — become fully activated. He sees himself as being in grave danger, not from an external threat, but from one that he cannot escape. No matter where he goes, his mind goes with him. Mike adopts a battlefield mentality. He is alert, on-guard, aggressive, unable to sleep. Because he views this extreme mentality as unwarranted(“It’s only a burned hand!“) — he takes these symptoms as proof of his weakness.
Mike also engages in extensive behavioral avoidance. He believes he must avoid all that he loves, or risk tainting it with insanity. He also engages in emotional avoidance through the use of alcohol. But avoidance fuels his belief of weakness. He is in a double bind: “If I avoid, I’m in control, I can function. But If I avoid, it means I’m helpless, defective, out of control. But if I don’t avoid, I’m in danger.”
To summarize, when individuals develop PTSD, they put dysfunctional meanings to their symptoms: intrusions, cognitions, emotions, avoidance, and arousal, among others. Their dysfunctional behaviors and the intensity of their emotions are understandable once we grasp the assumptions they are making. Their assumptions make sense once we comprehend the core beliefs that have become activated. The trauma itself doesn’t directly lead to PTSD; rather it is the meanings they attribute to the trauma, to their cognitive, emotional, physiological, and behavioral symptoms, and to their changed circumstances that are more closely tied to the development of the disorder.
Ehlers, A. & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder, Behaviour Research and Therapy 38, 319-345.
Foa, E.B., Hembree, E.A., & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD. Oxford: Oxford University Press.
Morris, D. (2015). The Evil Hours. New York: Houghton Mifflin Harcourt.
Resick, P. A. (2001). Cognitive therapy for posttraumatic stress disorder. Journal of Cognitive Psychotherapy, 15(4), 321 – 329.
Rothbaum, B.O. (2006). Virtual Vietnam: Virtual Reality Exposure Therapy. (2006). In M. Roy (Ed.), Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder. Amsterdam: IOS Press.
US Dept of Veteran’s Affairs: How common is PTSD? PTSD: National Center for PTSD. (n.d.). Retrieved May 26, 2015, from http://www.ptsd.va.gov/PTSD/public/PTSD-overview/basics/how-common-is-ptsd.asp
This study aimed to gain an understanding of the aspects of trauma-focused cognitive behavioral therapy (Trauma-Focused-CBT) for post-traumatic stress disorder (PTSD) that service-users find important in contributing to their improvement. Nine people (5 females and 4 males, mean age 53 years old who had received on average 12 sessions of Trauma-Focused-CBT) who reported a significant reduction in their symptoms following treatment of PTSD took part in semi-structured interviews. Interpretative phenomenological analysis identified five themes: Living with Symptoms before Therapy; Feeling Ready for Therapy; Being Involved; Bringing About Therapeutic Change; and Life After Therapy. This study contributes towards a clearer understanding of the aspects of the Trauma-Focused-CBT process that service-users found important in aiding their improvement. In particular, it highlights the central role that participants attributed to their own involvement in the therapeutic process and how much they valued this. Limitations and future directions are discussed.
Lowe, C., & Murray, C. (2014). Adult service-users’ experiences of trauma-focused cognitive behavioural therapy. Journal of Contemporary Psychotherapy, 44, 4, 223-231.
I recently presented a Master’s Clinician Class at the Anxiety and Depression Association of America. My topic was cognitive conceptualization of personality disorders. I asked for a volunteer to describe a case so as a group, we could conceptualize the client, using the Cognitive Conceptualization Diagram (Beck, 2005). I have changed certain details to protect the client but his difficulties are fairly typical of someone with avoidant personality disorder.
Joe is a 52 year old man who developed PTSD 32 years before, following a series of traumatic incidents. For a long time, he lived with his family and led a fairly reclusive life. He then moved into subsidized housing which he dislikes.
Joe has been in and out of therapy for many years with many therapists. Although he no longer displays symptoms of PTSD, and hasn’t for a long time, he suffers from dysthymia. His anxiety is fairly low as he avoids situations that could lead to distress. He hasn’t had a job since he developed PTSD and has made only half-hearted attempts to secure one. He does have a few friends, “drinking buddies,” but isn’t particularly close to any of them. His relationships with his family are somewhat strained.
When the therapist listed Joe’s automatic thoughts in situations where he either felt some (mild) distress or acted in a dysfunctional way (using avoiding something), it became clear that Joe has very strong core beliefs of helplessness. Many patients have a belief in one of the three subcategories of helplessness; Joe seems to have core beliefs of being ineffective in all three.
When Joe discusses his future, he says, “My crummy apartment is preventing me from living my life.” When he considers doing his therapy homework, he thinks, “I won’t be able to do it right.” This represents the subcategory of believing one is ineffective in getting things done.
When Joe imagines going to session without having done his homework, he thinks, “She [his therapist] will be mad if I don’t do it.” When they discuss fixing up his apartment, he thinks, “I don’t want to talk about this. It will be too upsetting.” This represents the subcategory of believing one is ineffective in being able to protect oneself, in this case, in being emotionally vulnerable.
When Joe discusses his past, he thinks, “I’ve wasted so many opportunities. I’m a loser.” When Joe fails to protest a teasing insult from his buddy, he thinks, “I should have said something. I’m a wimp.” This represents the subcategory of being ineffective as compared to others.
Joe’s sense of helplessness has led to extensive behavioral avoidance. He procrastinates, avoids doing homework or cleaning up his apartment. It has led to extensive social avoidance. He avoids intimacy in relationships. And it has led to extensive cognitive and emotional avoidance. He over-intellectualizes, changes the subject in therapy, and avoids even thinking about upsetting topics. And he fails to take responsibility for improving his life, blaming his mother, PTSD, and his living situation for holding him back.
Clients’ emotional and behavioral reactions always make sense once we understand what they are thinking. And the patterns or themes in their thinking always make sense once we understand the fundamental ways they view themselves, other people, and their worlds.
Beck, J. S. (2005). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York: Guilford Press.
Background: Efficacy studies on treatment in adolescent victims of single rape are lacking, even though sexual victimization is most likely to occur during adolescence and despite the fact that adolescents are at risk to develop subsequent posttraumatic stress disorder.
Aim: The aim of this prospective observational study was to evaluate the short- and long-term outcomes of a nine-session cognitive behavior group therapy (STEPS), including a parallel six-session parents’ group on rape-related symptomatology in female adolescents (13-18 years). STEPS includes psychoeducation, exposure in sensu as well as in vivo, cognitive restructuring, and relapse prevention.
Methods: Fifty-five female adolescents with mental health problems due to single rape, but without prior sexual trauma, received STEPS while their parents participated in a support group. Subjects were assessed on posttraumatic stress (PTS) and comorbid symptoms using self-report questionnaires prior to and directly after treatment, and at 6 and 12 months follow-up.
Results: Repeated measures analysis showed a significant and large decrease in symptoms of PTS, anxiety, depression, anger, dissociation, sexual concerns, and behavior problems directly after treatment, which maintained at 12 months follow-up. Time since trauma did not influence the results. Dropout during STEPS was 1.8%.
Conclusions: The results potentially suggest that the positive treatment outcomes at short- and long-term may be caused by STEPS. The encouraging findings need confirmation in future controlled studies on the effectiveness of STEPS because it may be possible that the treatment works especially well for more chronic symptoms, while the less chronic part of the sample showed considerable improvement on its own.
Bicanic, I., de Roos, C., van Wesel, F., Sinnema, G., & van, d. P. (2014). Rape-related symptoms in adolescents: Short- and long-term outcome after cognitive behavior group therapy. European Journal of Psychotraumatology, 5.
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