International Journal of Applied Psychology 2014, 4(6): 229-239

DOI: 10.5923/j.ijap.20140406.04

Behavioral-Cognitive Inhibition Therapy for

Posttraumatic Stress Disorder: A Cognitive Behavior
Therapy Developed from the Behavioral-Cognitive
Inhibition Theory
Nenad Paunovic

Department of Psychology, Stockholm University, Stockholm, Sweden

Abstract A first outline of a new cognitive-behavior therapy program for posttraumatic stress disorder (PTSD) is
presented with regards to its underlying theories and treatment components. It is based on the behavioral-cognitive inhibition
(BCI) theory for PTSD (Paunović, 2010) and is named Behavioral-cognitive inhibition (BCI) therapy. The treatment program
is presented descriptively session by session. The program rests on the following main blocks: (1) overview of the whole
treatment program and normalization of PTSD symptoms in terms of the BCI- theory, (2) the development of narrative stories
of valued life event memories, (3) emotional processing of valued life event memories, (4) cognitive processing of
dysfunctional trauma-, pre-trauma and posttrauma beliefs central in the maintenance of PTSD, (5) exposure inhibition that
consists of (i) emotional processing of valued life event memories, (ii) a single imaginal exposure to central trauma memory
details, and (iii) repeating the emotional processing of valued life event memories, and (7) identifying current most valued life
areas and utilizing valued narrative stories, emotional processing of valued life event memories and behavioral activation in
valued directions.
Keywords Cognitive-Behavior Therapy, Behavioral-Cognitive Inhibition Therapy, Posttraumatic Stress Disorder,
Valued Narrative Stories, Emotional Processing, Exposure Inhibition, Dysfunctional Beliefs, Behavioral Activation

1.2. Valued Narrative Storytelling

1. Introduction The aim is to counter overgeneralized positive memories
The behavioral-cognitive inhibition (BCI) theory was first in PTSD through repeated re-telling of valued life event
developed in order to conceptualize posttraumatic stress memories. Overgeneralized positive memories in PTSD are
disorder (PTSD) [1]. In this article a cognitive-behavior counteracted by developing specific valued life event stories.
therapy for PTSD is presented that is named A second aim of valued narrative story telling is to help
Behavioral-cognitive inhibition (BCI) therapy. The BCI the individual to focus on what is most valued in life in order
therapy is tailored to the DSM-V criteria for PTSD [2], and to start to plan and engage in (or expand the engagement of)
developed from the BCI theory. The BCI therapy program valued life activities. A third aim is to use the information
consists of elements described next. from these stories in order to dispute dysfunctional beliefs in
PTSD. A fourth aim is to utilize the information from valued
1.1. Normalization of PTSD Symptoms in Terms of the life stories in order to inhibit central trauma memory
BCI-theory elements. Positive autobiographical event memories are
overgeneralized in PTSD, i.e. are difficult to retrieve [3, 4].
The PTSD symptoms are normalized in terms of the Difficulties in retrieving overgeneralized autobiographical
BCI-theory. The purpose is to educate the client about PTSD memories in PTSD may contribute to the maintenance of
symptoms with the aim of normalizing the PTSD symptoms PTSD [4]. Overgeneralized autobiographical memory is an
from the client’s perspective. important predictor in the time course of PTSD [5].
Overgenerality in PTSD has also been linked with deficits in
* Corresponding author:
kontakt@kbterapi.se (Nenad Paunovic)
social problem solving, suggesting a role in symptom
Published online at http://journal.sapub.org/ijap maintenance [6]. In addition, a decline in overgeneralized
Copyright © 2014 Scientific & Academic Publishing. All Rights Reserved memories following cognitive-behavior therapy appears to
230 Nenad Paunovic: Behavioral-Cognitive Inhibition Therapy for Posttraumatic Stress Disorder: A Cognitive
Behavior Therapy Developed from the Behavioral-Cognitive Inhibition Theory

correspond with a reduction in overgeneral memories [7]. positive autobiographical event memories helps the client to
Furthermore, Ehlers and Clark [8] state that “…the get access to un-integrated memory information that is
re-experiencing symptoms are isolated memory fragments incompatible to the meaning of the trauma and PTSD
that are triggered by matching cues and that they are symptoms, and (b) valued narrative story telling is one
experienced as if things were happening in the ´here and means to activate such memories. See examples of memory
now´ because they are not integrated with other details that have been extracted from valued life event
autobiographical information”. One way to view such a memories in the lower-right part of figure 1.
theoretical proposition is as follows: (a) the activation of

