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Jill, a 32-year-old Afghanistan War Veteran This case example explains how Jill’s therapist used a cognitive worksheet as a starting point for engaging in Socratic dialogue.
This is a case example for the treatment of PTSD using Cognitive Behavioral Therapy. Cognitive Behavioral Therapy is strongly recommended by the APA Clinical Practice Guideline for the Treatment of PTSD.
Jill, a 32-year-old Afghanistan war veteran, had been experiencing PTSD symptoms for over 5 years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device (IED) while driving a combat supply truck. Over the years, Jill became increasingly depressed and began using alcohol on a daily basis to help assuage her PTSD symptoms. She had difficulties in her employment, missing many days of work, and she reported feeling disconnected and numb around her husband and children. In addition to a range of other PTSD symptoms, Jill had a recurring nightmare of the event in which she was the leader of a convoy and her lead truck broke down. She waved the second truck forward, the truck that hit the IED, while she and her fellow service members on the first truck worked feverishly to repair it. Consistent with the traumatic event, her nightmare included images of her and the service members on the first truck smiling and waving at those on the second truck, and the service members on the second truck making fun of the broken truck and their efforts to fix it — “Look at that piece of junk truck — good luck getting that clunker fixed.”
After a thorough assessment of her PTSD and comorbid symptoms, psychoeducation about PTSD symptoms, and a rationale for using trauma focused cognitive interventions, Jill received 10 sessions of cognitive therapy for PTSD. She was first assigned cognitive worksheets to begin self-monitoring events, her thoughts about these events, and consequent feelings. These worksheets were used to sensitize Jill to the types of cognitions that she was having about current day events and to appraisals that she had about the explosion. For example, one of the thoughts she recorded related to the explosion was, “I should have had them wait and not had them go on.” She recorded her related feeling to be guilt. Jill’s therapist used this worksheet as a starting point for engaging in Socratic dialogue, as shown in the following example:
Therapist: Jill, do you mind if I ask you a few questions about this thought that you noticed, “I should have had them wait and not had them go on?”
Therapist: Can you tell me what the protocol tells you to do in a situation in which a truck breaks down during a convoy?
Client: You want to get the truck repaired as soon as possible, because the point of a convoy is to keep the trucks moving so that you aren’t sitting ducks.
Therapist: The truck that broke down was the lead truck that you were on. What is the protocol in that case?
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Client: The protocol says to wave the other trucks through and keep them moving so that you don’t have multiple trucks just sitting there together more vulnerable.
Therapist: Okay. That’s helpful for me to understand. In light of the protocol you just described and the reasons for it, why do you think you should have had the second truck wait and not had them go on?
Client: If I hadn’t have waved them through and told them to carry on, this wouldn’t have happened. It is my fault that they died. (Begins to cry)
Therapist: (Pause) It is certainly sad that they died. (Pause) However, I want us to think through the idea that you should have had them wait and not had them go on, and consequently that it was your fault. (Pause) If you think back about what you knew at the time — not what you know now 5 years after the outcome — did you see anything that looked like a possible explosive device when you were scanning the road as the original lead truck?
Client: No. Prior to the truck breaking down, there was nothing that we noticed. It was an area of Iraq that could be dangerous, but there hadn’t been much insurgent activity in the days and weeks prior to it happening.
Therapist: Okay. So, prior to the explosion, you hadn’t seen anything suspicious.
Therapist: When the second truck took over as the lead truck, what was their responsibility and what was your responsibility at that point?
Client: The next truck that Mike and my other friends were on essentially became the lead truck, and I was responsible for trying to get my truck moving again so that we weren’t in danger.
Therapist: Okay. In that scenario then, would it be Mike and the others’ jobs to be scanning the environment ahead for potential dangers?
Client: Yes, but I should have been able to see and warn them.
Therapist: Before we determine that, how far ahead of you were Mike and the others when the explosion occurred?
Client: Oh (pause), probably 200 yards?
Therapist: 200 yards—that’s two football fields’ worth of distance, right?
Therapist: You’ll have to educate me. Are there explosive devices that you wouldn’t be able to detect 200 yards ahead?
Therapist: How about explosive devices that you might not see 10 yards ahead?
