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Cognitive Behavioral Therapy
for Posttraumatic Stress
Disorder in Persons With
Psychotic Disorders
Clinical Case Studies
8(6) 438­–453
© The Author(s) 2009
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DOI: 10.1177/1534650109355188
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Stephanie C. Marcello,1 Katie Hilton-Lerro,1
and Kim T. Mueser2
Abstract
The prevalence of trauma in people with a serious mental illness (SMI) is high and poses a
significant health problem. In addition, trauma exposure often leads to the development of
posttraumatic stress disorder (PTSD). People with comorbid PTSD and a SMI have significantly
poorer treatment outcomes. Despite the high occurrence of these two disorders, people with
a SMI are often excluded from research on PTSD. To address this gap, Mueser, Rosenberg, and
Rosenberg developed a cognitive restructuring (CR) program.This article describes a case study
utilizing the CR program. The program is specifically tailored for people with psychotic and
mood disorders with a focus on modifying dysfunctional beliefs and behaviors. Results suggest
that addressing PTSD in people with a SMI is necessary and that the CR program can promote
recovery in this population.
Keywords
trauma, posttraumatic stress disorder, serious mental illness, psychosis, schizophrenia, cognitive
restructuring, cognitive behavioral therapy
Cognitive behavioral therapy (CBT) has been shown to be effective for the treatment of posttraumatic stress disorder (PTSD) in the general population, with the preponderance of evidence
supporting the efficacy of exposure therapy and cognitive restructuring (CR; Foa, Keane,
Friedman, & Cohen, 2009). However, research on the treatment of PTSD in the general population has typically ruled out a large number of prospective study participants for a variety
of reasons, including the presence of psychotic symptoms, cognitive impairment, substance
abuse, and comorbid medical conditions (Spinazzola, Blaustein, & van der Kolk, 2005). The
treatment of PTSD in persons with psychotic disorders and other severe mental illnesses poses
special challenges.
1
University of Medicine and Dentistry of New Jersey
Department Medical School, Hanover, NH
2
Corresponding Author:
Stephanie C. Marcello, PhD, University of Medicine and Dentistry of New Jersey, University Behavioral HealthCare,
Division of Schizophrenia Research, 151 Centennial Avenue, Piscataway, NJ 08854
Email: [email protected]
Marcello et al.
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To address this issue, Mueser, Rosenberg, Jankowski, Hamblen, and Descamps (2004) developed a time-limited program based on breathing retraining, psychoeducation, and CR for people
with a serious mental illness (SMI) and PTSD (Mueser, Rosenberg, & Rosenberg, 2009). The
program was developed as an “add on” to other services that the client may be receiving, such as
case management, pharmacological treatment, and psychiatric rehabilitation. The program is
designed to focus on the teaching of two cognitive-behavioral skills, breathing retraining (BRT)
for the management of anxiety, and CR to target and modify trauma-related beliefs that underlie
PTSD symptoms. These skills are taught in a flexible but structured manner appropriate to the
individual client’s cognitive and emotional capacity, with homework assignments collaboratively developed with the client to ensure practice of the skills outside of sessions. One randomized
controlled trial of 108 clients with SMI and PTSD found that this program was more effective
than usual services at improving PTSD, depression, and other psychiatric symptoms, with treatment gains maintained at 6 months post-treatment (Mueser et al., 2008).
In this article we provide an illustration of the treatment model in a client with co-occurring
severe PTSD and schizoaffective disorder. Emphasis was placed on the use of functional assessments in case conceptualization, which suggested the client’s PTSD symptoms were severe and
the traumatic experiences appeared to have contributed to his delusional thinking. We describe
the client’s progress through the different parts of the program, and summarize improvements in
PTSD and related symptoms. We also discuss the role of homework in teaching skills in the
program.
1 Theoretical and Research Basis
Psychological trauma refers to the experience of an uncontrollable event which is perceived to
threaten a person’s sense of integrity or survival (Horowitz, 1986). In defining a traumatic
event, the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV; American
Psychiatric Association, 1994) adopts a narrower definition to include events involving direct
threat of death, severe bodily harm, or psychological injury, which the person at the time finds
intensely distressing or fearful. PTSD is defined in the DSM-IV by three types of symptoms,
including re-experiencing of the trauma, overarousal, and avoidance of trauma-related stimuli,
which persist or appear at least one month after exposure to the event (American Psychiatric
Association, 1994).
The prevalence of traumatic events in the lives of people with SMI is high and poses a significant public health problem. Read, Perry, Moskowitz, and Connolly (2001) reported that 69% of
female and 60% of male psychiatric inpatients had histories of physical and sexual abuse. Estimates of lifetime exposure to traumatic events in people with schizophrenia range from 34% to
98% (Greenfield, Strakowski, Tohen, Batson, & Kolbrener, 1994; Mueser et al., 1998; Ross,
Anderson, & Clark, 1994). In addition, reported rates of PTSD in people with schizophrenia
range from 29% to 43% (Cascardi, Mueser, DeGiralomo, & Murrin, 1996; Mueser et al., 2001).
