Main Cognitive-Behavioral Therapies for Trauma 2nd Edition

Cognitive-Behavioral Therapies for Trauma 2nd Edition

This volume presents cutting-edge cognitive and behavioral applications for understanding and treating trauma-related problems in virtually any clinical setting. Leading scientist-practitioners succinctly review the "whys," "whats," and "hows" of their respective approaches. Encompassing individual, group, couple, and parent-child treatments, the volume goes beyond the traditionally identified diagnosis of PTSD to include strategies for addressing comorbid substance abuse, traumatic revictimization, complicated grief, acute stress disorder, and more. It also offers crucial guidance on assessment, case conceptualization, and treatment planning.
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Cognitive-Behavioral Therapies for Trauma

Therapies for Trauma
Second Edition

Edited by

Victoria C. Follette
Josef I. Ruzek

New York London

© 2006 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
All rights reserved
No part of this book may be reproduced, translated, stored
in a retrieval system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from
the Publisher.
Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Cognitive-behavioral therapies for trauma / edited by
Victoria M. Follette, Josef I. Ruzek.— 2nd ed.
p. cm.
Includes bibliographical references and index.
ISBN 1-59385-247-9
1. Post-traumatic stress disorder—Treatment.
2. Cognitive therapy. I. Follette, Victoria M. II. Ruzek,
Josef I.
RC552.P67C65 2006

About the Editors




Deborah J. Brief, PhD, VA Boston Healthcare System, Boston University School
of Medicine, Psychology Service, Boston, Massachusetts
Richard A. Bryant, PhD, School of Psychology, University of New South Wales,
Sydney, New South Wales, Australia
Shawn P. Cahill, PhD, Center for the Treatment and Study of Anxiety,
Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
Marylene Cloitre, PhD, Department of Psychiatry and Child Study Center
Institute for Trauma and Stress, New York University, New York, New York
Jill S. Compton, PhD, Department of Psychiatry and Behavioral Sciences, Duke
University Medical Center, Durham, North Carolina
Esther Deblinger, PhD, Department of Psychiatry and Center for Children’s
Support, School of Osteopathic Medicine, University of Medicine and Dentistry
of New Jersey, Stratford, New Jersey
Edna B. Foa, PhD, Center for the Treatmen; t and Study of Anxiety, Department
of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
Victoria M. Follette, PhD, Department of Psychology, University of Nevada,
Reno, Reno, Nevada
William C. Follette, PhD, Department of Psychology, University of Nevada,
Reno, Reno, Nevada
David W. Foy, PhD, Graduate School of Education and Psychology, Pepperdine
University, Encino, California
Ellen Frank, PhD, Department of Psychiatry, University of Pittsburgh School of
Medicine, Pittsburgh, Pennsylvania
Matthew J. Friedman, MD, PhD, National Center for PTSD, VA Medical Center,
White River Junction, Vermont
Steven C. Hayes, PhD, Department of Psychology, University of Nevada, Reno,
Reno, Nevada
Terence M. Keane, PhD, National Center for PTSD, VA Boston Healthcare
System, Boston University School of Medicine, Boston, Massachusetts



Barbara S. Kohlenberg, PhD, Department of Psychiatry and Behavioral
Sciences, University of Nevada, Reno, Nevada
Robert J. Kohlenberg, PhD, Department of Psychology, University of
Washington, Seattle, Washington
Edward S. Kubany, PhD, National Center for PTSD, Department of Veterans
Affairs, Honolulu, Hawaii
Linnea C. Larson, MA, MPH, Headington Program in International Trauma,
Graduate School of Psychology, Fuller Theological Seminary, Pasadena,
Leah M. Leonard, MA, Department of Psychology, University of Nevada, Reno,
Reno, Nevada
Marsha M. Linehan, PhD, Department of Psychology, University of Washington,
Seattle, Washington
Candice M. Monson, PhD, Women’s Health Sciences Division, National Center
for PTSD, VA Boston Healthcare System, Boston, Massachusetts
Lisa M. Najavits, PhD, Department of Psychiatry, Harvard Medical School,
Cambridge, Massachusetts; Trauma Research Program (Alcohol and Drug
Treatment Center); McLean Hospital, Belmont, Massachusetts
Amy E. Naugle, PhD, Department of Psychology, Western Michigan University,
Kalamazoo, Michigan
Elizabeth M. Pratt, PhD, National Center for PTSD, VA Boston Healthcare
System, Boston University School of Medicine, Boston, Massachusetts
Tyler C. Ralston, MA, National Center for PTSD, Department of Veterans
Affairs, Honolulu, Hawaii
Patricia A. Resick, PhD, Women’s Health Sciences Division, National Center for
PTSD, VA Boston Healthcare System, Boston, Massachusetts
David S. Riggs, PhD, Center for the Treatment and Study of Anxiety,
Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
Anna Rosenberg, BA, Adult Anxiety Clinic, Department of Psychology, Temple
University, Philadelphia, Pennsylvania
Josef I. Ruzek, PhD, National Center for PTSD, VA Palo Alto Health Care
System, Menlo Park, California
Erika Ryan, PhD, New Jersey CARES (Child Abuse Research Education Service)
Institute, School of Osteopathic Medicine, University of Medicine and Dentistry
of New Jersey, Stratford, New Jersey
Katherine Shear, MD, Department of Psychiatry, University of Pittsburgh School
of Medicine, Pittsburgh, Pennsylvania; Bereavement and Grief Program,
Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
Jillian C. Shipherd, PhD, Women’s Health Sciences Division, National Center
for PTSD, VA Boston Healthcare System, Boston, Massachusetts



Amy E. Street, PhD, Women’s Health Sciences Division, National Center for
PTSD, VA Boston Healthcare System, Boston, Massachusetts
Reena Thakkar-Kolar, PhD, New Jersey CARES (Child Abuse Research
Education Service) Institute, School of Osteopathic Medicine, University of
Medicine and Dentistry of New Jersey, Stratford, New Jersey
Mavis Tsai, PhD, private practice, Seattle, Washington
Amy W. Wagner, PhD, Department of Psychiatry and Behavioral Sciences,
University of Washington, Seattle, Washington
Robyn D. Walser, PhD, National Center for PTSD and Sierra-Pacific Mental
Illness Research, Education, and Clinical Centers (MIRECC), VA Palo Alto
Health Care System, Menlo Park, California



This second edition of Cognitive-Behavioral Therapies for Trauma assembles
contributions from leading developers of cognitive-behavioral therapies
applied to trauma-related problems. Cognitive-behavioral treatment (CBT)
approaches, together with the research and theoretical models on which they
are based, are increasingly the treatment of choice. Because they are evidence-based helping methods, CBT approaches, in their popularity, are fostering more widespread use of methods that we know are working. Nowhere
is this more evident than in the treatment of trauma. In the several practice
guidelines for treatment of PTSD that have been developed since the first
edition of this book was published (i.e., Foa, Keane, & Friedman, 2000; VA/
DoD Clinical Practice Guideline Working Group, 2003; American Psychiatric Association Work Group on ASD and PTSD, 2004; National Collaborating Centre for Mental Health, 2005), cognitive-behavioral treatments are
universally acknowledged to have the most significant empirical support.
CBT approaches figure prominently in the recommendations made in these
documents because cognitive-behavioral interventions have been routinely
evaluated by reliable and valid assessment tools. Systematic, ongoing assessment of client functioning has always been integral to cognitive-behavioral
and behavioral therapies. The empirical tradition of these approaches positions them well in an era where enthusiastic endorsements of treatments are
less and less sufficient to justify them.
In addition to reviewing the research evidence supporting many cognitive-behavioral1 interventions, the 17 chapters in this volume describe and analyze a large range of treatment methodologies that have been applied across
many trauma populations and contexts of care. Many of the treatments
reviewed in these chapters are complex packages that target not only PTSD but
also other trauma-related problems and processes. The complexity of the alternatives the authors offer reflects the fact that treatment providers and their clients have an impressive set of pragmatic tools for addressing problems to

the sake of brevity, the umbrella term “cognitive-behavioral” is used in this text to encompass a range of treatment approaches that have emerged from different behavioral and cognitive therapeutic models.




choose from. In this Preface, we illustrate some of the ways in which cognitivebehavioral interventions can assist providers in their work with traumatized clients, illustrated by the contributions of our chapter authors.

Our main rationale for developing this text is the idea that clinicians should
base treatment on a detailed assessment of their client’s unique individual
needs, rather than simply administering a structured treatment package.
Cognitive-behavioral assessment of PTSD and other trauma-related problems remains centered on a functional analysis of behavior, outlined in
Chapter Two by Follette and Naugle. Their approach is that there is no
“average” patient. It is necessary to develop an individualized understanding
of the functional relationships among a person’s behaviors, life conditions
preceding the trauma, how those factors are maintained after the trauma.
For the clinician wrestling with trying to understand a complex human being
in a set of complex social environments, these authors’ emphasis on identifying important, controllable, and causal factors is critical: what are the specific variables that, when changed, will lead to large improvements in the
behaviors of clinical interest, that can be affected by the clinician and client
working together, and that when modified, reliably produce changes in the
target problem?
Cognitive-behavioral practitioners also believe that it is important to
assess changes in problem behaviors and symptoms and thereby evaluate the
effectiveness of their helping efforts. In their review of recent advances in
psychological assessment of PTSD in adults, Pratt, Brief, and Keane in Chapter Three conclude that the assessment devices available for evaluating PTSD
are comparable to or better than those for other psychological disorders.
They identify a variety of measures that are helpful in assessing the effectiveness of treatment, as do most of the chapter authors with regard to their particular interventions.

