Marcus was engaging in Cognitive Behavior Therapy (CBT) for posttraumatic stress disorder (PTSD) related to an accident he witnessed during his military service when the COVID-19 pandemic began. As we transitioned to telehealth, Marcus reported an increase in distress related to the pandemic.
Clients often experience stressful events during PTSD treatment, such as the death of a loved one or relationship discord. With everything going on in the world, there is also the potential for current events to trigger clients. When stressors emerge during CBT for PTSD, how do you address them?
The best course of action will likely vary from situation to situation, based on your conceptualization of the client. Sometimes it may be necessary to temporarily focus on the new stressor to problem-solve or process reactions to significant events. For example, clients may need to take a session to grieve a loss or express anger when those in power abuse or endanger others. Oftentimes, negative emotions are appropriate to the situation and serve a purpose, such as the anger we feel in response to injustice that propels us to advocate for change.
One emotion Marcus was feeling was sadness. When asked what was going through his mind when he felt sad, Marcus reported he was sad because many people had died from COVID-19. I agreed it was a sad situation and encouraged him to be aware of and allow himself to experience his sadness.
As you consider the effects of a recent stressor on your client, it is helpful to examine how the stressor, and your client’s reactions to it, fit with their trauma history and trauma-related beliefs. Likely, there may be themes that cut across thoughts and beliefs about past traumas and recent events, such as control (e.g., whether the event was preventable), safety (e.g., dangerousness of the world and other people), and trust (e.g., trustworthiness of others). If so, it can be helpful to first work through that theme as it pertains to the original traumatic event.
Even before the COVID-19 pandemic, Marcus was grappling with the controllability of events. He believed, “The accident could have been prevented if I or others were more vigilant.” Therefore, he thought, “If I’m always in control, I can prevent bad things from happening; if I’m not in control, something terrible will happen.” In response to COVID-19, Marcus experienced anxiety, thinking “If I’m not in total control, I’m going to get COVID-19 and die.” Because the trauma’s occurrence was serving as “evidence” for his thought of “If I’m not in control, something terrible will happen,” we continued to examine his beliefs about the cause of the accident before addressing the more overgeneralized beliefs.
Control is a common theme that emerges as people try to make sense of experiences. Individuals with PTSD often struggle with whether they or others could have prevented the trauma. Often, they could not because they did not have the knowledge of what was going to happen or the power to stop it. Yet, we all would like to believe that we can control what happens, so many individuals get stuck in a process of trying to determine how they could have controlled the situation better to get a different outcome.
New events might reactivate concerns about control. When terrible things happen, clients might have intrusive thoughts about whether it could have been prevented by the victim(s) or other observers. For some clients, these automatic thoughts may lead to feeling helpless and underutilizing coping resources. For others, they may lead to precautionary behaviors overshadowing valued actions (e.g., never leaving the house for fear of being assaulted). While some precautions are prudent (e.g., social distancing during COVID-19, greater vigilance in certain circumstances), clients must decide on a level of action based on the full scope of their experiences and their values.
Marcus was willing to continue working on the traumatic event that brought him into treatment. In the next session, we continued to use Socratic questioning to evaluate the controllability of the trauma. After reviewing the facts, Marcus concluded that although he wished someone could have prevented the accident, realistically, it was unforeseeable. He also noted it was unrealistic to have full control in the situation because he could not be in all places at once or know where danger would occur in advance. Marcus concluded, “I can’t control everything or prevent everything bad from happening.” While this thought made Marcus sad and a little scared, it also relieved his guilt. It meant he did not have to prevent all bad outcomes from occurring.
Later in the session, I asked Marcus to connect his conclusions back to COVID-19. We reviewed statistics about dying from COVID-19, including in his area and for his demographic. Marcus determined, “While it’s possible I could die from COVID-19, it is unlikely. It’s not possible to control everything to prevent all bad outcomes, but I can take reasonable precautions to keep myself safe.”
In summary, clients with PTSD often experience stressors during treatment. To determine how to help, conceptualize reactions in relation to clients’ backgrounds and belief systems. Even high-profile events take on different meanings to different individuals. For many clients, resolving the presenting trauma and reducing PTSD will put them in a better position to respond to new stressors based on their values.