Furthermore, it has been suggested that the frequency of trauma among people with schizophrenia may be underestimated, due to patients’ underreporting traumatic experiences and insufficient
assessments of traumatic events at mental health facilities (Eilenberg, Fullilove, Goldman, &
Mellman, 1996; Read & Fraser, 1998; Resnick, Bond, & Mueser, 2003).
A substantial amount of research has documented the negative effects of trauma on people
with schizophrenia. Trauma exposure has been linked to more severe symptoms (Mueser et al.,
1998), increased rates of substance abuse (Read & Fraser, 1998), depression and more severe
cognitive impairment (Schenkel, Spaulding, DiLillo, & Silverstein, 2005), and suicidality (Strauss
et al., 2006). In addition, trauma exposure in people with schizophrenia is associated with
increased use of mental health services, including an earlier age at first hospitalization, higher
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rate of hospital readmissions, and greater use of seclusion and restraints during inpatient
treatment (Goodman, Rosenberg, Mueser, & Drake, 1997; Mueser, Salyers et al., 2004; Resnick
et al., 2003).
Overview of the CR Program
Research on the treatment of PTSD in the general population has demonstrated the effectiveness
of exposure therapy and cognitive restructuring, with neither intervention consistently found to
be more effective than the other, nor the combination more effective than either one alone
(Benish, Imel, & Wampold, 2008; Bradley, Green, Russ, Dutra, & Westen, 2005). CR was chosen
as the main active ingredient in the program for people with SMI developed by Mueser et al.
(2009) for two main reasons. First, it was expected that CR would be less stressful and more
acceptable to clients with SMI than prolonged exposure. Second, there is abundant experience
using CR to treat other symptoms (e.g., psychotic symptoms, depression) in people with a SMI
(e.g., Beck, Rector, Stolar, & Grant, 2008; Kingdon & Turkington, 2004).
CR is based on the premise that depression, anxiety, and other negative feelings are mediated
by individuals’ thoughts and beliefs about events, themselves, and the world (Beck, Rush, Shaw,
& Emery, 1979; Ellis, 1962). Specific thoughts and beliefs related to traumatic experiences may
or may not be accurate. To the extent that negative, self-defeating thoughts or beliefs are inaccurate, correcting them can reduce or eliminate the associated upsetting feelings. Individual
differences in the personal meaning or appraisal of a traumatic event are a major factor in determining which individuals develop PTSD (Ehlers & Clark, 2000). Life experiences that introduce
conflict into fundamental beliefs that an individual previously had about the world are more
likely to be perceived as traumatic (Brewin & Holmes, 2003; Horowitz, 1979, 1986). PTSD is
more likely to develop in people who have exaggerated, negative cognitive appraisals of traumatic events that emphasize the inherent danger in the world, mistrust of other people and the
individual’s own response to trauma, such as being mentally defeated by an event (Dunmore,
Clark, & Ehlers, 1999; Ehlers, Maercker, & Boos, 2000; Halligan, Michael, Clark, & Ehlers,
2003). When a person encounters stimuli that resemble events related to the trauma, these cues
evoke trauma-related schemas that trigger distress due to perceptions of threat, loss, or personal
inadequacy.
CR involves teaching people how to identify, examine, challenge, and change inaccurate
thoughts associated with negative feelings. Treatment programs using CR for posttraumatic disorders involve helping clients examine and modify these inaccurate trauma-related beliefs
(Ehlers, Clark, Hackmann, McManus, & Fennell, 2005; Mueser et al., 2009; Resick & Schnicke,
1993). The CR program developed by Mueser et al. (2009) was designed to treat the broad population of persons with PTSD, while accommodating to the special needs of vulnerable populations
such as persons with SMI, addiction, adolescents, or individuals exposed to natural disaster or
mass violence. The program includes teaching BRT for the management of anxiety, education
about PTSD and other trauma-related problems, and a primary focus on CR for addressing posttraumatic symptoms. CR is taught to clients as a skill for managing negative feelings and
modifying posttraumatic appraisals that underlie PTSD symptoms, based on cognitive theories
of PTSD described above. Since posttraumatic symptoms are defined partly in terms of their
intrusive and upsetting effects on individuals’ daily lives, teaching CR as a way of coping with
negative feelings naturally leads to addressing trauma-related thoughts and beliefs. Teaching CR
as general self-management skill for dealing with any negative feelings, rather than using it
solely to target cognitions believed to be related to traumatic experiences, simplifies the process
of teaching the skill for therapists and clients alike, as it requires no distinction to be made
between which thoughts or feelings are or are not related to the traumatic events.
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The CR Program
The program is provided in 12-16 1-hour individual, weekly therapy sessions. To facilitate the
teaching of skills in a systematic yet flexible manner, each session adheres to the following structure: (a) present a brief agenda for the current session; (b) briefly review the previous session;
(c) review homework; (d) cover session’s material (most of the session time is spent on this
item); (e) assign homework; (f) review session.