Cognitive-behavioral treatments are built around a set of fundamental helping procedures that target different sets of problems encountered by trauma
survivors. These are (1) coping skills training, that focuses on teaching clients
to respond effectively to the many situation-specific challenges associated
with PTSD and other trauma-related difficulties, and to replace existing maladaptive responses with more effective ones; (2) prolonged exposure, that
works to reduce conditioned fear responses connected with trauma memories and the stimuli that elicit them; (3) cognitive therapy, that assists survivors
in modifying ways of thinking that create distress and interfere with recovery; and (4) acceptance methods, which recognize that some of the problems of



trauma survivors are caused or worsened by avoidance behaviors, therefore
encouraging survivors to fully experience and accept their own traumarelated emotions, thoughts, and feelings without trying to avoid them.
A primary feature of most treatments for PTSD is to educate clients
about the disorder and the rationales for treatment. Treatments focus on
providing information and teaching new skills for living. Those who deliver
cognitive-behavioral interventions explicitly conceptualize much of what they
do as skills training, and as the field has developed, cognitive-behavioral
methods have been designed to address a wide and growing array of skills
that can be taught by clinicians to their clients. In this book, skills training
approaches are outlined across chapters and form large parts of some of the
interventions discussed, such as Dialectical Behavior Therapy (DBT) as summarized by Wagner and Linehan in Chapter Six, the Skills Training in Affect
and Interpersonal Regulation (STAIR) treatment described by Cloitre and
Rosenberg in Chapter Thirteen, and the Seeking Safety protocol presented
by Najavits in Chapter Ten. The book as a whole includes extensive discussion of the client skills sets that are related to distress tolerance, emotion regulation, interpersonal effectiveness, personal safety, and mindfulness. The
chapter authors show how cognitive-behavioral skills training technologies
can be used to ensure that clients learn, practice, test, and transfer these
skills into the real world of their daily lives.
Central to approaches that focus on reduction of posttraumatic fear
reactions is exposure therapy. Prolonged Exposure (PE) treatment is the
most well-validated psychosocial treatment for PTSD. As described by Riggs,
Cahill, and Foa in Chapter Four, it focuses on reducing trauma-related anxiety by encouraging the client to confront situations, activities, thoughts, and
memories that are feared and avoided but that are not inherently dangerous.
Treatment incorporates four primary procedures: education about trauma
and PTSD, breathing retraining, in vivo or “real-world” exposure to feared
but safe trauma-related situations that the client normally avoids, and
imaginal exposure in which the client repeatedly describes memories of the
traumatic event.
Many cognitive-behavioral approaches also emphasize how important to
the recovery process it is to deal with distressing trauma-related appraisals
and beliefs. Such beliefs are at the core of the difficulty experienced by clients, and this is readily apparent to most treatment providers. Cognitive Processing Therapy (CPT) represents perhaps the best articulated application of
cognitive therapy methods to the problem of PTSD, and is described at
length in this book by Shipherd, Street, and Resick in Chapter Five. CPT is
built on the testable hypothesis that “an approach that elicits memories of
the traumatic event and then directly confronts maladaptive beliefs, faulty
attributions, and inaccurate expectations may be more effective than exposure therapy alone.” Cognitive therapies also resonate with therapist experience in that they readily expand the range of trauma-related emotions tackled in therapy to include anger, sadness, helplessness, and guilt. The latter
emotion often complicates treatment for those with PTSD; in Chapter



Eleven of this volume, Kubany and Ralston provide both a cognitive-behavioral conceptualization of trauma-related guilt and a detailed account of cognitive therapy applied to trauma-related guilt and shame.
Acceptance-based interventions are increasingly being integrated into
cognitive-behavioral treatments for trauma survivors. These approaches are
represented in these pages, on DBT in Chapter Six by Wagner and Linehan
and on Acceptance and Commitment Therapy (ACT) in Chapter Seven by
Walser and Hayes. DBT stresses the tension between acceptance and change,
between accepting clients as they are but also attempting to modify their
behavior. Both change-oriented and acceptance-oriented goals are seen as
important in this therapy. ACT (which also stand for Accept, Choose, and
Take Action) embraces the same two goals as DBT. It emphasizes a conscious abandonment of the mental and emotional change agenda when
these change efforts do not work. The client is encouraged to accept
thoughts, feelings, memories, and sensations without trying to eliminate or
control them; to engage in practical, safe, and valued behaviors that may
include changing the situation; and to discriminate between unworkable
solutions (e.g., avoiding emotions) and workable solutions (e.g., commitment to behavior change).
Those who have been exposed to traumatic events are at risk for developing many kinds of problems, and if cognitive-behavioral methods are to be
widely adopted by a broad range of practitioners, they need to assist clinicians in comprehensively addressing the needs of their clients. This book
illustrates the fact that those who are developing cognitive-behavioral treatment have been showing increased attention to significant problems trauma
survivors face that are beyond the traditionally identified diagnosis of PTSD.
In this text, this attention is reflected in the work of Najavits in extending
cognitive-behavioral methods to the treatment of substance abuse concurrent with PTSD, Cloitre and Rosenberg in conceptualizing interventions to
reduce risk of revictimization among sexual assault survivors, and by Shear
and Frank in Chapter Twelve in their work on complicated grief. It is also
shown in Chapter Nine, in Bryant’s adaptation and extension of the procedures found effective in management of chronic PTSD to treat acute stress
disorder. In the final chapter in this volume, Chapter Seventeen, Ruzek discusses the potential for cognitive-behavioral psychology to inform efforts to
prevent development of PTSD and shows how the work of Bryant and others
has led cognitive-behavioral practitioners to become increasingly active in
developing and testing early interventions with survivors of recent traumas.

Addressing Survivor’s Interpersonal Problems. Trauma survivors’ problems often
show themselves in the survivors’ interpersonal interactions. Cognitive-



behavioral psychology has, of course, a rich history of attention to the interpersonal context of behavior problems, a focus that is seeing increasing
development related to PTSD. In this book, interventions that focus on couples concerns are described in Chapter Fourteen by Leonard, Follette, and
Compton. Deblinger, Thakkar-Kolar, and Ryan in Chapter Sixteen describe
interventions that work conjointly with both children and parents in addressing child traumatic experiences. Group psychotherapy, an important component of treatment for many trauma survivors, is reviewed in Chapter Fifteen
by Foy and Larsen. The latter authors point to the advantages for trauma
survivors, whose experiences so commonly involve social isolation, social
alienation, perceptions of being ostracized from the larger society, shame,
and diminished feelings for others, of working toward recovery with other
Working with Challenging Clinical Behaviors. Mental health providers must
navigate many difficult situations in their interactions with survivors. For
example, clients with a history of trauma in the family of origin may have
developed a number of maladaptive coping mechanisms to deal not only
with the trauma but also with other invalidating aspects of their environment. In fact, much of what is particularly helpful in cognitive-behavioral
interventions goes beyond the core treatment components outlined in the
sections above, and includes procedures that help the therapist both to motivate the client and to avoid or manage difficult clinical situations such as suicidal behavior. These procedures include encouraging the client to take an
active role in setting the goals of treatment, presenting persuasive rationales
for treatment, assigning and ensuring completion of homework tasks,
instructing clients in techniques of self-monitoring, and so on. For example,
Najavits emphasizes in her Seeking Safety treatment ways of giving clients
control whenever possible, “listening” to client behavior more than words,
giving positive and negative feedback to clients, and asking clients about
their reactions to treatment. In the same spirit, Wagner and Linehan utilize a
number of techniques from DBT to address noncompliance, suicidal ideation, and other self-injurious behavior.
Using the Therapeutic Relationship. In their historical perspective on cognitivebehavioral therapies for trauma, Monson and Friedman in Chapter One
observe that cognitive-behavioral therapy is often stereotyped as a mechanical form of therapy lacking in a certain type of human contact. But the attention to interpersonal processes that is included in many cognitive-behavioral
therapies also extends to the client–therapist relationship. Generally, most of
the approaches described in this text emphasize the importance of the therapeutic relationship. In particular, Functional Analytic Psychotherapy (FAP)
as described in Chapter Eight by Kohlenberg, Tsai, and Kohlenberg provides
an extensive introduction to how providers of cognitive-behavioral treatments can use the therapeutic relationship as a primary component of treat-



ment. This conceptualization, in contrast to the stereotypes of cognitivebehavioral treatments, places the client–therapist relationship at the core of
the change process. FAP theory indicates that the therapeutic process is facilitated by a caring, genuine, sensitive, and emotional client–therapist relationship. The therapeutic relationship itself is used to help identify interpersonal
stimuli that lead to problems and to provide in vivo opportunities to change
interpersonal repertoires. Therapists are taught to recognize and address
clinically relevant behaviors that occur in session, and to strengthen client
improvements within the therapy session itself. DBT similarly posits that a
strong relationship characterized by mutual trust, respect, and positive
regard will increase the likelihood that the client will engage in efforts to
change that are difficult and uncomfortable, and that a strong relationship
can be therapy in itself.