Client: Sure. If they are really good, you wouldn’t see them at all.
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Therapist: So, in light of the facts that you didn’t see anything at the time when you waved them through at 200 yards behind and that they obviously didn’t see anything 10 yards ahead before they hit the explosion, and that protocol would call for you preventing another danger of being sitting ducks, help me understand why you wouldn’t have waved them through at that time? Again, based on what you knew at the time?
Client: (Quietly) I hadn’t thought about the fact that Mike and the others obviously didn’t see the device at 10 yards, as you say, or they would have probably done something else. (Pause) Also, when you say that we were trying to prevent another danger at the time of being “sitting ducks,” it makes me feel better about waving them through.
Therapist: Can you describe the type of emotion you have when you say, “It makes me feel better?”
Client: I guess I feel less guilty.
Therapist: That makes sense to me. As we go back and more accurately see the reality of what was really going on at the time of this explosion, it is important to notice that it makes you feel better emotionally. (Pause) In fact, I was wondering if you had ever considered that, in this situation, you actually did exactly what you were supposed to do and that something worse could have happened had you chosen to make them wait?
Client: No. I haven’t thought about that.
Therapist: Obviously this was an area that insurgents were active in if they were planting explosives. Is it possible that it could have gone down worse had you chosen not to follow protocol and send them through?
Client: Hmmm. I hadn’t thought about that either.
Therapist: That’s okay. Many people don’t think through what could have happened if they had chosen an alternative course of action at the time or they assume that there would have only been positive outcomes if they had done something different. I call it “happily ever after” thinking — assuming that a different action would have resulted in a positive outcome. (Pause) When you think, “I did a good job following protocol in a stressful situation that may have prevented more harm from happening,” how does that make you feel?
Client: It definitely makes me feel less guilty.
Therapist: I’m wondering if there is any pride that you might feel?
Client: Hmmm…I don’t know if I can go that far.
Therapist: What do you mean?
Client: It seems wrong to feel pride when my friends died.
Therapist: Is it possible to feel both pride and sadness in this situation? (Pause) Do you think Mike would hold it against you for feeling pride, as well as sadness for his and others’ losses?
Client: Mike wouldn’t hold it against me. In fact, he’d probably reassure me that I did a good job.
Therapist: (Pause) That seems really important for you to remember. It may be helpful to remind yourself of what you have discovered today, because you have some habits in thinking about this event in a particular way. We are also going to be doing some practice assignments [Challenging Questions Worksheets] that will help to walk you through your thoughts about what happened during this event, help you to remember what you knew at the time, and remind you how different thoughts can result in different feelings about what happened.
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Client: I actually feel a bit better after this conversation.
Another thought that Jill described in relation to the traumatic event was, “I should have seen the explosion was going to happen to prevent my friends from dying.” Her related feelings were guilt and self-directed anger. The therapist used this thought to introduce the cognitive intervention of “challenging thoughts” and provided a worksheet for practice. The therapist first provided education about the different types of thinking errors, including habitual thinking, all-or-none thinking, taking things out of context, overestimating probabilities, and emotional reasoning, as well as discussing other important factors, such as gathering evidence for and against the thought, evaluating the source of the information, and focusing on irrelevant factors.
More specifically, Jill noted that she experienced 100 percent intensity of guilt and 75 percent intensity of anger at herself in relation to the thought “I should have seen the explosive device to prevent my friends from dying.” She posed several challenging questions, including the notion that improvised explosive devices are meant to be concealed, that she is the source of the information (because others don’t blame her), and that her feelings are not based on facts (i.e., she feels guilt and therefore must be guilty). She came up with the alternative thought, “The best explosive devices aren’t seen and Mike (driver of the second truck) was a good soldier. If he saw something he would stopped or tried to evade it,” which she rated as 90 percent confidence in believing. She consequently believed her original thought 10 percent, and re-rated her emotions as only 10 percent guilt and 5 percent anger at self.
REPRINTED WITH PERMISSION
Treating PTSD with cognitive-behavioral therapies: Interventions that work This case example is reprinted with permission from: Monson, C. M. & Shnaider, P. (2014). Treating PTSD with cognitive- behavioral therapies: Interventions that work. Washington, DC: American Psychological Association