During the first few sessions, establishing the therapeutic alliance is essential. The overall
goal is to create an empathic and supportive environment where trauma work can be conducted
in a safe, contained, yet task-focused manner. Session 1 begins with administering the PTSD
Checklist Stressors Specific Version (PCL-S; Blanchard, Jones-Alexander, Buckley, & Forneris,
1996), with the client’s index trauma written at the top in order to assess severity of PTSD symptoms, and the Beck Depression Inventory-II (BDI; Beck, Steer, & Brown, 1996) to evaluate
depression severity. Next, a brief orientation to the program and its components is provided,
along with a discussion of homework and logistical aspects of treatment (e.g., cancellations).
Then, a written crisis plan is developed to address any changes in the client’s psychiatric disorder
or functioning that could signal a relapse or threaten the person’s continued participation in the
program (e.g., increase or resumption of substance use, increased depression, suicidal thoughts,
increased hallucinations, social isolation). In the last 15 minutes of the session, BRT is taught and
practiced in session. A homework assignment is developed collaboratively with the client to
regularly practice the BRT on his or her own, at first practicing it in safe and comfortable situations until the person has developed sufficient competence with the skill.
In session 2, common reactions to trauma are discussed. The primary goal of psychoeducation
is to help the client understand the nature of PTSD and establish it as a treatable disorder. The
three main symptoms of PTSD that are discussed are: (a) re-experiencing the trauma; (b) active
avoidance; (c) overarousal. In session 3, other common reactions to trauma are discussed, including: (a) four types of negative feelings: fear and anxiety, sadness and depression, guilt and shame,
and anger; (b) relationship difficulties; (c) drug and alcohol abuse. Both psychoeducation sessions are taught using handouts that are read and discussed in an interactive manner in order to
make the information as useful and pertinent to the client’s own experiences. Review questions
are periodically asked to evaluate comprehension of the material, with additional reviews conducted as needed. Finally, at the end of session 3, treatment goals are set, based on the client’s
discussion with the therapist of how PTSD has affected their lives, and the changes they would
most like to see as a result of participating in the program.
Session 4 starts with completing the PCL and BDI-II to assess the individual’s symptoms. It
is not expected that most clients will experience an improvement in symptoms at this point,
because CR has not been taught yet. However, some clients do report symptomatic improvement
just from learning BRT and the psychoeducational sessions. If symptoms do improve, it is helpful to talk with the client about what they attribute these changes to. Occasionally, symptoms are
slightly worse at the fourth session, and it is helpful for the therapist to normalize this experience,
and to reframe it as part of the process of recovery from trauma.
Following the review of symptoms, the remainder of session 4 is spent introducing cognitive
restructuring, which is continued in session 5. The primary goal of these sessions is to first
explain to the client the relationship between thoughts and feelings, and second to introduce a
strategy for identifying and correcting common biases in thinking (frequently referred to as “cognitive distortions” in the CR literature, or Common Styles of Thinking (CST), in the program
developed by Mueser et al., 2009). Clients are taught that CST are thinking patterns that people
often have in reaction to everyday events, but which are inaccurate and unhelpful, and contribute
to upsetting feelings. Some examples are: catastrophizing, all-or-nothing thinking, emotional
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reasoning, “must” “should” or “never” statements, emotional reasoning, and inaccurate or excessive self-blame. In order to normalize this type of thinking, the therapist emphasizes to the client
that everyone engages in these thinking patterns sometimes, but some people may be more prone
to them than others because of their personal life experiences, including traumatic ones. Understanding which CST the client engages in can help them identify and correct thoughts and beliefs
that lead to their upsetting feelings.
After the client has gained some familiarity with recognizing and correcting CST, usually by
session 5 or 6, the therapist introduces a more powerful approach to cognitive restructuring: the
5 Steps of CR. These steps include (a) describe the situation; (b) identify different feeling states
(in particular, the “big four” feelings: fear and anxiety, sadness and depression, guilt and shame,
and anger); (c) identify “automatic thoughts” associated with each feeling and focus on the most
upsetting thought; (d) evaluate the thought and weigh the evidence for and against them; and
(e) take action by either changing the thought or making a plan to remedy the problem situation.
Homework assignments are developed with the client to practice using the 5 Steps of CR.
Most of the remainder of the program is spent working through examples of CR that the client
brings in from his/her life. After the initial introduction to the 5 Steps of CR, the following sessions are devoted to helping the client learn how to use the skill for dealing with negative feelings,
and addressing trauma-related beliefs and schemas that underlie their PTSD symptoms. The sessions start with a homework review to evaluate the client’s efforts at using the 5 Steps of CR,
focusing on helping clients learn steps for which they experienced difficulties. Then, the rest of
the session is spent teaching the client how to use the 5 Steps of CR to address other negative
feelings experienced during the week, specifically PTSD symptoms or depressive symptoms, or
other trauma-related thoughts or beliefs that can be identified.