Providing Training and Support for Clinicians. A prime obstacle to the
increased use of cognitive-behavioral methods to assist trauma survivors is
the fact that most clinicians have not received training in the types of
approaches outlined in this book. Awareness of this is leading developers of
cognitive-behavioral treatments to explore ways of improving the training of
community providers in using their approaches. For example, Riggs, Cahill,
and Foa note the lack of opportunities for training in PE, and also acknowledge that conventional training workshops are ineffective in changing the
behavior of practitioners; few workshop attendees actually end up using
exposure. In response they have developed two models of training. In the
first, experts provide intensive training as well as continued supervision of
therapist trainees. In the second model, experts provide intensive initial
training, but ongoing supervision of the new practitioners is provided by
local supervisors who consult with the experts but over time become experts
themselves. Other authors in this book who devote attention to training and
supervision issues include Foy and Larsen, who consider the requisite therapist skills for conducting CBT trauma groups; and Kohlenberg, Tsai, and
Kohlenberg, who discuss issues of clinical supervision in FAP. As outlined by
Wagner and Linehan, DBT is notable for its explicit assertion that “therapists treating BPD patients need support.” Therapist consultation groups are
an essential component of DBT: they provide that needed support, as well as
development, and can help minimize therapist burnout.
Enabling Integration with Other Treatment Approaches. The point should be
made that cognitive-behavioral methods are more likely to be widely used if
they have the potential be integrated with other approaches. Disseminating
cognitive-behavioral approaches does not mean that they should replace the
other approaches. Rather, they would be a complement to methods they’re
used in conjunction with, perhaps addressing aspects of the problem not



dealt with well by the principal orientation. In the present volume, many of
the authors speak to the capacity for integration of their approaches with
other treatments. Walser and Hayes state that if research indicates that a client’s problems would be better treated by a different approach, that latter
treatment should be implemented first or integrated into the course of ACT.
DBT and Seeking Safety are designed to be frontline stages of treatment for
individuals with PTSD, so as to get the client stabilized prior to introducing
exposure treatment. Najavits has explored how to integrate trauma processing therapy with Seeking Safety. Kubany and Ralston introduce a variety of
ways to understand and challenge trauma-related guilt. Awareness of the
role of guilt, and Kubany and Ralston’s interventions, would be combined
with other treatments not designed to systematically address guilt. An element that Monson and Friedman touch on is that psychopharmacological
treatments can either help or impede a concurrent cognitive-behavioral
treatment. Complicated Grief Treatment (CGT), described in this volume by
Shear and Frank, illustrates well the capacity for integration of cognitivebehavioral treatments with those based on other theoretical orientations.
Shear and Frank created CGT by mixing Interpersonal Therapy—an existing
short-term, present-oriented treatment for grief—with cognitive-behavioral
methods for treatment of PTSD, as well as with cognitive strategies for dealing with the distress of separation.

The question of how CBT should be packaged for delivery by clinicians and
programs is an important one. Many of the treatments described in this
book are broken down into a series of steps, so that clinicians can provide
the treatments and apply them effectively. This does not mean that one must
slavishly follow the steps of treatment. Indeed, such structured cognitivebehavioral treatments are flexible, provide therapists with options, and rely
heavily on therapist and client decision-making. Just as “assessment” is really
a process of coming to understand a unique individual, so too treatment
must reach beyond “cookbook” applications and formulate a cognitivebehavioral approach that fits the individual client. We hope that readers of
this book will become familiar with a host of cognitive-behavioral interventions.
In fact, some of the contributors to this book refer to the limitations of
step-based, or “manualized,” treatments and they propose alternatives. Leonard, Follette, and Compton identify two major potential problems in delivering formalized, prepackaged treatment techniques to survivor couples. The
problems are that use of prepackaged techniques may not sufficiently discourage therapists from losing sight of the individual or couple. Manualized
treatments, based on a treatment manual, do not prepare therapists to cope
with problems outside the manual’s scope. These authors argue that treat-



ment manuals may lead therapists to believe that they understand a person
based on his or her initial presentation or diagnosis, but then they fail to
assess clients on a continuing basis. In the worst case, treatment providers
are concerned with getting back on the protocol rather than listening to the
couple. As an alternative to treatment packages that either are overly formulaic or could be misused that way in the wrong hands, Leonard, Follette, and
Compton recommend the development of a “principle-based” couples intervention that relies on helping principles rather than particular techniques or
structures. Similarly, Wagner and Linehan consider DBT to be a principledriven (not protocol-driven) intervention.

Cognitive-behavioral approaches to helping trauma survivors continue to
evolve, with treatment methods remaining a work in progress. A number of
limitations remain in the current evidence base, but despite this, the chapters in this book provide a significant argument that cognitive-behavioral
approaches taken as a whole constitute a powerful form of treatment. They
provide the clinician with a substantial and growing set of treatment concepts and tools, address a wide range of trauma-related problems and populations, address the interpersonal context of treatment. They reflect the complexity of the individual, and increasingly they take into account the
perspective and needs of treatment providers in the field. The contributors
to this text are working to develop comprehensive treatment approaches
based on the foundation of science. We believe that in doing so, they are
providing an invaluable service to the many people who will survive a traumatic experience.

American Psychiatric Association Work Group on ASD and PTSD. (2004). Practice
guideline for the treatment of patients with acute stress disorder and posttraumatic stress
disorder. Washington, DC: American Psychiatric Association.
Foa, E. B., Keane, T. M., & Friedman, M. J. (2000). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York:
Guilford Press.
National Collaborating Centre for Mental Health. (2005). Post-traumatic stress disorder:
The management of PTSD in adults and children in primary and secondary care. London: National Institute for Clinical Excellence.
VA/DoD Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of
Defense. (2003). Management of post-traumatic stress (publication 10Q-CPG/
PTSD-04). Washington, DC: Office of Quality and Performance.




Back to the Future of Understanding Trauma: Implications
for Cognitive-Behavioral Therapies for Trauma
Candice M. Monson and Matthew J. Friedman



Functional Analytic Clinical Assessment in Trauma Treatment
William C. Follette and Amy E. Naugle



Recent Advances in Psychological Assessment of Adults
with Posttraumatic Stress Disorder
Elizabeth M. Pratt, Deborah J. Brief, and Terence M. Keane



Prolonged Exposure Treatment
of Posttraumatic Stress Disorder
David S. Riggs, Shawn P. Cahill, and Edna B. Foa



Cognitive Therapy for Posttraumatic Stress Disorder
Jillian C. Shipherd, Amy E. Street, and Patricia A. Resick



Applications of Dialectical Behavior Therapy
to Posttraumatic Stress Disorder and Related Problems
Amy W. Wagner and Marsha M. Linehan



Acceptance and Commitment Therapy in the Treatment of
Posttraumatic Stress Disorder: Theoretical and Applied Issues
Robyn D. Walser and Steven C. Hayes



Functional Analytic Psychotherapy and the Treatment
of Complex Posttraumatic Stress Disorder
Barbara S. Kohlenberg, Mavis Tsai, and Robert J. Kohlenberg





Cognitive-Behavioral Therapy for Acute Stress Disorder
Richard A. Bryant



Seeking Safety: Therapy for Posttraumatic Stress Disorder
and Substance Use Disorder
Lisa M. Najavits



Cognitive Therapy for Trauma-Related Guilt and Shame
Edward S. Kubany and Tyler C. Ralston



Treatment of Complicated Grief: Integrating CognitiveBehavioral Methods with Other Treatment Approaches
Katherine Shear and Ellen Frank



Sexual Revictimization: Risk Factors and Prevention
Marylene Cloitre and Anna Rosenberg



A Principle-Based Intervention
for Couples Affected by Trauma
Leah M. Leonard, Victoria M. Follette, and Jill S. Compton



Group Therapies for Trauma Using
Cognitive-Behavioral Therapy
David W. Foy and Linnea C. Larson



Trauma in Childhood
Esther Deblinger, Reena Thakkar-Kolar, and Erika Ryan



Bringing Cognitive-Behavioral Psychology to Bear on Early
Intervention with Trauma Survivors: Accident, Assault, War,
Disaster, Mass Violence, and Terrorism
Josef I. Ruzek




Trauma History


Back to the Future
of Understanding Trauma
Implications for Cognitive-Behavioral Therapies
for Trauma
Candice M. Monson
Matthew J. Friedman

Cognitive-behavioral therapy (CBT) for trauma represents a broad class of
therapies unified by a shared emphasis on observable outcomes, symptom
amelioration, time-limited and goal-oriented intervention, and an expectation that patients will assume an active role in getting better. An additional
strength of CBT applied to trauma is its adherence to evidence-based conceptualization of patients’ posttraumatic psychopathology. We assert that
increased understanding of the nature of posttraumatic reactions can translate into enhanced effectiveness and innovations in CBT for trauma. Here
we trace the evolving history of understanding posttraumatic pathology, and
with an appreciation of this past, offer a vision of upcoming achievements
and challenges in the application of CBT for trauma.

