Chapter Nine – Cognitive ProcessingTreatment-Guide-Chapter-9

As noted earlier, victims of interpersonal violence can be prone to a variety of negative cognitive phenomena, including self-blame, guilt, shame, low self-esteem, overestimation of danger, and other negative beliefs and perceptions.

 

The adolescent survivor of childhood physical and emotional abuse may view his or her maltreatment as just punishment for being “bad,” and may suffer guilt and a poor self-image. A teenage woman battered by her partner may assume that she deserves to be beaten. Individuals who have been repeatedly exposed to situations in which they were helpless to escape or otherwise reduce their trauma exposure may develop a sense of having little power to affect future potentially negative events. Some adolescent survivors view their posttraumatic symptoms as evidence of being mentally ill. Victims of sexual trauma often feel ashamed and isolated by their experiences, partially as a function of socially-transmitted myths about rape.

In general, cognitive therapy of posttraumatic disturbance involves the guided reconsideration of negative perceptions and beliefs about self, others, and the environment that arose from the trauma. As these negative assumptions are reevaluated, a more affirming and empowering model of self and others can take their place. At the same time, the client may develop a more detailed and coherent understanding of the traumatic event, a process that is generally associated with clinical improvement.

 

Cognitive Reconsideration

In ITCT-A, trauma-related cognitive disturbance is generally addressed through a detailed verbal exploration of the traumatic event and its surrounding circumstances. As the survivor repeatedly describes the trauma in the context of safety and acceptance, he or she, in a sense, relives the past while viewing it from the perspective of the present. By verbally recounting the traumatic event, the adolescent (with the assistance of the therapist) has the opportunity to “hear” the assumptions, beliefs, and perceptions that were encoded at the time of the trauma, and to compare them with what he or she now knows. Together, the client and therapist can then work to create a more accurate cognitive model of what occurred. In Self-Trauma and ITCT language, this process is referred to as cognitive reconsideration (Briere & Scott, 2012).

Cognitive reconsideration may foster more positive self-perceptions, as the client comes to reinterpret former “bad” behaviors, deservingness of maltreatment, and presumed inadequacies in a more accurate light. For example, the client who has always interpreted her behavior just prior to a rape as “sluttish” or “asking for it” may gain from the opportunity to relive and review what actually happened, and to see if her judgments about herself seem valid. Exploration of the events prior to the rape may reveal that she was not behaving in a “seductive” manner, nor is she likely to recall actually wanting to be abused or otherwise hurt.

In addition, increased awareness of what one could reasonably have done at the time of the trauma – i.e., what one’s options actually were – can be antidotal to inappropriate feelings of responsibility, self-blame, or self-criticism. For example, describing memories of childhood abuse in detail – while at the same time listening to them from the perspective of an older adolescent – may lead the adolescent to the realization that he or she had few options other than accommodation at the time of the abuse. The notion that “I should have done something to stop it,” for example, can be countered by a greater understanding of the size and power differentials inherent in an adult forcing himself on a 7-year-old child.

Finally, blaming or shaming statements made by an assailant may eventually lose their power when examined in the context of a safe environment. Many victims of interpersonal violence tend to, on some level, accept rationalizations used by the perpetrator at the time of the assault. These include rapist statements that the adolescent victim was asking to be sexually assaulted, child abuser statements that physical abuse was merely appropriate punishment for bad behavior, or the youth exposed to chronic emotional abuse who internalizes perpetrator comments that he or she is bad, fat, ugly, or worthless. As the client and therapist discuss the circumstances of the event, and consider perpetrator statements in the absence of current danger or coercion, the objective lack of support for these statements may become more apparent to the client.