After the client has been introduced to the 5 Steps of CR, the clinician shifts the focus of
teaching to help the client learn and use the steps him/herself, rather than continuing to lead the
client through the steps. This involves giving responsibility for completing the worksheet to the
client in the session, asking questions to prompt the client to identify each step and its purpose
(e.g., “OK, so what’s the first step of CR? Why is it important to describe the situation?” “Now
that you’ve identified your upset feeling, what’s next?”), and providing hints or strategies to help
the client use the skill more effectively. It is also important to reinforce the client for using the
steps correctly, both by providing positive feedback and drawing attention to reductions in distress that usually occur when the 5 Steps of CR are completed.
When working through the 5 Steps of CR, if the client concludes in the fifth step that the
evidence supports his/her distressing thought, an Action Plan needs to be created to help the
client deal with that upsetting situation. Learning how to face problems and how to develop
effective Action Plans can counter the natural tendency of many trauma survivors to attempt to
avoid such problems, and this new skill will ultimately give them greater control over their lives.
Action Plans include the following four components: (1) a clear goal; (2) a list of possible strategies for achieving the goal; (3) a step-by-step plan for implementing the selected strategies; and
(4) a date to follow up on the plan.
From the outset of the CBT for PTSD program, the therapist aims at helping clients generalize
the skills taught in session to their daily lives, and to maintain those skills after the program has
ended. The more competence clients develop at CR over the course of treatment, the more likely
it is that they will continue to be able to use the skill after the program ends. Central to teaching
clients how to use CR is the therapist’s systematic use of shaping, or the successive reinforcement of approximations to a desired goal or skill. In order to shape the client’s competence at
using cognitive restructuring, the therapist needs to actively engage him or her in repeatedly
practicing the skill during treatment sessions, and provide feedback and guidance to hone the skill
over multiple efforts. Homework practice between therapy sessions gives clients the opportunity
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to see whether they can use the CR skill taught in session on their own. Throughout treatment the
therapist clearly communicates to the client that the CBT program is time-limited. Such clear
communication is necessary to shape expectations, motivate participants to make use of the
therapy sessions, and prepare them for termination. In the second to last session, there is a joint
meeting between the PTSD therapist, client, and case manager/primary clinician. In this session,
the client teaches their primary case manager the 5-steps of CR and they discuss how they will
utilize this skill in their sessions.
2 Case Presentation
“Mr. X” was in his 50’s when he was referred for treatment after scoring within the severe
range for PTSD on the PCL. He was currently attending a partial hospital program 4 days per
week for treatment of his schizoaffective disorder symptoms. Upon admission, he struggled
with limited social skills, paranoid ideation, disorganization, and depressed mood. He lived in
supported housing and was unemployed. He presented with depressed mood, anxiety, disorganization, episodes of irritability and agitation, difficulty in making decisions, ruminating
thoughts, and paranoid ideation. Mr. X also had a long history of polysubstance abuse dating
back into his 20’s, although he had been abstinent for many years. As part of his partial hospitalization treatment, Mr. X was assessed for PTSD and scored within the high range. He
reported that his PTSD symptoms were negatively affecting his ability to function on a daily
basis; he spent most of his time alone, did not have many close relationships, and had difficulty
in taking care of himself.
Mr. X presented with multiple PTSD symptoms. He expressed difficulties in trusting people
and forming close relationships. He had severe anxiety and feared that something bad would
happen to him, despite a lack of evidence. Mr. X presented with severe hyperarousal symptoms including, hypervigilance, and difficulties in falling asleep and concentrating. He engaged
in many of the Common Styles of Thinking (CST) patterns, such as, all or nothing thinking,
overgeneralization, emotional reasoning, and catastrophizing. Some of the themes in his distorted thinking included, “I’m no good at all,” “no one likes me,” and “I will always get hurt
in a relationship.”
3 Presenting Complaints
Mr. X’s primary presenting problems were anxiety and mood lability with a history of psychotic
features. His secondary problems included inability to live independently, lack of social skills
and social supports, and failure to obtain and hold employment. Mr. X experienced occasional
panic attacks. He noted that his anxiety tended to be general in nature, but more recently centered
on his interactions with other people. Mr. X stated that his paranoid thoughts made him more
anxious during his social interactions. He reported that he often felt like what he had to say was
“not important,” and would ruminate about his daily interactions, feeling like his contributions
to groups and peers were “stupid.” This prevented him from being able to fall asleep, speaking
up, trying to meet new people, or expressing his feelings to his family or friends. With Mr. X’s
symptom report at onset of PTSD treatment, it appeared as though he was also suffering from
social anxiety disorder.
Mr. X also reported that his depression had increased to the point that he often couldn’t get out
of bed in the morning. He stated, however, that since being in the partial hospital program and
improving his coping skills his severe depressive episodes had occurred less frequently. He also
attributed the improvements to adhering to his prescribed medication. Mr. X stated that feeling
rejected or abandoned had often triggered depressive episodes. When in the midst of feeling
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depressed he struggled with feelings of guilt, being self-critical, loss of confidence, feeling like
he should be punished, loss of interest and energy, and indecisiveness.
