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Jill, a 32-year-old Afghanistan war veteran, had been experiencing PTSD symptoms for over 5 years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device (IED) while driving a combat supply truck. Over the years, Jill became increasingly depressed and began using alcohol on a daily basis to help assuage her PTSD symptoms. She had difficulties in her employment, missing many days of work, and she reported feeling disconnected and numb around her husband and children.

In addition to a range of other PTSD symptoms, Jill had a recurring nightmare of the event in which she was the leader of a convoy and her lead truck broke down. She waved the second truck forward, the truck that hit the IED, while she and her fellow service members on the first truck worked feverishly (worked in a hurry) to repair it.

Consistent with the traumatic event, her nightmare included images of her and the service members on the first truck smiling and waving at those on the second truck, and the service members on the second truck making fun of the broken truck and their efforts to fix it — “Look at that piece of junk truck — good luck getting that clunker fixed!”

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Following a thorough assessment of her PTSD and comorbid symptoms, psychoeducation about PTSD symptoms, and a rationale for using trauma focused cognitive interventions, Jill received 10 sessions of cognitive therapy for PTSD. She was first assigned cognitive worksheets to begin self-monitoring events, her thoughts about these events, and consequent feelings.

These worksheets were used to sensitize Jill to the types of cognitions that she was having about current day events and to appraisals that she had about the explosion. For example, one of the thoughts she recorded related to the explosion was, “I should have had them wait and not had them go on”. She recorded her related feelings to be guilt. Jill’s therapist used this worksheet as a starting point for engaging in counselling dialogue.

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Moreover, another thought that Jill described in relation to the traumatic event was “I should have seen the explosion was going to happen to prevent my friends from dying”. Her related feelings were guilt and self-directed anger. The therapist used this thought to introduce the cognitive intervention of “challenging thoughts” and provided a worksheet for practice.

The therapist first provided education about the different types of thinking errors, including habitual thinking, all-or-none thinking, taking things out of context, overestimating probabilities, and emotional reasoning, as well as discussing other important factors, such as gathering evidence for and against the thought, evaluating the source of the information, and focusing on irrelevant factors.

Jill, more specifically, noted that she experienced 100 percent intensity of guilt and 75 percent intensity of anger at herself in relation to the thought “I should have seen the explosive device to prevent my friends from dying”. She posed several challenging questions, including the notion that improvised explosive devices are meant to be concealed, that she is the source of the information (because others don’t blame her), and that her feelings are not based on facts (i.e. she feels guilt and therefore must be guilty).

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Ultimately, she came up with the alternative thought, “The best explosive devices aren’t seen and Mike (driver of the second truck) was a good soldier. If he saw something, he would have stopped or tried to evade it”, which she rated as 90 percent confidence in believing. She consequently believed her original thought 10 percent, and re-rated her emotions as only 10 percent guilt and 5 percent anger at self.