Documented human history is replete with descriptions of individual reactions to traumatic events. For example, a survivor of the Great Fire of London in the 1600s wrote in his diary 6 months after his exposure, “it is strange
to think how to this very day I cannot sleep a night without great terrors of
the fire; and this very night could not sleep to almost two in the morning
through great terrors of the fire” (quoted in Saigh & Bremner, 1999, p. 1).
There has been remarkable consistency in the description of such posttrau1


Trauma History

matic reactions throughout the centuries, whether written by poets and novelists or clinicians and scientists. Despite this general agreement on observable phenomenology, many different causal mechanisms and diagnostic
labels have been proposed. Indeed, the theoretical etiology of these reactions as organic versus psychological as well as the diagnostic classification of
traumatic reactions have evolved over time.

Historical Conceptualizations
When the scientific approach to psychopathology emerged in the 19th century, the zeitgeist was to determine organic pathogeneses, such as lesions of
the nervous system, as the major cause of nervous disorders. Posttraumatic
reactions were no exception to this theoretical organic orientation. Some of
the most detailed writings and elaborated conceptualizations of traumatic
reactions are found in the literature on combatants.
Starting with the Civil War, American conceptualizations of posttraumatic reactions were understood mostly as somatic/physiological reactions,
usually affecting the cardiovascular system. According to Hyams, Wignell,
and Roswell (1996), proposed somatic/physiological diagnoses were Da
Costa syndrome/irritable heart (Civil War), soldier’s heart, neurocirculatory
asthenia and shell shock (World War I), and effort syndrome (World War II).
Attributing these reactions to organic causes had a number of sociopolitical
implications: Soldiers could avoid the stigma and sense of personal failure
associated with mental disorders, and the military could ignore the need for
psychological interventions.
Although there is only a smattering of accounts of the psychological
sequelae of natural and technological disasters during the late 19th century,
it is known that civilian traumas were also attributed to organic causes. For
example, “Railway spine” was considered to be the result of railroad accidents that produced theoretical, but usually unobservable, physical lesions or
insults to the brain, spinal cord, or peripheral nervous system. This condition is representative of the tendency to attribute otherwise unexplainable
physical disabilities to abnormal central nervous system mechanisms.
Indeed, an English surgeon, John Erichsen (1882), cautioned against confusing (what he assumed to be) the organically caused symptoms of railway
spine with hysteria, the prevailing diagnosis of the times (van der Kolk,
Weisaeth, & van der Hart, 1996). When physical injuries could not be found
in these patients, their symptoms were attributed to subtle forms of neurological damage and a general functional disturbance of the nervous balance
or tone. The German neurologist Herman Oppenheim (1915) is credited
with coining the term “traumatic neurosis.” He proposed that functional
problems were a result of subtle molecular changes in the central nervous
system following exposure to trauma.
Posttraumatic reactions were not left out of Kraepelin’s (1896) efforts in
the 1800s to classify and organize mental disorders. He developed a com-

Trauma History


mon label for these multiple nervous and psychic phenomena: “schreckneuroses,” or fright neuroses. Schreckneuroses were believed to result from
severe emotional upheaval or sudden fright, and to have neurological underpinnings. The symptoms of schreckneuroses were observed after serious
accidents and injuries, particularly fires, railway derailments or collisions
(Saigh & Bremner, 1999).
Sigmund Freud rebelled against the primary focus on organic explanations for psychopathology in vogue during that period. Because of his influence, psychological etiologies began to be proposed for understanding and
treating psychopathology, in general, and posttraumatic reactions, in particular. Freud theorized that, because traumatic events overwhelm the psyche,
traumatized individuals must engage extremely primitive defense mechanisms such as dissociation, repression, and denial. Catharsis and abreaction,
involving high levels of emotional expression, were considered the necessary
treatment for countering these primitive defenses (Freud, 1950). Other contemporaneous psychological conceptualizations of combat trauma included
nostalgia (Civil War), battle fatigue/combat exhaustion/operational fatigue
(World War I), and war/traumatic neurosis (World War II) (Hyams et al.,
Although Freud stood strong against the winds of the medical and scientific culture pertaining to organic versus psychological explanations of psychopathology, he unfortunately wavered in the winds of Victorian culture
regarding childhood sexual abuse. His emphasis on the internal workings of
individuals—psychosexual drives and early developmental processes—to the
exclusion of external stressors such as childhood sexual abuse was a serious
oversight from our modern perspective (see Pendergrast, 1999, for more
thorough review of this debate). Freud’s legacy is also found in the recovered
memory versus false memory debate that erupted in the early 1990s. His
notion of the primitive defenses involved in traumatization, and especially
repression, as the foundation of claims regarding recovered memories of
sexual abuse. Although the potential for psychogenic amnesia of traumatic
events cannot be completely ruled out, the past 15 years of scientific evidence questions the veracity of such memories and the possible iatrogenic
effects of psychotherapy in creating them (Brewin, 2003).
Freud’s contemporary, Pierre Janet, was also instrumental in bringing a
psychological approach to posttraumatic reactions, and his writings include
some precursor elements of CBT. Indeed, cognitive-behavioral theories of
traumatic reactions find their roots in Janet’s writings about the categorization and integration of memories. He contended that people develop meaning schemes based on past experiences that prepare them to cope with subsequent challenges. When people experience “vehement emotions” in
response to frightening experiences, their minds are not capable of integrating the events with existing cognitive schemes. When the memories cannot
be integrated into personal awareness, something akin to dissociation
occurs. Janet also introduced the notion of patients experiencing a “phobia


Trauma History

of memory” that prevents the integration of traumatic events. The memory
traces linger as long as they are not translated into a personal narrative. In
his conception of trauma, synthesis and integration are the goals of treatment, which was in contrast to the psychoanalytic goals of catharsis and abreaction prevalent at the time (Janet, 1907).
Abram Kardiner, a psychoanalyst who treated World War I veterans,
was an early proponent of uniting these organic and psychological conceptual streams. He proposed that veterans who experienced an enduring clinical syndrome resulting from war-zone exposure suffered from a
“physioneurosis.” This label denotes both physiological and psychological
components of trauma reactions and the complex biobehavioral clinical picture exhibited by these veterans. In that regard, Kardiner anticipated, by
almost 40 years, many of the symptoms included in the first formal diagnosis
of posttraumatic stress disorder (PTSD). Because of this insight, which contradicted prevailing psychoanalytic doctrine, Kardiner might be considered
the father of psychobiological theory, research, and practice concerning
trauma. As a therapist he acknowledged the changes in self-concept that can
occur after trauma exposure, and he was a proponent of psychotherapy to
ameliorate both psychological and physiological trauma sequelae (Kardiner,
Kardiner’s work was rediscovered by Lawrence Kolb (1987), who theorized that fear conditioning in the limbic system, especially the amygdala,
was responsible for the stable psychological and physiological abnormalities
found in posttraumatic reactions. Since Kolb’s work, there has been an
explosion of basic and translational research documenting psychobiological
alterations in trauma patients and thereby providing a rationale for pharmacological interventions (Charney, 2004; Friedman, 2003; Friedman, Charney,
& Deutch, 1995; Yehuda & McFarlane, 1997).

Diagnostic Evolution
Our evolving conception of posttraumatic reactions is exemplified by
sequential revisions of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) with regard to both diagnostic categories and PTSD diagnostic criteria across the DSM revisions. To account for the war-related psychopathology discussed above, the first edition of the DSM (DSM-I; American Psychiatric Association [APA], 1952) included the diagnosis “gross stress reaction.”
This diagnosis was seen as appropriate for cases involving exposure to
“severe, physical demands or extreme stress, such as in combat or civilian
catastrophe” (p. 40). Like other disorders in the DSM-I, diagnostic criteria
delineating the disorder were not specified. Bucking the prevailing notion of
the times that those who developed this reaction were characterologically
weak, the DSM-I noted that the diagnosis often applied to “previously more
or less ‘normal’ persons who experience intolerable stress” (p. 40). Unfortunately, gross stress reaction was diluted in the second edition of the DSM

Trauma History


(DSM-II; APA, 1968) to “transient situational disturbance.” Although there
was a continued emphasis on the “overwhelming” nature of an environmental stressor(s) over individual diatheses in causing the reaction, the focus was
exclusively on “transient fear associated with military combat and manifested
by trembling, running and hiding” (p. 48). There was no diagnostic acknowledgment that such symptoms might characterize a chronic, rather than an
acute and naturally resolving, condition.
Influential writings in the 1970s and 1980s about the clinical presentations of sexual assault and domestic violence victims led to the “rape trauma
syndrome” and “battered women syndrome” designations (Burgess &
Holmstrom, 1974; Walker, 1984). These newly recognized conditions, in tandem with research on the mental health of World War II prisoners of war,
survivors of the Nazi Holocaust, and returning Vietnam veterans, led to
greater realization of the generalizability of reactions to life-threatening
stressors. During this time, the PTSD diagnosis was unveiled as an anxiety
disorder in the third edition of the DSM (DSM-III; APA, 1980). Criteria for
the traumatic stressor and specific symptoms were organized into three clusters. Accounting for the range of potentially traumatic events, the stressor
criterion was described as something “generally beyond the realm of normal
human experience that would evoke significant symptoms of distress in most
people” (p. 236). The DSM-III revision (DSM-III-R; APA, 1987) resulted in
few changes in the stressor definition and symptom inclusion and organization, but did delineate age-specific features.
The fourth revision of the DSM (DSM-IV; APA, 1994) and its text revision (DSM-IV-TR; APA, 2000) excluded the provision that the traumatic
stressor be generally outside the range of normal human experience. This
change reflects the empirical evidence that the experience of a stressor capable of producing PTSD is actually quite common. In fact, 75% or more of
people will experience such a stressor in their lifetime (Breslau, 2002). More
importantly, in the DSM-IV the nature of the individual’s reaction to a traumatic stressor was taken into account. The nomothetic standard that the
experience would evoke significant symptoms of distress in most people was
replaced with an idiographic, subjective criterion. According to the DSM-IV,
individuals who have been “traumatized” must have had an overwhelming
emotional reaction, defined as “intense fear, helplessness or horror” (p. 428)
when confronted by an extremely stressful experience. The operational definition of stressful experiences was also expanded to include observing or
receiving information about the traumatic events suffered by others.
Although some of the symptom clusters were rearranged and diagnostic
thresholds were adjusted, the greatest changes in the symptom criteria were
the requirements of additional functional impairment and 1–month of
symptom duration.
As described by Brewin (2003) in his more complete discussion of the
controversy surrounding diagnosis of posttraumatic reactions, “skeptics” of
the PTSD diagnosis assert that the diagnosis is a sociopolitical invention that


