Case Example: Jill, a 32-year-old

Afghanistan War Veteran

This is a case example for the treatment of PTSD using Cognitive Behavioral
Therapy. It is strongly recommended by the APA Clinical Practice Guideline for the
Treatment of PTSD. Download case example (PDF, 108KB).

Jill's Story
Jill, a 32-year-old Afghanistan war veteran, had been experiencing PTSD symptoms for more
than five 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 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.”
After 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 feeling to be guilt. Jill’s
therapist used this worksheet as a starting point for engaging in Socratic dialogue, as shown
in the following example:
Therapist: Jill, do you mind if I ask you a few questions about this thought that you noticed,
“I should have had them wait and not had them go on?”
Client: Sure.
Therapist: Can you tell me what the protocol tells you to do in a situation in which a truck
breaks down during a convoy?
Client: You want to get the truck repaired as soon as possible, because the point of a convoy
is to keep the trucks moving so that you aren’t sitting ducks.
Therapist: The truck that broke down was the lead truck that you were on. What is the
protocol in that case?
Client: The protocol says to wave the other trucks through and keep them moving so that you
don’t have multiple trucks just sitting there together more vulnerable.
Therapist: Okay. That’s helpful for me to understand. In light of the protocol you just
described and the reasons for it, why do you think you should have had the second truck wait
and not had them go on?
Client: If I hadn’t have waved them through and told them to carry on, this wouldn’t have
happened. It is my fault that they died. (Begins to cry)
Therapist: (Pause) It is certainly sad that they died. (Pause) However, I want us to think
through the idea that you should have had them wait and not had them go on, and
consequently that it was your fault. (Pause) If you think back about what you knew at the
time — not what you know now 5 years after the outcome — did you see anything that
looked like a possible explosive device when you were scanning the road as the original lead
truck?
Client: No. Prior to the truck breaking down, there was nothing that we noticed. It was an
area of Iraq that could be dangerous, but there hadn’t been much insurgent activity in the
days and weeks prior to it happening.
Therapist: Okay. So, prior to the explosion, you hadn’t seen anything suspicious.
Client: No.
Therapist: When the second truck took over as the lead truck, what was their responsibility
and what was your responsibility at that point?
Client: The next truck that Mike and my other friends were on essentially became the lead
truck, and I was responsible for trying to get my truck moving again so that we weren’t in
danger.
Therapist: Okay. In that scenario then, would it be Mike and the others’ jobs to be scanning
the environment ahead for potential dangers?
Client: Yes, but I should have been able to see and warn them.
Therapist: Before we determine that, how far ahead of you were Mike and the others when
the explosion occurred?
Client: Oh (pause), probably 200 yards?
Therapist: 200 yards—that’s two football fields’ worth of distance, right?
Client: Right.
Therapist: You’ll have to educate me. Are there explosive devices that you wouldn’t be able
to detect 200 yards ahead?
Client: Absolutely.
Therapist: How about explosive devices that you might not see 10 yards ahead?
Client: Sure. If they are really good, you wouldn’t see them at all.
Therapist: So, in light of the facts that you didn’t see anything at the time when you waved
them through at 200 yards behind and that they obviously didn’t see anything 10 yards ahead
before they hit the explosion, and that protocol would call for you preventing another danger
of being sitting ducks, help me understand why you wouldn’t have waved them through at
that time? Again, based on what you knew at the time?
Client: (Quietly) I hadn’t thought about the fact that Mike and the others obviously didn’t see
the device at 10 yards, as you say, or they would have probably done something else. (Pause)
Also, when you say that we were trying to prevent another danger at the time of being “sitting
ducks,” it makes me feel better about waving them through.
Therapist: Can you describe the type of emotion you have when you say, “It makes me feel
better?”
Client: I guess I feel less guilty.
Therapist: That makes sense to me. As we go back and more accurately see the reality of
what was really going on at the time of this explosion, it is important to notice that it makes
you feel better emotionally. (Pause) In fact, I was wondering if you had ever considered that,
in this situation, you actually did exactly what you were supposed to do and that something
worse could have happened had you chosen to make them wait?
Client: No. I haven’t thought about that.
Therapist: Obviously this was an area that insurgents were active in if they were planting
explosives. Is it possible that it could have gone down worse had you chosen not to follow
protocol and send them through?
Client: Hmmm. I hadn’t thought about that either.
Therapist: That’s okay. Many people don’t think through what could have happened if they
had chosen an alternative course of action at the time or they assume that there would have
only been positive outcomes if they had done something different. I call it “happily ever
after” thinking — assuming that a different action would have resulted in a positive outcome.
(Pause) When you think, “I did a good job following protocol in a stressful situation that may
have prevented more harm from happening,” how does that make you feel?
Client: It definitely makes me feel less guilty.
Therapist: I’m wondering if there is any pride that you might feel?
Client: Hmmm...I don’t know if I can go that far.
Therapist: What do you mean?
Client: It seems wrong to feel pride when my friends died.
Therapist: Is it possible to feel both pride and sadness in this situation? (Pause) Do you think
Mike would hold it against you for feeling pride, as well as sadness for his and others’ losses?
Client: Mike wouldn’t hold it against me. In fact, he’d probably reassure me that I did a good
job.
Therapist: (Pause) That seems really important for you to remember. It may be helpful to
remind yourself of what you have discovered today, because you have some habits in
thinking about this event in a particular way. We are also going to be doing some practice
assignments that will help to walk you through your thoughts about what happened during
this event, help you to remember what you knew at the time, and remind you how different
thoughts can result in different feelings about what happened.
Client: I actually feel a bit better after this conversation.
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.
More specifically, Jill 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). 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 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.