Because the therapist may see these cognitive distortions more clearly than does the client, he or she may feel pressed to voice an opinion regarding the lack of culpability of the victim or the obvious cruelty of the perpetrator. This is understandable, and, in small doses, appropriate. Rarely, however, will such statements, in and of themselves, substantially change the client’s opinion. In fact, clinical experience suggests that cognitive therapy is unlikely to be helpful when the clinician merely disagrees (or argues) with the client about his or her cognitions or memories, or makes definitive statements about what reality actually is. Rather, cognitive interventions are most effective when they provide opportunities for the client to experience the original trauma-related thoughts and self-perceptions (e.g. feelings of responsibility and guilt when recalling being beaten by a parent), while, at the same time, considering a more contemporary and logical perspective (for example, that the beatings were, ultimately, about the parent’s chronic anger, alcoholism, and feelings of inadequacy, and not due to the client’s failure to be a good child or show proper respect).

As suggested by various writers, the reconsideration of trauma-related assumptions, expectations, or beliefs is probably most effective when it occurs while the adolescent is actively remembering the trauma and reexperiencing the thoughts and feelings that he or she had at the time (Resick & Schnicke, 1993). Merely discussing a traumatic event without some level of emotional memory activation is less likely to change the cognitions related to the memory. In contrast, active recall and description of a traumatic event probably trigger two parallel processes: observation of one’s own trauma-related attributions regarding the specifics of the event, and activation of the emotions associated with the event. The second component of this response is covered in detail in the next chapter, under the heading of titrated exposure. However, it is important to acknowledge it here because emotional activation allows the client to more directly to relive the traumatic event, such that any cognitive interventions are more directly linked to specific memories of the trauma.

There are two major ways that the youth can remember and, to some extent, reexperience traumatic events during the process of treatment: by describing them in detail, and by writing about them. In the first instance, the therapist asks the client to describe the traumatic event or events in as much verbal detail as is tolerable, including thoughts and feelings he or she experienced during and after victimization experience. As noted in Chapter 10, this is an important component of titrated exposure. It also facilitates cognitive processing, however, if it includes discussion of conclusions or beliefs the survivor formed from the experience. In response to the client’s description, the therapist generally asks open-ended questions that are intended to make apparent any cognitive distortions that might be present regarding blame, deservingness, or responsibility. As the client responds to these questions, the therapist provides support and encouragement, and, when appropriate, carefully offers information or psychoeducation that might counter the negative implications or self-perceptions that emerge in the client’s responses (see Chapter 6). The client might then have responses that lead to further questions from the therapist. Or, the topic might shift to the client’s emotional processing of the implications of any new information, insights, or feelings that arose from the discussion process.

The second major form of cognitive processing involves the use of “homework.” As described in the next chapter, the adolescent is asked to write about a specific topic related to the trauma, bring it to the next session, and read it aloud in the presence of the clinician. In this way, the client has the opportunity to continue therapeutic activities outside of the session, including desensitization of traumatic memories and continued cognitive reconsideration of trauma-related assumptions and perceptions. In addition, research suggests that the mere act of writing about an upsetting event, especially if done on multiple occasions, can reduce psychological distress over time (Pennebaker, 1993; Pennebaker & Campbell, 2000). See Chapter 10 for an example of trauma processing homework, Written homework about my trauma).

It should be noted, however, that although therapeutic “homework” is a mainstay of various cognitive-behavioral therapies, self-exposure to trauma-related thoughts or feelings (i.e., without a therapist present) may be challenging, if not overwhelming, for some adolescent survivors. If writing about a trauma activates extreme fear, self-hatred, or other sufficiently strong negative states, certain youths (e.g., those with low affect regulation capacity) may become “retraumatized” – sometimes then engaging in deleterious avoidance or tension-reduction behaviors, such as maladaptive substance use, self-injury, or binge eating. This is not a common scenario; most traumatized adolescents appear capable of processing trauma-related memories and cognitions on their own, between sessions. Nevertheless, it is recommended that such homework be offered only to those survivors who appear able to tolerate it.

Similarly, written homework about past traumas is best done when the home environment is stable and safe. If the youth is homeless, or if there is even a slight chance that the perpetrator of the trauma (or some other abusive family member) might get access to a description of what he or she did to the client, the clinician should ask that the homework be done within the session only, where safety can be guaranteed.