Figure 1. Behavioral-cognitive inhibition theory for posttraumatic stress disorder: ① (lower part of the figure) A. Avoidance / escape / coping of
activated trauma-related memory elements; B. Trauma-related memory elements dysfunctionally inhibit valued memory elements; C. Valued memory
elements therapeutically inhibiting trauma-related memory elements; D. Current valued activities and functional coping inhibiting trauma-related memory
elements and E. The reinforcement and expansion of valued memory elements. ② (upper part of the figure) A. Activating events (overt and cognitive) of
PTSD symptoms; B. Avoidance/escape/ coping behaviours (overt and cognitive); C. Consequences of trauma-related avoidance/ escape/ coping
behaviours and trauma-related beliefs; and D. trauma-,pre- and post-trauma related dysfunctional beliefs in PTSD
 International Journal of Applied Psychology 2014, 4(6): 229-239 231

1.3. Emotional Processing of Valued Life Event Emotionally processing valued emotions before imaginal
Memories trauma exposure counteracts numbing symptoms and
The purpose of this part of the treatment is to emotionally increases the tolerance to trauma exposure, (b) during
process central details of most valued life event memories in imaginal exposure the client is to re-tell the traumatic event
order to (a) counter numbing symptoms, (b) get access to in detail once in order to activate the trauma memory and to
experiential information that can be utilized as corrective prepare for an integration into the valued event memory
information in relation to trauma-, pre-trauma and network, and (c) the client is to repeatedly and continuously
posttrauma dysfunctional beliefs in PTSD, and (c) utilized in re-tell and be re-told by the therapist the central details of
order to inhibit central trauma memory elements. In this part one’s most valued life event moments. The purpose is to
of the treatment central memory elements of valued life inhibit the central trauma memory elements (e.g., see
event memories are identified and imaginally relived. Paunović, 1999, 2002, 2003, 2011) so that they can become
Examples of the content of central valued event memories integrated into the valued memory network. The emotional
are depicted in the lower-right part of figure 1. processing of valued life event memories includes
remembering the event, the perceived details of the event
1.4. Cognitive Processing of Dysfunctional Beliefs in that were encoded through the five senses, and the
PTSD concomitant emotions and beliefs. Also, these memory
elements constitute information that can be used in order to
Trauma-, pre-trauma and post-trauma dysfunctional cognitively process dysfunctional trauma-, pre-trauma and
beliefs are identified and cognitively processed. Such post-trauma beliefs in PTSD. In order to consolidate the
cognitions are conceptualized in terms of (a) themes of exposure inhibition the client is to (i) listen to the audio tape
danger, trust, intimacy, control and self-esteem [9], (b) guilt of the session in its entirety as often as possible, and (ii)
cognitions [10, 11], (c) anger cognitions [12, 13], (d) conduct daily in vivo exposure. If the exposure inhibition
betrayal, sadness, loss, helplessness and hopelessness process has been conducted successfully during the session,
schemas [14], and (e) conceptualizations from CBT-models the in vivo exposure is expected to activate the newly formed
for PTSD such as trauma-related appraisals of PTSD memory network in which the trauma memory has been
symptoms and post-trauma events [8], and erroneous incorporated within the valued event memory network. The
associations primarily related to danger and incompetence inhibition of central trauma event memory elements by
beliefs [15]. After the identification of central trauma-, valued event memory elements is depicted in the lower part
pre-trauma and post-trauma dysfunctional beliefs that are of figure 1, by the arrow “C”.
considered important in the maintenance of PTSD, the client
is to practice cognitive techniques [16]. The latter consists of 1.6. Valued Behavioral Activation
the utilization of challenging questions and erroneous Valued behavioral activation is implemented and guided
thought patterns in order to dispute dysfunctional beliefs that by the valued narrative stories and the emotional processing
maintain PTSD. As illustrated in figure 1 central trauma-, of valued life event memories. The client is to utilize the
pre-trauma and post-trauma dysfunctional beliefs can be parts of the valued narrative stories that are considered to be
traced to (a) the daily dysfunctional interpretations and the most important and possible to behaviorally engage in
meanings of PTSD-related stimuli, behaviors and within the present life situation. I.e., the valued narrative
consequences as depicted in the upper part of the figure, and stories are analyzed in terms of what is most important to the
(b) beliefs whose development can be identified from central client to engage in at the present moment in life. These most
life event memories of (i) the primary traumatic event that valued parts for the present life situation are to be re-told as a
generates PTSD symptoms, (ii) other traumatic events that story with the purpose of increasing the problem-solving
have contributed to the development of dysfunctional beliefs choices to the individual. The emotional processing of these
in PTSD, and (iii) other negative life events that have most valued life stories can be utilized in order to increase
contributed to the development of other dysfunctional beliefs the motivation to engage behaviorally in one’s most valued
that maintain PTSD. directions. The last part of this treatment component is to
help the client plan and implement the engagement in theses
1.5. Exposure Inhibition of the Traumatic Memory
most valued behavioral activities [21, 22].
The aim of exposure inhibition is to accomplish an
inhibition of central trauma memory elements by
emotionally processing valued memory elements. This
2. Behavioral-Cognitive Inhibition
treatment component consists of the following procedure: (a)
Therapy for PTSD: A Preliminary
the client is to repeatedly and continuously re-tell and be
Treatment Protocol
instructed to remember the central details of one’s most Here is a preliminary outline of the behavioral-cognitive
valued life event moments before the implementation of a inhibition therapy for PTSD that has been developed from
single imaginal exposure to central trauma memory details. the behavioral-cognitive inhibition theory.
232 Nenad Paunovic: Behavioral-Cognitive Inhibition Therapy for Posttraumatic Stress Disorder: A Cognitive
Behavior Therapy Developed from the Behavioral-Cognitive Inhibition Theory