Trauma History

has been created in a litigious Western society that seeks to place blame and
identify victims and perpetrators. Skeptics argue that PTSD is not found in
non-Westernized cultures and contend that normal human reactions to a
stressful event only become pathological when diagnoses are applied to
them. At their worst, these opponents propose that diagnosing posttraumatic reactions has iatrogenic effects on those who are diagnosed.
These criticisms have been countered by empirical data showing that
individuals manifest ongoing trauma-related reactions when there are no
identifiable secondary gain issues, and after any of these potential gains has
been resolved (e.g., disability compensation, civil or criminal lawsuits; Bryant
& Harvey, 2003). Furthermore, evidence has accumulated that PTSD is
readily identifiable in traditional, nonindustrialized cultures, although it
remains controversial whether more culture-specific idioms of posttraumatic
distress might provide a better diagnostic characterization of such syndromes (de Jong, 2002; Green et al., 2003; Marsella, Friedman, Gerrity, &
Monsour, 1996).
Prospective studies reveal that a large majority (i.e., 94%) of traumatized
individuals will manifest symptoms consistent with a PTSD diagnosis or
other mental health problems (e.g., depression, panic, anxiety) in the immediate aftermath of trauma. However, by 3 to 6 months, most individuals’
symptoms have resolved (Foa & Riggs, 1995; Kessler, Sonnega, Bromet,
Hughes, & Nelson, 1995; Marsella et al., 1996; Norris, Murphy, Baker, &
Perilla, 2003; Schlenger et al., 2002). Thus it is important to emphasize that
there is a significant amount of “normal” distress that follows exposure to
traumatic events that should not be construed as pathological. These data
have led several researchers to offer the conceptualization of PTSD as a disorder of “nonrecovery” from trauma exposure (e.g., Rothbaum, Foa, Riggs,
Murdock, & Walsh, 1992; Shalev, 1997). It is the persistence and severity of
symptoms and the functional impairments that merit diagnosis. Epidemiological studies also argue against the notion of a naturally remitting course
for those who do not recover from traumatic events and develop PTSD,
given that approximately one-third of affected individuals continue to suffer
from the disorder 10 years after their trauma exposure (Kessler et al., 1995).
Biological investigations, including psychophysiological, neurohormonal,
and neuroimaging studies, contradict the notion that all traumatic reactions
are part of a normal stress adaptation process (Yehuda & McFarlane, 1997).
It is important to acknowledge the criticisms leveled against the diagnosis of posttraumatic reactions because they have important implications for
deciding whether or not, and when, to provide intervention following traumatic events. From our perspective, there are definitely pathological posttraumatic reactions that call for intervention. We contend that the challenges of treating trauma with CBT are not related to uncertainty regarding
the pathological conditions that can develop in response to traumatic exposure, but rather concern the nature and clinical phenomenology of such
reactions for treatment.

Trauma History


As we previously noted, a scientifically grounded conceptualization of
patients’ problems is the first step to effective CBT for trauma. Historical
review of the understanding of posttraumatic reactions illuminates several
important opportunities for the future of CBT for trauma. Translational
research and continued interface between science and practice will further
the conceptualization of traumatic reactions in order to improve CBT of
them. In general, developers and practitioners of CBT for trauma, looking
toward the future should capitalize on the evidence that the sequelae of trauma are wide-ranging, multidimensional, and multidetermined.
Several factor-analytic studies since DSM-IV was published have raised
questions about the nature and processes underlying PTSD (Foa, Riggs, &
Gershuny, 1995; King, Leskin, King, & Weathers, 1998). These studies reveal
that, contrary to the DSM-IV, there appear to be four, not three, clusters of
PTSD symptoms. Symptoms of effortful avoidance and emotional numbing,
included together in the DSM-IV, appear to have different properties, functions, and possible etiologies, according to these studies. Moreover, memory
loss, a symptom included in the DSM-IV’s avoidance/numbing cluster, does
not appear to be associated with the overall construct of PTSD or the symptom clusters. Interestingly, the most conclusive of these studies (King et al.,
1998) does not support the notion that PTSD is an overarching, unitary disorder comprised of four symptom clusters. Rather, PTSD appears to be best
conceptualized as a heterogeneous disorder with correlated, but separate,
symptom manifestations. Recent typology efforts also support this heterogeneity in PTSD presentation (Miller, Greif, & Smith, 2003).
Another important classification consideration on the horizon is
whether or not acute stress disorder (ASD) and PTSD should be classified as
anxiety disorders. Evidence supporting abandonment of the anxiety disorder
placement indicates that a myriad of emotions, including guilt, shame, disgust, anger, and sadness, have been implicated in preventing recovery from
posttraumatic symptoms (Resick, 2001). Moreover, Pitman (1993) has
argued that the pathophysiology of arousal in posttraumatic reaction is not
simply anxiety. The International Statistical Classification of Diseases, Injury, and
Causes of Death—10th Edition (ICD-10; World Health Organization [WHO],
1992) does not classify PTSD as an anxiety disorder; rather, it is categorized
within the spectrum of “reactions to severe stress, and adjustment disorders,” with the common denominator of stress-related precipitation. A
recent taxometric study also buttresses the dimensional versus categorical
system of trauma-related diagnoses (Ruscio, Ruscio, & Keane, 2002).
A spectrum of stress disorders, with specifiers beyond “acute,”
“chronic,” and “delayed onset” currently used for PTSD, could more fully
describe the phenomenology of trauma survivors and have important treatment ramifications. Like other major DSM-IV disorder classes (e.g., mood,
psychotic), there could be a range of disorders with various symptom con-


Trauma History

stellations and specifiers. SD as well as the dissociative disorders, could be
placed in this class. PTSD specifiers such as “prominent dissociation,”
“prominent emotional numbing,” and “prominent anger” could have important theoretical and treatment implications. Additionally, age-related features and presentations of these stress reactions are important. There may
even be room for chronic stress reactions to nontraumatic stressors.
It is important to remember that previous statistical approaches to organizing the core features of posttraumatic reactions are limited by the items
that comprise the statistical analyses. The DSM-IV PTSD Work Group
restricted criteria to “essential features” for making the PTSD diagnosis.
However, this approach risks the danger of missing characteristics that have
important clinical and treatment relevance. We suggest that, in addition to
moving beyond anxiety-based symptom presentations and to enhance recovery among survivors of traumatic stress, CBT for trauma consider and
address other frequently observed serious psychological, emotional, and
interpersonal problems. Regardless of the diagnostic scheme used, the epidemiological and taxometric findings argue for distinct assessment of, and
multicomponent treatment for, the multidimensional nature of posttraumatic pathology (Flack, Litz, Weathers, & Beaudreau, 2002; Keane & Kaloupek,
In spite of having several very efficacious CBTs for trauma-related
pathology (described in this book), it is important to realize that about 50%
of the patients in efficacy studies maintain their trauma-related diagnoses at
the end of treatment and at follow-up periods (Zayfert, Becker, & Gillock,
2002). This symptom maintenance may be related, in part, to our current
conceptualization of trauma sequelae and to the fact that the current evidence-based treatments, in isolation, address some specific aspects of trauma
better than others. For example, some treatment studies reveal that avoidance and numbing symptoms, and especially emotional numbing, may be
less responsive to our current CBT treatments (e.g., Glynn et al., 1999;
Keane & Kaloupek, 1982). There is also some early evidence that different
CBTs may be better at addressing the different emotional disturbances
resulting from traumatization (e.g., Resick, Nishith, Weaver, Astin, & Feuer,
In this vein, efforts to determine predictors of treatment response to
CBT for trauma may help address diagnostic dilemmas and ultimately
improve treatment planning and outcomes. We recommend that future
studies consider predictors beyond those that have been traditionally investigated (e.g., PTSD severity, anger, substance abuse), and develop theoretically
driven models that can be tested. Following from our recommendations
about broadening the range of trauma symptoms to consider, interpersonal
functioning, social support, affective regulation, and self-efficacy might be
considered. Biological markers may even be useful to consider in the future,
as the psychobiological findings become more robust and are shown to correspond with CBT treatment response.