Mr. X had a history of suicidal ideation, but had not experienced these symptoms in 8 years.
He reported increased instances of suicidal ideation when under the influence of mood altering
substances. He stated that, when under the influence, the thoughts would start off as “it would be
better for everyone if I wasn’t here” and then escalate to thinking of a plan.
Mr. X had been receiving partial hospitalization services since 2001. He stated that he was
frustrated with his current symptoms because he wanted to be able to find employment and possibly find a significant other to share his life with, but felt his current level of functioning
prevented him from moving forward on either of these goals.
4 History
Mr. X was born and raised in New Jersey to a middle-income family; he was the youngest of
3 children. He met developmental milestones and performed at a satisfactory level in school,
although he reported difficulty in keeping up with his peers academically. Mr. X had a limited
circle of friends when in school and was described as a shy child.
When Mr. X was a child, he was sexually abused by a neighbor from ages 6 through 13. Mr. X
said that he was afraid that no one would believe him if he told and his abuser reinforced those
fears. He did not report this to his parents until he was much older and the neighbor had moved
away.
Mr. X reported experiencing problems with anxiety since his childhood and depressive episodes since his teens. He had a history of psychiatric symptoms since his early 20’s, which were
aggravated by his heavy polysubstance dependence. He reported that the anxiety and depression
had varied in their severity throughout his treatment and that he had experienced periods where
it was difficult for him to have healthy activities of daily living or to leave the house.
Mr. X abused multiple mood altering substances. This started in high school and escalated
throughout his 20’s and 30’s. Abused substances included alcohol, marijuana, cocaine, and
heroin. During periods of active addiction, Mr. X would prostitute himself with men in order to
obtain drugs. These encounters would bring up memories of his childhood sexual abuse and as a
result, he would use increased amounts of drugs to medicate the pain. For weeks after prostituting behaviors, when he was not using mood altering substances, he would have flashbacks and
experience symptoms of hyper-arousal: increased heart rate, sweating, trembling, and agitation.
Since his 20’s, Mr. X had been involved in various levels of care and had 4 psychiatric hospitalizations. Each time Mr. X was hospitalized, it was for an increase in his depression and
psychotic symptoms. Mr. X had found the partial hospitalization treatment to be the most effective program for him. As a client in the partial hospitalization program, he had been receiving
group therapy and pharmacological treatment and had been able to maintain stability in the community without the need for inpatient treatment.
Although Mr. X had received individual therapy before, he stated that it did not focus on his
traumatic experiences. When he was approached by his individual therapist about trauma he had
difficulty “putting his feelings about the events into words.” As a result, he would wind up discussing other matters instead.
Mr. X brought several strengths to his PTSD treatment. He was motivated and willing to
attend 16 weeks of treatment, and was open to learning about PTSD. Although he was initially
unaware of how his thoughts, emotions, and feelings were connected to one another, he was
motivated to learn about this, and was able to improve his insight in this regard despite his cognitive limitations. Mr. X had difficulty in understanding his thoughts and his metacognitive deficit
was worked on throughout treatment (Lysaker, Buck & Ringer, 2007).
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5 Assessment
To better assist in diagnosis, conceptualization, treatment planning, and monitoring outcome,
Mr. X completed several assessments at intake, during the course of treatment, and at the end of
treatment. As part of an ongoing assessment, two measures were administered every third session
over the course of the 16-week CR program: Beck’s Depression Inventory-II (BDI-II) and PTSD
Checklist Stressor Specific Version (PCL-S). Careful assessment of the client’s understanding and
response to treatment is important throughout the program. This monitoring is done both formally
and informally with the client and his/her treatment team (e.g., case manager). Integration of the
PTSD program with current treatment is also important. During treatment, there was regular consultation with the case manager/primary therapist to review client progress, particularly outside of
therapy (e.g., have there been times when the skills learned in the program have helped and have
there been crises that might be related to the PTSD treatment?).
Mr. X also had cognitive deficits, including difficulties following through on tasks due to
impaired memory and attention, poor problem solving skills. Due to his cognitive impairments,
several strategies were implemented to more effectively teach the critical information and skills.
For example, material was presented at a slower pace and the therapist periodically checked in
with him throughout each session to verify and correct his understanding of the material.
Paper-and-Pencil Measures
PTSD checklist stressor specific version (PCL-S; Weather et al., 1993). The PCL-S has been found
to be both a reliable and valid instrument as a brief self-report inventory of PTSD (Blanchard,
et al., 1996), including in clients with SMI (Mueser et al., 2001). The PCL-S is a 17-item selfreport measure based on the criteria for a DSMI-IV diagnosis of PTSD. Items are rated on a
5-point Likert-type scale ranging from 1 (not at all) to 5 (extremely). There are several versions
of the PCL. The PCL-S (which was used with Mr. X) asks about specific problems in relation to
an identified “stressful experience.” Scores range from 0 to 85 and interpretation is based on total
score. Scores above 45 are indicative of severe PTSD, what is needed to participate in this treatment. Prior to administering the PCL-S, an “index trauma” or the trauma that is currently causing
the most distress in the person’s life is identified in session. Because people with co-occurring
schizophrenia and PTSD to have numerous traumas in their lives, by identifying the event causing the most distress, we can monitor the symptoms more accurately.
