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Introduction

Cognitive behavioral therapy (CBT) is an approach used by occupational therapist to address distorted thinking and/or unrealistic cognitive appraisals (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Cognitive distortions are often experienced by war veterans with PTSD such as, awfulizing, self-directed shoulds, other-directed shoulds, low frustration tolerance, self-worth, irritability, catastrophizing, overgeneralization, personalizing, selective abstraction, and cognitive errors (Muran & Motta, 1993). The goal for a therapist when using CBT is to work with clients on replacing maladaptive thoughts and beliefs by using cognitive reconstruction, coping skills, and problem solving (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). There is a growing amount of research presenting the psychological distress experienced by veterans who struggle with PTSD and the effects that it has within their intimate relationships (Shnaider, Pukay-Martin, Fredman, Macdonald, & Monson, 2014).

Theory

Cognitive behavioral therapy (CBT) is a framework that is appropriate for individuals living with distorted thinking. It’s emphasis on structure aims at changing behaviors by changing thoughts. Emotional states are changed through a problem-oriented approach (Brown, 2011).  If thoughts influence our behaviors, therefore changing beliefs has a direct effect on our behaviors (Taylor, 2011). This hierarchy of change is described with the following levels: core beliefs, intermediate beliefs, automatic thoughts and images. One of the categories of CBT is cognitive restructuring, which would be a beneficial framework for the interventions of a client living with PTSD. This category is assigned to cases where the problem is coming from within the individuals, in this case, their core beliefs (Taylor, 2011). According to Taylor (2011), the goal of CBT is to “… replace distorted thinking and unrealistic cognitive appraisals with more realistic and adaptive appraisals” (p.18). Lastly, the client should be equipped to be his or her own therapist upon completion of therapy after a four month period (Taylor, 2011).

Evidence

The current literature reveals significant evidence that CBT is a safe and effective intervention for both acute and chronic PTSD (Kar, 2011). Importantly, the effect of CBT has been mediated mostly by the change in maladaptive cognitive distortions associated with PTSD (Kar, 2011). War often has a lasting effect on individuals with associated PTSD. Additionally, CBT showed promise in group of combat male veterans with PTSD by improving social functioning, specifically in increasing social engagement and interpersonal functioning (Kar, 2011). Benefits of CBT have also been demonstrated in improving relationship satisfaction, mental health, well-being, and ameliorating PTSD symptoms (Monson, Macdonald, & Brown-Bowers, 2012).  

Case study

Samuel is a 28-year old veteran of the army national guard. As a combat medic on patrol in Afghanistan his convoy encountered an improvised explosive device (IED). Due to this traumatic event Samuel experienced a TBI and now suffers from PTSD. Samuel has developed distorted thinking, which has led to trust issues when interacting with others. Because of his trust issues with others, Samuel has a hard time maintaining relationships especially with his son and wife. Samuel will often meet other people in his woodworking group class but will avoid attempts made by them to establish friendships because of the lack of trust he possesses to further reciprocate. Samuel wants to increase his trust in others, but he realizes that the first step is changing his perceptions of other people. He wants to attend more outings with his woodworking class, develop friendships, and deepen the relationship with his wife and son by reducing his distorted thinking pattern.

Intervention Plan

Problem statement

Client is unable to maintain relationships for social participation due to distorted thinking.

Long term goals

1. Samuel will report decreased overgeneralization towards people by developing 1 new relationship to improve social participation in 8 weeks.
2. Samuel will report 60% reduction in negative labeling towards people in his diary by independently using his cognitive restructuring strategies to improve his relationships in 8 weeks.

Short term goals

1. Samuel will be able to role play with the therapist in a 2 minute conversation and only report 2 negative thoughts patterns during the conversation to improve social participation in 2 weeks.
2. Samuel will be able to independently identify 3 innate positive characteristics of people in his diary to reduce distorted thinking in 2 weeks for social participation.
3. Samuel will be able to verbalize key components of CBT theory, process, and benefits for people living with PTSD, independently, in 2 weeks for social participation.

Intervention format

Individual

Setting

Samuel will meet individually with the occupational therapist in a outpatient clinic 2x a week for 60 minutes.