Trauma History


In the last decade the field of CBT for trauma has seen a series of
head-to-head trials designed to determine the treatment “winner.” These
trials have resulted in many more “ties” than declared winners. We anticipate that the next generation of dismantling, combination therapy, and
effectiveness studies will reveal very intriguing findings about the key
ingredients of efficacious treatment as well as the limits and challenges to
using these treatments in clinical settings. Given that many patients simultaneously receive two or more treatments in clinical practice (e.g., Rosen
et al., 2004), studies that determine how best to time or integrate treatments for greater efficacy will be valuable. The possibility for psychopharmacological treatments to potentiate or possibly interfere with CBT for
trauma should also be investigated. Like others (Foa, Rothbaum, & Furr,
2003), we call for more combination studies aimed at addressing nonresponse or partial response to treatment, in lieu of the rates of non- and
partial response found in previous studies.
An additional factor to investigate with regard to treatment timing and
sequencing relates to the co-occurring diagnoses often given to traumatized
individuals. Determining the best sequence or combination of treatments to
treat these disorders is very important for the future of CBT for trauma. As
an example, many prior PTSD treatment studies have excluded patients with
comorbid substance dependence, suggesting that these issues should be
addressed prior to a course of CBT for PTSD. There have been a few developing efforts to provide serial or integrative trauma and substance abuse
treatment (Coffey, Dansky, & Brady, 2003; Najavits, 2002). Depression, personality disorders, anger problems, self-harming behavior, and relationship
dysfunction are other frequently co-occurring diagnoses or clinical issues to
address. Researchers have designed several treatments to specifically address
these problems in tandem with PTSD treatment (Chemtob, Novaco, Hamada, & Gross, 1997; Cloitre, Koenen, Cohen, & Han, 2002; Monson, Schnurr,
Stevens, & Guthrie, 2004). However, other researchers have argued that the
existing CBTs for PTSD should be undertaken first, because effective treatment for PTSD can remedy many of these co-occurring issues (e.g., Cahill,
Rauch, Hembree, & Foa, 2003). These are questions in need of further
empirical investigation.
The cognitive-behavioral framework has an important role in informing
prevention and early-intervention efforts. Because this area has been
wrought with controversy, leading with a strong theoretical grounding for
these interventions will be crucial. In addition, the caricature of CBT is that
it is a mechanical and technical venture devoid of any humanity. A solid therapeutic relationship is essential to all forms of psychotherapy. Treatment
process studies that pinpoint specific dimensions of the therapeutic relationship that are detrimental or facilitative of trauma recovery are essential
(Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004).
There are a number of intriguing questions to be answered with regard
to the effectiveness, versus efficacy, of CBT for trauma. Most of the outcome


Trauma History

studies to date have been undertaken in outpatient research clinics. Ongoing
efforts to transport these best practices into clinical settings, and likewise, to
use the clinical experiences to inform research, will be invaluable.
Although several CBTs for trauma, with solid evidence bases, are available there remains a need for innovative treatments that can help the significant number of patients who do not respond to our current treatments.
Understanding of the nature and treatment of trauma is a continuously
evolving process. We have come a long way in conceptualizing the aftereffects of trauma and in developing elegant, theoretically driven CBTs that
work. We look forward to the advancements that will be made in the next
generation of CBT for trauma.

This research was supported by a Clinical Research Career Development Award to
Candice M. Monson from the Department of Veterans Affairs (VA) Cooperative
Studies Program and by the VA National Center for Posttraumatic Stress Disorder.

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New York: New York Academy of Sciences.
Zayfert, C., Becker, C. B., & Gillock, K. G. (2002). Managing obstacles to the utilization of exposure therapy with PTSD patients. In L. Van de Creek & T. L. Jackson (Eds.), Innovations in clinical practice: A source book (pp. 201–222). Sarasota,
FL: Professional Resource Press.



Analytic Clinical Assessment


Functional Analytic Clinical
Assessment in Trauma Treatment
William C. Follette
Amy E. Naugle

Assessment serves a variety of functions. In Chapter 3 of this volume, Pratt,
Brief, and Keane provide a review of assessment procedures for the diagnosis
of posttraumatic stress disorder (PTSD) as well as scales for assessing treatment outcome. One purpose of assigning a diagnostic label is its implication
that a particular treatment will lead to a useful outcome, when properly
applied to the appropriate person. If that useful outcome were always the case,
then assessment for the purpose of diagnosis, along with an evaluation of treatment integrity, would be all that were necessary. Although much of this volume
addresses how to treat patients who have experienced significant traumatic
stressors, there is no treatment that is completely guaranteed to alleviate all of
the symptoms a patient might report. This chapter focuses on the application
of behavioral principles to assess areas of functioning that might need to be
considered as treatment planning and implementation proceeds.
Since the establishment of the diagnosis of PTSD in the DSM-III and
subsequent updates (American Psychiatric Association, 1980, 1987, 1994,
2000), a considerable volume of literature has been published that describes
clinical problems that may be likely to co-occur with PTSD. At the level of
diagnostic labels, PTSD is noted to co-occur with depression, anxiety, phobia, and panic disorders perhaps in part because of symptom overlap in diagnostic criteria (Davidson & Foa, 1991). A variety of other diagnostic labels
are also associated with PTSD, including substance abuse and Axis II cluster
B disorders, such as borderline personality disorders with impulsivity (Foa,
Davidson, Frances, & Anxiety Disorders Association of America, 1999).
Treatment guidelines include cognitive therapy to address unrealistic
assumptions, thoughts, and beliefs; anxiety management and stress inoculation techniques, including relaxation training; and imaginal or in vivo expo17



sure (Foa et al., 1999). The same guideline document describes a variety of
adjunct medication treatments for more complex cases (Foa et al., 1999).
The experience of trauma exposure is not rare; however, the trauma
responses of avoidance and arousal spontaneously extinguish in the majority
of people exposed (Breslau, Davis, Andreski, & Peterson, 1991; Breslau et al.,
1998). It has been argued that those who experience PTSD have flatter generalization gradients and do not respond to cues of safety (Foa, Steketee, &
Rothbaum, 1989; Foa, Zinbarg, & Rothbaum, 1992; Rothbaum & Davis, 2003).
Rothbaum and Davis describe the conditions that are likely to produce more
or less successful outcomes in response to exposure-based treatments.
PTSD is not a response to a traumatic event that occurs in isolation; other
factors might serve to ameliorate, maintain, or exacerbate symptoms and
course. The purpose of this chapter is to complement what is known about the
treatment of PTSD by calling attention to a more complete analysis of variables
that are potentially clinically important to consider when treating PTSD.
For the purposes of this chapter, it is assumed that an evidenced-based
intervention treatment for PTSD is already being provided. A primary
assumption behind applying an empirically supported treatment for PTSD
in a specific case is that a significant proportion of variance in outcome can
be accounted for by the mechanism(s) presumed to be affected by the treatment protocol (Haynes, Kaholokula, & Nelson, 1999). The effect size for any
particular patient will vary depinding on whether those mechanisms of
change targeted by an empirically supported treatment are the same mechanisms as those controlling symptoms in a specific patient. For any specific
patient, it is likely that common as well as unique factors will influence the
presenting problems and outcomes, and the unique factors could well
account for the major portion of outcome variance.
Because PTSD is one of the few diagnostic categories in the DSM for
which the etiology of the disorder is specified, one might presume that a
very homogeneous set of causal factors is present and therefore that each
individual patient will respond predictably to treatment. However, patients
with PTSD may report a complex set of symptoms that still qualify for the
diagnosis. As mentioned earlier, PTSD has a high rate of comorbidity; this
comorbidity makes the causal analysis of a particular patient’s problems even
more difficult. One goal of this chapter is to describe a method that can
identify additional (or even alternative) causal factors that, when properly
addressed, produce the largest benefits for patients.

The Purpose of Functional Analysis
The purpose of functional analytic clinical assessment is to identify factors
that, when addressed, will lead to an individualized understanding of the

Functional Analytic Clinical Assessment


relationship between behaviors and their antecedent conditions and maintaining effects. A functional analysis is a process that identifies causal relationships between observable, manipulable variables and clinically important
target behaviors. In any particular patient there may be a number of variables that are affecting the frequency and severity of a clinical problem.
Haynes and O’Brien (1990) have suggested limiting the vast universe of factors to be considered to those that are important, controllable, and causal.
By “important” they mean, the identification of a variable that, when altered,
leads to a large change in the target behavior or the behavior of clinical interest. Because most behaviors are multiply determined, it is conceivable that
therapists could waste valuable time and patient goodwill by attending to
many small sources of influence that, when targeted in treatment, simply do
not effect enough benefit for clients. Simply stated, when looking for sources
of influence over a particular behavior, choose the ones that get you “the biggest bang for the buck.”
The second heuristic to which to attend is to select controllable variables for study. “Controllable” here means to attend to a variable about
which the therapist and the patient can do something. For example, the therapist cannot change the patient’s age, but the therapist, could, in principle,
change the patient’s social repertoire in a way that increases his or her access
to social reinforcement. This issue is particularly important in the treatment
of PTSD when the patient would like more than anything to erase the traumatic stressor that seemingly caused all his or her problems in the first place.
Of course, the event itself cannot be changed, but many of its consequences
can be changed in the present.
The last criterion Haynes and O’Brien suggest is to identify causal variables. “Causal” in this context is not so much a notion of ultimate causality as
a reference to those variables that, when changed, reliably precede and produce change in the targeted clinical problem. If the therapist can identify
unique functional relationships that ameliorate specific individual problems
for individual patients, then the therapist will also observe additional treatment effects to those derived by administering a protocol-driven treatment
plan that is designed for the hypothetical “average patient.” For example, for
a rape victim, a sexual encounter with a new romanitic partner may seemingly cause anxiety and distress. In fact, it is not the current romantic
encouter that is the ultimate cause of symptoms—the rape is. However, from
a clinical standpoint, the current sexual stimuli such as touch, smells, and
arousal can serve as cues for when and what desensitization strategies should
be applied.