Beck Depression Inventory-II (BDI-II; Becket al., 1996).The BDI-II is the most widely used instrument to assess severity of depressive symptoms (Lambert & Stephenson, 2000). The BDI-II is a
21-item Likert-type scale with individual scores ranging from 0 to 3, with higher scores representing increased symptomatology. Each item represents a symptom that is a DSM-IV
characteristic of depression, such as loss of pleasure, suicidal thoughts, sadness and feelings of
worthlessness. Scores range from 0 to 63 and interpretation is based on total score. Scores from
0 to 13 indicate minimal depressive symptomatology, from 14 to 19 indicate mild depressive
symptoms, and from 29 to 63 indicate severe depressive symptomatology.
6 Case Conceptualization
Through a review of biopsychosocial factors, it was hypothesized that Mr. X’s PTSD and psychotic symptoms may have been caused, maintained and/or exacerbated by the traumatic events
in his childhood. One explanation for this is that earlier life experiences that introduce conflict
into one’s belief system can make a person more vulnerable to developing PTSD and other
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mental illnesses. In addition, his maladaptive thinking patterns appeared to play a role in both
types of symptoms.
The psychotic symptoms Mr. X struggled with in the past included paranoid ideation about
family and supports in his life, inappropriate affect, disorganized and tangential thoughts, and a
history of auditory hallucinations, the content of which was negatively centered around his selfworth, safety around others, and commands to harm himself. Upon initiation of PTSD treatment,
Mr. X’s psychotic symptoms included paranoid ideation toward family and peers, mild auditory
hallucinations, and tangential thinking. He verbalized multiple core beliefs that reflected distorted thinking such as, “I’m stupid, I’m worthless, no one will every love me.” Several treatment
goals were developed that included increasing daily social interaction because of his tendency to
isolate when he experienced symptoms, developing better coping skills for symptoms, identifying continued triggers for substance abuse, working on his relapse and recovery thoughts, and
expanding his social connections outside of the partial hospital program.
7 Course of Treatment and Assessment of Progress
Session 1
In session 1, Mr. X established a good rapport with his PTSD therapist. The client completed a
crisis plan to assist him throughout treatment. He understood that he could refer to the crisis plan
at any time, in or out of session. Mr. X defined crises that would be difficult to handle as increased
anxiety, depression or psychosis, and the urge to use drugs or alcohol. Maintaining Mr. X’s sobriety was very important to him, so the urge to use was quite distressing. He was aware of his early
warning symptoms of a possible crises, which included becoming argumentative with supportive
others, withdrawing from others, increased anxiety or depression, and strong urges to use substances. He was able to clearly identify individuals he could go to for help if these signs occurred,
including people both at the program and in the community. Mr. X’s crisis plan consisted of
reaching out to his support system, taking his medications, and alerting members of his treatment
team as soon as he noticed an early warning sign.
After completing his crisis plan, Mr. X was taught the BRT skill. Mr. X learned this skill fairly
quickly, as he had had exposure to breathing exercises in other forms of treatment. Mr. X reported
that the BRT made him feel calmer and more relaxed. He expressed a willingness to practice and
use the skill throughout treatment program.
Sessions 2 and 3
As planned, Mr. X did very well in following through on his homework to practice BRT on his
own, and soon he was able to begin using the skill when he started to feel stressed at home.
During psychoeducation about PTSD, Mr. X completed the in-session handouts and discussed
his symptoms. He reported that he had nightmares about the trauma several times a month that
disrupted his sleep. Mr. X reported that, after he had a nightmare, he would be afraid to fall
asleep for several days. He also reported avoidance symptoms. Mr. X stated that he often would
avoid crowded places or situations where he would be around groups of men, because being in
the presence of men triggered memories of his sexual abuse. He also experienced many of the
overarousal symptoms. Mr. X stated that these symptoms were one of the most disruptive to his
daily functioning. Over-arousal symptoms included heart pounding and chest pain, sweating,
shaking, trouble falling asleep, restlessness, nausea, jumpiness, irritability, and being always on
guard. Mr. X also discussed difficulty with feelings of fear and anxiety, sadness and depression,
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guilt and shame, and anger. Another problem that Mr. X found to be particularly troublesome
was relationship difficulties. Mr. X stated it was often difficult for him to feel close to another
person or trust other people. He stated that in his existing relationships, he was often afraid that
the people he loved would leave him. Mr. X identified that he struggled with conflict with family
members and establishing and maintaining relationships.
In addition to the previous goals Mr. X established when he first entered the partial program
(discussed above), he also set goals in the CR Program. The goals Mr. X identified where to build
healthier, close relationships, to find a significant other to share his life with, and to be able to
return to work. Mr. X felt that if he could learn to mange his PTSD symptoms these goals would
be possible for him.