The goal of writing and/or verbally presenting trauma narratives is to activate the client’s memories of the traumatic event and to facilitate their cognitive processing. During the therapy session, such discussions are guided by a series of gentle, usually open-ended inquiries that allow the client progressively to examine the assumptions and interpretations he or she has made about the victimization experience.

Typical questions stimulate detailed discussion of:

  • The youth’s thoughts during and after the trauma, including why he she came to think those things at that time
  • Ways in which those thoughts may have become current assumptions, despite
    • their relatively unexamined nature and
    • the fact that aspects of the trauma may have prevented clear thinking at the time (e.g., the need for survival, the client’s youth/relative lack of power when the event occurred, and/or the ability of the perpetrator to control the client’s thinking)
  • Whether negative cognitions about himself/herself “make sense,” given what the adolescent now knows and given the perspective associated with the client’s now greater age and current greater safety
  • Whether, in light of the specific aspects of the trauma (e.g., the client’s youth, lesser power/strength/social entitlements, relative unavailability of help, etc.), there was much the client could have done other than what he or she did do
  • Whether he or she actually deserved what happened (e.g., was what happened appropriate punishment, abusive behavior, or a good way to treat a child)
  • Whether, in fact, he or she “asked for it,” including whether the client can recall wanting to be raped, beaten, or maltreated, or, if the trauma was sexual victimization, whether he or she can remember actually desiring sexual contact with the abuser
  • Whether the adolescent’s judgments of himself or herself can be generalized to others (e.g., if the trauma happened to another child, would the survivor come to the same conclusions about the other child’s badness/stupidity/unacceptability)
  • To the extent that that the adolescent seems to have internalized the statements of the perpetrator or the responses of other unsupportive people, whether these individuals would generally be people whom the client would take seriously or trust regarding their opinions on other topics

The intent of such cognitive exploration is for the youth to update his or her trauma-based understanding – not to incorporate the therapist’s statements or beliefs regarding the true state of reality or the client’s “thinking errors.” Although therapist feedback about the presumed reality of things may sometimes be helpful, much of the knowledge the client acquires in therapy is best learned from himself or herself. By virtue of the opportunity repeatedly to compare “old” trauma-based versions of reality with newer understandings, especially in the context of a safe, and supportive environment, the client can often revise his or her personal history – not in the sense of making things up, but by updating assumptions and beliefs that were made under duress and never revisited in detail. Importantly, good cognitive therapy is not an argument between client and therapist; instead, it represents an opportunity for the adolescent to reconsider previous assumption and beliefs in the context of current safety, support, gentle inquiry, and new information.

The therapist may stimulate these discussions as the description of the trauma unfolds, or after the client’s verbal rendition is completed. Often the latter approach is especially helpful: encouraging the client to describe the trauma in detail, and then following up with questions and detailed exploration. In doing so, the client can fully expose himself or herself to the story, with its associated emotional triggers, and the therapist has a better chance of determining what the client thinks about the trauma without the rendition being affected by therapist responses.

However accomplished, the intent of cognitive therapy in this area is to assist the client to explore, fully and accurately, his or her beliefs or assumptions, without lecturing, arguing, or labeling such beliefs as “wrong.” Instead, such cognitions should be viewed (and reflected back to the client) as entirely understandable reactions to overwhelming events that involved extreme anxiety and distress, incomplete information, coercion, confusion, and, in many cases, the need for survival defenses. Trauma-related cognitions should be treated not as the product of client error, but rather as logical initial perceptions and assumptions that require updating in the context of safety, support, and better/new information. Not only does such a therapeutic stance tend to be more effective than merely informing the client of his or her misperceptions of reality, it is less likely to alienate chronically traumatized youth who may have been on the wrong end of authoritarian power dynamics for many years.