A Functional Analysis Is Not Always Stable
The identification of important clinical functional relationships between
stimuli and responses can greatly enhance therapy outcome. However, therapists must keep certain qualifications in mind when conducting a functional



analysis (see Haynes & O’Brien, 1990, pp. 651–653). A functional analysis of
a clinical problem rarely exhausts all possible sources of influence. Identifying how one causal variable affects a target behavior does not prove, or
even imply, that other causal relationships do not exist between other potentially important variables and the target behavior. It is quite possible that
many sets of independent variables exist. Another caveat is that a functional
relationship that exists at one point in time may not function in the same
way at another point in time. Emotional distancing following a traumatic
event may be caused by high levels of distressing arousal immediately following the trauma. This same distancing may be maintained at a later time
because of marital distress that occurred subsequently. This phenomenon is
referred to as “functional autonomy”—that is, the notion that behaviors that
come into existence under the control of one reinforcer can be maintained
at a different point in time or set of circumstances because of an entirely different set of reinforcers. A third point to remember about an apparent functional relationship is that it likely to exist under some circumstances but not
others (Johnston & Pennypacker, 1980). A patient may avoid talking about
the traumatic stressor with some people because doing so with these particular individuals arouses feelings of distress, guilt, or stigmatization. The same
patient may be quite willing to discuss the stressor with others who respond
more instrumentally.
A functional analytic case conceptualization is never perfect. It “is
always hypothesized, probabilistic, and incomplete” (Haynes, Leisen, &
Blaine, 1997, p. 337). One generally starts the analysis by referring to the
research on empirical relationships that have been identified in experimental or clinical settings. This information provides guidance as to where and
how to gather data to generate working hypotheses. These data include insession behavioral observations, observations of interactions between the
patient and others, structured role-playing tasks, self-report data, and reports
from significant collaterals. Given the qualifiers on the robustness of hypothesized functional relationships, it is not unusual to gather conflicting data—
perhaps because, as noted, a causal relationship may exist under one set of
observational conditions, but not others. Reports from collaterals may be
inconsistent because they are reporting on observations that were true in the
past but are no longer accurate. Patients, collaterals, and clinicians are all
prone to making a variety of heuristic errors that add inaccuracy to observational reporting, thus complicating case formulation (Arnoult & Anderson,
1988; Kahneman, Slovic, & Tversky, 1982; Turk & Salovey, 1988).
As mentioned previously, the intended result of a functional analytic
case conceptualization is the identification of important, controllable, and
causal variables that, if altered, would lead to useful change for the patient.
Ideally, the therapist would identify alterable variables that would result in
the largest changes first. However, without an empirical trial, the therapist
cannot know if the selected variable is the most important change; he or she
can only select a variable and then observe the effect. If the hypothesized

Functional Analytic Clinical Assessment


relationship does not result in a change in the target behavior, the functional
analysis should be reevaluated and modified in light of these new data. On
other occasions, the clinician may believe that he or she knows an important
functional relationship but not have the technology available to create the
necessary conditions to produce change. For example, say a therapist
hypothesizes that a comorbid depression that was initially the result of a
traumatic stressor is being maintained by a distressful marital relationship.
The patient’s spouse may now be quite willing to address relationship problems, but the patient is not. At present, there is relatively little research or
clinical evidence that clinicians can alter motivation in this type of situation.
Such an analysis would fail the controllability criterion described above. If
new treatment technology were to emerge that could effectively alter motivation to change in marital relationships, then this variable might well be a
good place to start an intervention.

Analysis of the Behavior in Context
One of the fundamental issues in functional understanding of clinical interventions is to appreciate the proper unit and level of analysis of a behavioral
problem. In the case of PTSD it can be tempting to see the problem as residing in the relationship between the patient and the traumatic stressor. In
fact, because there is considerable variability in how patients respond to
stressors, we must infer that there are other factors that affect course and
outcome. From a behavior analytic perspective it is important to appreciate
that examining behavior in isolation misses the point. The only meaningful
unit of analysis is the behavior in context. By “context” we mean that not
only must the patient’s responses to the characteristics of the stressor be considered, but they must be considered in light of the patient’s history prior to
the stressor, along with how the people, institutions, and agencies that are
part of the patient’s environment purposefully or inadvertently reinforce (or
punish) the patient’s responses. The behavior in context is the proper unit of
analysis; to study one part of the context independently of all others will lose
the meaning of the behavior. A behavior is only interpretable when considered in the context of its antecedents and consequences.

Functional Classes
One useful idea to understand is that behaviors that vary in topography (how
they appear) but share the same common effect on the environment all form
a functional class. One of the problems for clinicians working with complex
cases is to make sense out of the litany of problems that each patient reports
on any given day. On different days a patient might come to therapy angry,
suicidal, crying about a distressed relationship, or highly distracted. Each of
these behaviors looks very different from the others; that is, the behaviors
vary in their topography or form. However, from a functional analytic per-



spective, we would have to determine whether they were distinct behaviors
or whether they all functioned similarly. In this case, it may be that the topographically distinct behaviors all function to distract the therapist from talking about interpersonal closeness. All the behaviors in the class are negatively reinforced by having the therapist change topics to discuss the
topography of the behaviors. If the therapist notices this shared function
among these behaviors, he or she can begin to respond to all of them similarly and more usefully, rather than being distracted by trying to orient to
each specific behavior as if it required a completely different therapist

The point of describing what is entailed in a conceptual understanding of a
functional analytic case conceptualization is to notice the idiographic nature
of the assessment process for the purpose of identifying additional sources
of information of variance in problem behaviors to improve clinical outcome. There are many sources about how to conduct and even quantify a
functional analysis (e. g., Follette, Naugle, & Linnerooth, 2000; Hawkins,
1986; Hayes, Nelson, & Jarret, 1987; Haynes, 1992, 1998; Haynes & O’Brien,
2000; Haynes & Williams, 2003; Johnston & Pennypacker, 1980; Kanfer &
Grimm, 1977; Kanfer & Saslow, 1969; Naugle & Follette, 1998; Nelson &
Hayes, 1986). As mentioned above, reviewing the scientific literature about
likely sources of control in a particular clinical situation is a typical starting
point. In this section we present a few of the symptoms of PTSD and consider them as target behaviors that are the focus of treatment.
In applying an evidence-based intervention, we presume that many of
these symptoms are interrelated and may well remit when the nomothetic
treatment protocol is utilized. However, that may not, and often does not,
happen. There are certainly unique sources of variance not addressed by
standard treatment protocols that would improve treatment outcome if
properly identified and addressed.
Most of the symptoms of PTSD described under criteria B, C, and D in
the DSM-IV (American Psychiatric Association, 1994) are easily thought of as
reactions to stress. From a functional analytic perspective these reactions are
themselves behaviors that function in a complex context. As behaviors they
can be reinforced or punished by others and therefore become more or less
likely to occur in the same or similar circumstances. These same behaviors
can serve as discriminative stimuli or signs to others in the patient’s environment. A discriminative stimulus indicates that certain behaviors are likely to
be differentially reinforced or punished in the presence of that particular
stimulus. For example, tears could indicate that comforting comments may
be reinforcing to the patient. Additionally, these same behaviors can serve as
reinforcers or punishers in response to someone else’s behavior, thereby