Sessions 4 to 5
The teaching of CST proceeded slowly due to Mr. X’s cognitive deficits and the therapist’s need
to teach slowly, allow Mr. X to ask questions, and to review the concept of the common styles of
thinking several times. With practice, Mr. X began to learn how to recognize common styles in
inaccurate thinking, and how to challenge and correct those thoughts.
Sessions 6 to 12
Mr. X responded well to the 5-steps of CR. The therapist often stopped to check for comprehension before moving forward as sometimes Mr. X would say he understood, but it would become
clear he needed further clarification.
Mr. X struggled most with Step 4—evaluating the evidence for and against the thought. Every
session would require a review of the type of evidence that he needed to look for to accurately
complete the five steps. The therapist encouraged him to look for evidence like a police detective
investigating a case. This strategy was helpful to him in sessions, and he learned to prompt himself to pretend that he was a detective when using the skill on his own. The therapist needed to
utilize much repetition to reinforce these learning points session after session. Socratic questioning was also used to guide the client in using Step 4. When Mr. X veered way from relying on
factual information as evidence in Step 4, he responded well to his therapist asking him whether
he was focusing only on the facts. He also struggled with what it meant if a thought could be
identified as a Common Style of Thinking. He was often able to identify that his thoughts were
Common Styles of Thinking, but would need to be reminded that CST were inaccurate, and not
supported by the evidence.
Sessions 6 through 12 were spent practicing and honing the 5 Steps of CR. Despite Mr. X’s
initial difficulty with the different steps, he only needed to develop an Action Plan twice to deal
with problematic situations throughout treatment. Even when practicing the 5 Steps of CR on his
own, Mr. X was frequently able to correct inaccurate thoughts and beliefs, and get relief from his
distressing feelings.
When initially teaching the 5 Steps of CR, the therapist encouraged Mr. X to focus on upsetting everyday events, rather than ones clearly related to his sexual abuse. Around session eight,
as Mr. X became more skilled at using the 5 Steps of CR, the therapist began to utilize the worksheets about PTSD that Mr. X had completed, and distressing symptoms endorsed on the BDI-II
and PCL, to guide him toward more trauma-related thoughts. Mr. X identified trauma-related
thoughts such as “I’m a bad person” or “No one could ever love me.”
Mr. X believed that he was a weak, stupid person because he had allowed himself to be
abused. He was able to challenge this belief by working through the 5 steps in session, and after
completing CR, Mr. X was able to change the thought to “even though I felt stupid at the time,
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Clinical Case Studies 8(6)
I was a child when I was abused and it was not my fault.” Mr. X was able to look at the evidence
in Step 4 of CR and realize that as a child, the abuse was beyond his control and not his fault.
Another core belief that Mr. X reported was “no one will ever love me because I was abused.”
This belief was also challenged through the use of the 5 steps of CR. In step 4, Mr. X was able to
generate evidence against the thought (my family tells me they love me every time I speak to
them on the phone, my best friend wants to spend time with me and be around me; we hang out
2 times a week) and was able to come up with a new thought (“I have people in my life who love
me despite the fact that I was abused as a child”). After each session, Mr. X was assigned homework to use the 5 steps of CR daily.
Sessions 12 to 16
In sessions 10 to 12, the process of termination was discussed with Mr. X. The therapist explained
to him the importance of his case manager joining them in a session toward the end of the program
to learn about his participation, and about the 5 Steps of CR. Mr. X understood that the purpose of
this exercise was so he would continue to use the new skills even after the PTSD treatment program had ended. Mr. X’s case manager joined the client and therapist in the final session 16.
In the final session, the PCL and BDI-II were completed and discussed as Mr. X had shown
decreases in both measures from the time of the initial session. Mr. X commented that he did feel
a difference since the beginning of treatment and noticed that he was having fewer PTSD-related
symptoms. His case manager joined the session for about 20 minutes, and Mr. X did a nice job of
demonstrating the 5 Steps of CR for his case manager, with some assistance from the therapist.
The case manager asked several questions related to how well the treatment works and Mr. X
responded positively about how it had helped him change his thought patterns and reactivity. His
treatment team, including the PTSD therapist, noted positive changes in the client in regards to his
self-esteem and group participation. Mr. X’s clinician reported that their therapeutic relationship
continued to positively develop and treatment was smooth throughout the entire 16 sessions.
The remainder of the session was spent reviewing what areas of his life Mr. X felt were
improved by the treatment and what skills he found to be the most helpful. He found that over
the last few weeks of treatment, his thinking was more positive overall and he found he needed
to use the skill less and less. Mr. X also found that he had more patience with himself as well as
others. His overall anxiety level decreased as well. Mr. X agreed that these were skills that he
fully intended on using in the future as part of his treatment and in the community when he
noticed himself starting to get upset. Overall, Mr. X reported feeling very positively about his
PTSD therapy and responded well to the termination process.