While addressing cognitive distortions about the event and what it means to the client, the clinician also may encounter distortions the client has formed regarding the meaning of symptoms he or she is experiencing. In general, these involve beliefs that the intrusive-reliving, numbing/avoidance, and hyperarousal symptoms of traumatic stress represent loss of control or major psychopathology. In the style outlined above for trauma-related cognitions, the therapist can facilitate cognitive reconsideration of these perceptions or beliefs by asking the adolescent – especially after some level of psychoeducation has transpired – about

  • what might be a non-pathologizing explanation for the symptom (e.g., the survival value of hypervigilance, or the self-medicating aspects of substance use/abuse),
  • whether the symptom(s) actually indicate psychosis or mental illness (e.g., whether flashbacks are the same thing as hallucinations, or whether it is really “paranoid” to be fearful about trauma-reminiscent situations, especially if trauma is still possible), and
  • whether it is better to actively experience posttraumatic stress (especially reexperiencing) than to “shut down” or otherwise avoid trauma memories (Briere & Scott, 2012).

These and other questions may stimulate lively, clinically useful conversations, the goal of which is not for the clinician’s view to prevail, but for the client to explore the basis for (and meaning of) his or her internal experience.

 

Development of a coherent narrative

In addition to the cognitive processing of traumatic memories, therapy can provide broader meaning and context. Client descriptions of past traumatic events often become more detailed, organized, and causally structured as they are repeatedly discussed and explored in therapy – including during cognitive reconsideration. Increased narrative coherence is often associated with reduced posttraumatic symptoms (Foa, Molnar, & Cashman, 1995; Siegel, 1999). As the client is increasingly able to describe chronologically and analytically what happened, and to place it in a larger context, he or she may experience an increased sense of perspective, reduced feelings of chaos, and a greater sense that the universe is predictable and orderly, if not entirely benign. Creating meaning out of one’s experiences may provide some degree of closure, in that they “make sense” and thus may not require further rumination or preoccupation. Finally, a more coherent trauma narrative, by virtue of its organization and complexity, may support more efficient and complete emotional and cognitive processing. In contrast, fragmented recollections of traumatic events that do not have an explicit chronological order and do not have obvious cause-effect linkages can easily lead to additional anxiety, insecurity, and confusion – phenomena that potentially interfere with effective trauma processing.

The development of a coherent narrative usually occurs naturally during the cognitive aspects of trauma-focused therapy. As the traumatic event is discussed repetitively and in detail, a process sometimes referred to as context reinstatement may occur. Specifically, a detailed trauma description often triggers recall of additional details that, over time, provide a story that is more internally consistent and “hangs together.”

Although a more coherent narrative often arises naturally from repeatedly revisiting the trauma in therapy, the clinician can work to increase the likelihood of this happening. This generally involves gentle, nonintrusive questions regarding the details of the trauma, and support for the client’s general exploration of his or her thoughts and feelings regarding the event – in the same manner described earlier for cognitive processing. In partial contrast to cognitive processing interventions, however, narrative interventions explicitly support the development of broader explanations and a “story” of the traumatic event, its antecedents, and its effects.

Cognitive changes arising from non-overwhelming emotional activation during treatment

Not all cognitive effects of trauma therapy involve verbal reconsideration of traumatically altered thinking patterns – it is also possible for the survivor’s beliefs to change during the process of remembering and processing upsetting memories (Foa & Rothbaum, 1998). In the context of processing traumatic memories in therapy, the client repetitively experiences three things: (1) anxiety that is conditioned to the trauma memory, (2) the expectation that such anxiety signals danger and/or is, itself, a dangerous state and must be avoided, and yet (3) an absence of actual negative outcome (i.e., he or she does not actually experience physical or psychological harm from anxiety or what it might presage). This repetitive disparity (a technical term that will be discussed in more detail in the next chapter) between the expectation of anxiety as signaling danger and the subsequent experience of non-danger probably changes the expectation over time. Beyond its cognitive effects on beliefs and assumptions associated with the specific trauma memory, the repetitive experience of feeling anxious during trauma therapy – in the context of therapeutic safety – probably lessens the disruptive power of anxiety, per se. In many cases, the client becomes less anxious about anxiety – coming to see it as merely an emotion and not necessarily as a harbinger of danger, loss of control, or psychological disability. To paraphrase one young survivor, “I thought feeling all this stuff would kill me. It doesn’t.”