Functional Analytic Clinical Assessment


making the other person’s behavior more or less likely to occur. For example, the sampe tearful response following an expression of intimacy may
make intimacy less likely. In a social context, the stress reactions listed in criteria B, C, and D for PTSD can serve multiple functions at the same time,
thereby affecting, and being affected by, many others simultaneously. It
would be nice if all the consequences of these interdependencies disappeared as a result of, for example, a successful exposure treatment. However, the stress reaction behaviors have created effects of their own that may
not be related to the original traumatic event.
Let us consider an analysis of symptoms 5 and 6 from criterion C as target behaviors: feeling of detachment or estrangement from others, and
restricted range of affect. These behaviors are part of the numbing phenomena said to characterize PTSD. Presumably the numbing is functionally useful to the patient in that it is an avoidance strategy whose purpose is to control otherwise highly negative feelings. Without disagreeing that these
numbing responses are adaptive in the short run, let us further hypothesize
about how these target behaviors might arise and be maintained in a way
that could lead to an improved outcome if addressed from a functional perspective. The analysis might begin with an explanation of what would lead to
a feeling of closeness—the opposite of estrangement and restricted affect.
The therapist might begin by taking a behavioral history of the patient’s
close relationships and find that they were characterized by shared expressions of feelings, wants, and needs, and physical or emotional intimacy. In
the case of a couple, for example, the dyad has a common history expressing
and reinforcing all of the above.
The expression of these feelings, wants, and needs entails two important
verbal behavioral repertoires that Skinner referred to as the ability to tact
and mand (1945, 1957). A “tact” is a label for a state condition, or event
(including private events such as feelings) that is reinforced by the understanding of the listener (or the “verbal community,” as Skinner called it). A
“mand” is a request for something that is reinforced by the verbal community by providing whatever the speaker specified. An example of a simple
tact would be “I am hungry.” The tact is reinforced by the speaker being
understood by the listener. An example of a mand would be “Give me a
sandwich.” The mand would be reinforced by getting the sandwich.
Although there are many nuances, let us use these verbal operants to further
some additional hypotheses about the maintenance of the numbing behaviors described in criteria C.
Consider this scenario: A married woman experienced a rape. In addition to the initial avoidance behaviors that frequently occur immediately
after such a trauma, there is a substantial change in the communication
between her and her husband. The husband may be reluctant to ask the
question “How do you feel?” because he finds any discussion of what happened to his wife to be extremely aversive. It may remind him of a failure to
protect his family, whether the feeling is sensible or not. This change in hus-



band-initiated conversation may be a contributing variable to her feeling distant from intimate relations. Note that in this example, the husband’s
decrease in inquiries about feelings is only a function of the wife being present. Nothing she has done, other than be a stimulus in his presence, has led
to this change in his behavior. This fact in itself could lead to a sense of distancing in the relationship—and yet the patient has done nothing except be
But suppose the husband does engage in a conversation:
HUSBAND: How do you feel? [This is a mand to the victim to reply with a
statement of feelings. The wife now runs into an important deficit in
her own behavioral repertoire: Namely, she may have no verbal repertoire to label her feelings accurately. She has no experience with the
private events she is currently experiencing, so she is not likely to have
a learning history from interacting with others so that her verbal behavior would be shaped to describe her feelings.]
WIFE: I don’t know. [The husband’s mand has not been reinforced, which
could lead to a decreased likelihood of further inquiry into her feelings, making her feel more distanced.]
HUSBAND: But I really want to know [how you feel]. [This is a repeated
WIFE: Well, I guess I feel ashamed. [This is a tact, probably used for the first
time in this dyad under these circumstances and probably not completely accurate. In fact, there probably is no well understood label to
HUSBAND: Ashamed? You have no reason to be ashamed. It wasn’t your
fault. [In what might have been intended to be a supportive comment,
the husband has certainly not reinforced the spouse’s tact. Therefore,
she is not feeling understood.]
WIFE: Well, maybe guilty that I should have done something to prevent it.
[This is another attempt to tact her private experience.]
HUSBAND: There is no reason for you to feel guilty, Honey. There was nothing you could have done. [Again, the husband does not reinforce her
talking about her feelings by any indication that he understands them.
Although his responses may be intended to be soothing or supportive,
they function to make it less likely that she will try to describe her
important personal feelings.]
Because intimacy is partially characterized by the sharing of feelings and
mutual understanding, exchanges such as this one are likely to decrease her
efforts to talk about her feelings. If this pattern were to continue, it seems
likely that she would feel more distant from her husband, with whom she formerly felt intimate. One of the mechanisms for this feeling of estrangement

Functional Analytic Clinical Assessment


is the lack of intimate communication. An additional consequence of the victim’s decreased conversations with her husband may be the self-perception
of restricted affect because she is verbalizing less affective content (Bem,
The point of the above analysis is not to suggest that these symptoms of
numbing do not have other causes or functions. It is simply to point out that
a behavior that has one initial cause may be maintained or increased by influences not directly related to the trauma itself but rather to a change in communication behavior with important people in the individual’s environment.
Spousal communication could be concomitantly addressed while other kinds
of interventions were occurring if this hypothesis seemed plausible. One reason why this case example was chosen was because the victim described feelings of guilt. Whether the tact was understood by the husband is not the only
issue that is important. Empirically, there is evidence that feelings of guilt by
trauma survivors is a contributing factor in the development of PTSD, especially in the absence of social support (e.g., Kubany et al., 1996; Ullman &
Filipas, 2001). Identifying this source of control over portions of the numbing response could explain a significant amount of outcome response. Note
how a successful exposure or anxiety management treatment protocol might
not target this spousal interaction at all.
Another symptom of PTSD is the avoidance of thoughts, feelings, or
conversations associated with the trauma. Avoidance is a high-probability
response to trauma for which exposure based interventions could be useful.
An additional functional analysis of the victim’s social environment might
identify other factors that could lead to the maintenance of avoidance of
thoughts or conversations associated with trauma. Stigmatization is often
one unfortunate consequence of traumatic victimization. However, a functional analysis of stigmatization might yield a more useful understanding of
the discriminative stimulus functions of the patient. If we were to collect
reports from collaterals in the patient’s environment, we might discover that
other women who are important in the patient’s social network have shown
negative reactions to the patient when she starts to discuss anything related
to the trauma. Keeping in mind that behaviors are generally multiply determined, we would have to investigate several hypotheses. One possible determinant of the friends’ negative reactions is the fact that her experience is evidence that none of them is immune from this kind of victimization. She
elicits vague feelings of uneasiness that escalate when the topic of the trauma
is mentioned. These subtle social contingencies could make the patient less
likely to want to discuss or process the event. In fact, if we observed interactions between this patient and her friends, we might see the friends actively
punish the conversation or at least obviously change topics to help manage
their own discomfort. The patient then becomes unwilling to engage in conversation about the event not because it is necessarily aversive to her so
much as it is aversive to her friends, who have no repertoire for either discussing the topic or soothing their own discomfort at being vulnerable.



There are many other potential reasons a patient may appear to be
numb that are not directly related to the traumatic event, but are rather
under the control of social processes that must be addressed to achieve maximum treatment effects. Here, a last functional example reveals what we consider to be a discrimination deficit on the part of the client. In this instance
the client may have some repertoire for describing (tacting) her feelings.
However, she may not properly discriminate with whom to share these feelings. In given social interaction, the person with whom the patient is interacting would or would not be a good candidate for providing socially meaningful reinforcement. It is up to the patient to make that discrimination. Failure
to recognize with whom it is appropriate to seek support can lead to ineffective interactions that eventually extinguish all support-seeking behavior or
even lead to punishing interactions in which support is not only not forthcoming, but criticism comes instead. The latter might be the case if one discloses a traumatic event to someone who is too young to understand the
event or might even be negatively impacted by it.
The point of the general description of a functional analytic case assessment is to call attention to the fact that whereas there are likely common
causal factors that will be addressed by standardized treatment, there are
many other sources of causal influence that, when they are not considered,
may explain large differences in treatment outcome. The obvious etiology of
PTSD does not explain the vastly different responses to treatment. This
treatment response variability requires us to look more thoroughly for causal
factors on which we can intervene. These factors are most frequently found
in the posttrauma environment.

So far we have discussed sources of variance that could extend the effects of
a nomothetically derived evidence-based intervention by identifying additional factors that cause or maintain symptoms that are not part of the immediate posttraumatic response. Now let us consider observable factors that
might directly compete with active treatment components of an evidencedbased intervention.
Let us take two examples. One empirically supported treatment principle for PTSD is the use of cognitive therapy, whose techniques include identifying dysfunctional cognitions and gathering and evaluating evidence for
and against those cognitions. Presumably, examining this evidence will lead
the patient to a more realistic and functional set of beliefs and cognitions. If
that intervention did not achieve the anticipated results—and assuming that
the treatment was delivered competently—then we are left considering
whether there are other important causal factors that could be identified by
a functional analysis. In addition to the kinds of analyses already described,

Functional Analytic Clinical Assessment


we can also consider the existence of competing contingencies. Are there
salient contingencies operating in the patient’s environment that compete
with the goals of therapy? While the therapist is diligently helping the patient
identify dysfunctional beliefs and encouraging him or her to test them in the
real world, there may be people in the patient’s environment who are reinforcing the opposite behavior. If this is the case, the assessment issue,
becomes, what is controlling the therapy-interfering behavior of these other
people? Interviews, diaries, and journals may help generate hypotheses. A
child who realizes his mother is vulnerable may cling to her, preventing her
from doing exploratory homework. The child may even subtly support the
mother’s avoidance behavior. A spouse who initially worried about the victim’s safety may now actually prefer a more dependent partner, and, like the
child, may undermine treatment compliance.
As a second example, in an exposure-based treatment that is producing
poorer outcomes than might be expected, it is important to functionally analyze what environmental contingencies might be competing with therapy
tasks and goals. If the therapist had constructed an in vivo desensitization
hierarchy with the patient, and the patient reports doing the in vivo exposure
homework, why might the treatment not being working? Relying on theory
to help guide the assessment, we recall that PTSD patients generally have
very broad networks of stimuli that can produce aversive conditioned
responses that might be of a larger magnitude than expected. For example,
an element on the exposure hierarchy might be intimate touching with the
spouse. Each time the patient reaches this level of the hierarchy, she experiences a resurgence of anxiety that interferes with extinction. A careful analysis of the reactions to this activity on the hierarchy might reveal that though
the spouse is being as sensitive as possible during the task, the spouse may
possess some subtle physical characteristic of the perpetrator. It might be difficult to elicit this information from the patient, because the patient does not