Assessment of Progress
Mr. X learned that some of his symptoms, and much of his distress, was due to PTSD. Before
participating in the program, Mr. X had believed that all of his symptoms were related to his
schizoaffective disorder.
When Mr. X first learned the 5 Steps of CR, and throughout sessions six through eleven, it
would take the entire session to review his homework and work through a single worksheet.
From session 12 and on, Mr. X was able to complete multiple sheets in session as he was able to
move through the five steps quicker and get the same amount of relief, if not more.
Mr. X reported that, after learning the 5 Steps of CR, he was able to look at his thoughts with
different perspective. He stated that instead of getting angry or upset immediately, he had
improved control over his reactions and was able to come up with more realistic and helpful
thoughts. Mr. X experienced a decrease in depression and anxiety, irritability, and paranoid
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Marcello et al.
30
27
BDI-II score
25
22
21
20
15
BDI-II
14
10
12
10
5
0
1
4
7
10
Session #
13
16
Figure 1. BDI-II
60
57
51
PCL-S score
50
43
50
40
36
30
30
PCL-S
20
10
0
1
4
7
10
Session #
13
16
Figure 2. PCL-S
ideation. He found that by the end of treatment he was even using the 5 Steps of CR less often
and his negative thoughts were occurring less frequently. Mr. X reported feeling an increase in
positive thoughts and emotions and his treatment team noticed his improved mood and functioning level. Upon termination, Mr. X said he felt be able to work on getting a job and believed that
he was capable of developing and maintaining healthy, trusting relationships. See Figures 1 and
2 for Mr. X’s BDI-II and PCL-S scores.
8 Complicating Factors
One complicating factor was Mr. X’s cognitive difficulties. Several techniques worked well to
help him understand the material: (1) explaining and demonstrating the five Steps of CR (with
the therapist taking the lead); (2) prompting the client to use the steps of the skill (with the client
taking the lead); (3) praising the client for steps that were performed well; (4) providing additional
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Clinical Case Studies 8(6)
prompts or instructions to teach other steps; (5) gradually fading the instructions and prompts as
the client became more able to perform the skill independently.
9 Managed Care Considerations
There were no managed care considerations necessary, as Mr. X had social security benefits.
10 Follow-Up
No formal follow-up was scheduled with Mr. X; however, considerable emphasis was placed on
continuing to use the breathing exercises and CR once the sessions ended. In the last session,
Mr. X’s case manager was present and they created a plan to continue to work on the 5 Steps of
CR. Mr. X continued to attend the partial hospital program and is working toward discharge.
Some of the goals Mr. X had set in the early stages of PTSD treatment were to be able to
increase his peer support group, move to more independent living, and to return to work. At posttreatment, Mr. X was applying for more independent living, he had attended more recreation
events through his day program with peers he did not socialize with before, and was applying to
a supportive employment program. Mr. X is currently attending a vocational readiness group at
his day program.
11 Treatment Implications of the Case
This case provides an example of an effective implementation of a recently developed and
empirically supported program for treating PTSD in persons with SMI (Mueser et al., 2008,
2009). It also demonstrates the utility of offering a cognitive-behavioral treatment for severe
PTSD in people with a SMI.
12 Recommendations to Clinicians and Students
This case underscores the importance of assessing trauma and PTSD in people with SMI, who
tend to have experienced multiple traumas throughout their lives but are rarely evaluated for the
presence of PTSD, and of treating PTSD in this population that has been excluded from most
treatment research. In addition, the effect of homework and the clinician’s attitude and use of
shaping techniques to reinforce completing these assignments appeared to have contributed to
the effectiveness of the treatment. It is imperative that clinicians provide rationale for homework at the onset of treatment, develop homework assignments in a collaborative fashion with
input from the client, regularly follow-up on homework completion, and troubleshoot difficulties as needed.
Author’s Note
This paper is for the “Special Issue on Psychotherapies for Schizophrenia (S. Silverstein and P. Lysaker,
Guest Editors).”
Declaration of Conflicting Interests
The authors declared that they had no conflicts of interests with respect to their authorship or the publication of this article.
Funding
This research was supported by NIH grant #: R01 MH064662-04A1.
Marcello et al.
451
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Bios
Stephanie C. Marcello, PhD earned her doctorate in Counseling Psychology from Temple University. She
is a Research Associate at UMDNJ-UBHC in the Division of Schizophrenia Research. Dr. Marcello focuses
on people with serious mental illness, especially involving substance abuse and trauma.
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Katie Hilton-Lerro is a licensed professional counselor. She is a clinician at UMDNJ-University Behavioral Health Care and works directly with people who have serious and persistent mental illness.
Kim T. Mueser, PhD is a licensed clinical psychologist and a Professor in the Departments of Psychiatry
and Community and Family Medicine at the Dartmouth Medical School in Hanover, New Hampshire. Dr.
Mueser has extensive clinical and research experience in the psychosocial treatment of schizophrenia and
other severe psychiatric disorders. He has co-authored ten books and several hundred journal articles.