Supplies

Diary, pen, paper

Agenda

• Meet with Samuel build the relationship / rapport (5 minutes)
• Occupational profile (10 minutes)
• Define the problem and create problem list (10 minutes)
  • Ex: core belief that people are bad
  • Therapist and Samuel will work together to create a list of problems identifying those of priority. That can be accomplished with questions such as the following:
    • How often does this problem present itself in your everyday life?
    • Would changing the way you think about the problem be beneficial to you?

• Set goals (10 minutes)
  • Ex: Samuel will be able to recognize innate traits that are good in individuals.
• Educate on CBT and the direct benefits to client’s PTSD (10 minutes)
  • Emphasis on Cognitive Restructuring
  • Explain the model and process
• Go over homework assignment (10 minutes)
  • Begin a thought diary
  • Explain why it can be beneficial to identify thought patterns
  • Highlight positive thoughts with a blue highlighter and negative thoughts with a pink highlighter.
• Summarize the session and ask Samuel for his feedback on the session (5 minutes)

Documentation

S: “I don’t trust people because I believe everyone is innately bad”

O: Samuel participated in a 60 minute OT session targeting his distorted thinking. Client collaborated with therapist to define the problem. With two prompting cues, Samuel was able to state problems and worked with therapist to create a list of problems. Client identified that he wants to work on the relationships around him. Client described that he longs to be closer to his wife and son but has a hard getting negative thoughts out of his head after his time in the military. Samuel then worked with therapist to set goals. He identified the relationship with his son and his wife as priority. Therapist educated Samuel on cognitive behavioral therapy, specifically cognitive restructuring, and benefits that this therapy would have on his PTSD as well as achieving his goals. Therapist assigned a thought diary as CBT homework and asked Samuel to give feedback based on the session, which Samuel provided.

A: Samuel demonstrates some lack of insight, as he required prompting and assistance in the articulating the problems presents. Samuel’s distorted thinking surfaced when he explained that he will not take his son to the park because people cannot be trusted and it is safer to stay home. This expression from the client indicates that he is apprehensive being in public around people, which is having a negative impact on his relationship with his son. Although he was apprehensive at first, client become more relaxed and engaged after education of CBT and benefits were explained. He seemed hopeful as the goals were being set. Samuel demonstrated increased insight and motivation to move forward with CBT. The client would benefit from writing down a list of negative automatic thoughts and identify ways to reshape his intermediate and core beliefs based on his thoughts.

P: Next treatment session client will continue working on how the thought patterns present in his thought diary shape his daily activities and relationships. Client will continue attending 60 minute OT sessions, 2x a week, for four months.

References

Brown, C., Stoffel, V. C., & Munoz, J. P. (2010). Emotional Regulation. Occupational therapy in mental health : a vision for participation (p.345-357). Retrieved from http://ebookcentral.proquest.com

Hofmann, S., Asnaani, A., Vonk, I., Sawyer, A., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy & Research, 36(5), 427-440. doi:10.1007/s10608-012-9476-1

Kar, N. (2011). Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatric Disease and Treatment, 7, 167–181. http://doi.org/10.2147/NDT.S10389

Monson, C. M., PhD., Macdonald, A., PhD., & Brown-Bowers, A. (2012). Couple/family therapy for posttraumatic stress disorder: Review to facilitate interpretation of VA/DOD clinical practice guideline. Journal of Rehabilitation Research and Development, 49(5), 717-28. Retrieved from http://ezproxy.fiu.edu/login?url=https://search-proquest-com.ezproxy.fiu.edu/docview/1034971972?accountid=10901

Muran, E. M., & Motta, R. W. (1993). Cognitive distortions and irrational beliefs in  post-traumatic stress, anxiety, and depressive disorders. Journal of Clinical Psychology, 49(2), 166-176. Retrieved from http://ezproxy.fiu.edu/login?url=http://search.ebscohost.com.ezproxy. fiu.edu/login.aspx?direct=true&db=cmedm&AN=8486798&site=eds-live

Shnaider, P., Pukay-Martin, N., Fredman, S. J., Macdonald, A., & Monson, C. M. (2014). Effects of cognitive-behavioral conjoint therapy for PTSD on partners’ psychological functioning. Journal of Traumatic Stress, 27(2), 129-136. doi:10.1002/jts.21893

Taylor, Renee R. (2011). Overview of Cognitive Behavioral Therapy, Cognitive Behavioral Therapy for Chronic Illness and Disability (pp.15-17). Spring Street, New York: Springer Science +Business Media, Inc.