2.1. Session 1 (120 minutes) treatment program at least once until the next session.
(c) Read the information sheet Common symptoms after
2.1.1. Start Recording the Session traumatic events, to register own symptoms and to
register what has been learned after reading and
Instruct the client that the session will be audio-recorded,
discussing common symptoms in PTSD.
and that the recorded material will be given to the client as
(d) To register what (if) is not understood about the
homework to listen to until the next session. The client is
treatment program, the normalization of trauma
instructed to bring the audio-recording device to the next
symptoms.
session.
(e) To bring the recorded device and all registrations to
2.1.2. Present the Rationale and Overview of the Treatment the next session.
Program
2.2. Session 2 (120 minutes)
(a) Present the rational and an overview of valued
narrative story telling. 2.2.1. Review of Homework
(b) Present the rational and overview of emotional (a) The client hands over the recorded device to the
processing of valued life event memories. therapist, and the recording of this session is started.
(c) Present the rational and overview of cognitive If the audio-recording device has not been brought
therapy for trauma-, pre-trauma, and post-trauma back, start recording the session on another device.
beliefs in PTSD. (b) Ask the client to reflect on thoughts and feelings
(d) Present the rational and overview of exposure about the listening of the recorded session that was
inhibition. listened to since the last session.
(e) Present the rational and overview of valued (c) The client (or each individual in a group) presents
behavioral activation utilized trough valued narrative one’s understanding of all the treatment components
stories, emotional processing of valued life event wherein potential misunderstandings may appear.
memories and the planning and implementation of (d) The therapist corrects eventual misunderstandings
valued behavioral activation. and educates the client about the misunderstood
parts.
2.1.3. Normalization of PTSD Symptoms
(a) Describe common symptoms and related 2.2.2. Introduce Valued Narrative Story Telling
psychopathology symptoms in PTSD. (a) Present to the client the purpose and procedure of
(b) Identify the client’s most disturbing PTSD symptoms valued narrative story telling. First, explain how the
and discuss these with the client. intrusion symptoms numb the client to positively
(c) Discuss the meaning of client’s PTSD symptoms respond to current valued behavioral activities and
from the client’s perspective, the nature of the memories. Explain the nature of positive
distress and the consequences of symptoms in valued overgeneralized autobiographical memories, how
life areas. valued narrative story telling can increase the
specificity of these memories and in the long-term
2.1.4. Probe for the Clients Understanding of the Treatment
decrease PTSD symptoms. Secondly, explain that the
Program
trauma memories are separated from valued life
(a) Ask the client (or if a group each individual) to event memories. Thirdly, describe that the valued
summarize the understanding of the whole treatment narrative story telling will activate the valued life
program and the normalization of PTSD symptoms. event memory network that will help the client to
(b) Discuss the parts that were not well understood or not integrate these memories with the trauma memories
covered by the client. during the treatment program.
(c) Use socratic questioning and psycho education as (b) Instruct the client to write down a short note on one’s
needed in order to help the client to summarize the most valued life experiences in the following life
whole treatment program and the normalization of areas: valued relationships, valued accomplishments
PTSD symptoms. or skills, valued activities, valued appreciations /
(d) Resolve eventual remaining misunderstandings as affectionate responses from others, trustworthy
comprehensively as possible. individuals, intimate moments with life partners,
self-efficacy events, self-esteem inducing events, and
2.1.5. Homework other valued life events. Use the valued narrative
Instruct the client to: storytelling sheet for that purpose (see Appendix A).
(a) Listen at least twice to the recorded session until the (c) Instruct the client to choose one experience in each of
next session. the above areas if possible and to describe the most
(b) Read an information sheet that describes the whole valued event in each area as an event or life story.
 International Journal of Applied Psychology 2014, 4(6): 229-239 233

(d) Instruct the client to present a story of the chosen focused on the most central valued life event details
most valued narrative stories. by the same procedure.
(e) The therapist helps the client to create a streamlined 2.3.3. Homework
narrative for each valued narrative story. Include (a) Give the client the recording of the session to listen to
both external events as well as thoughts and feelings. at least twice until the next session.
2.2.3. Homework (b) Instruct the client to write down eventual new details
of the valued life event memories that are listened to
(a) Give the client the recording of the session to listen to and to bring the material to the next session.
at least twice until the next session.
(b) Instruct the client to write a detailed story of each 2.4. Session 4 (90 minutes)
chosen valued narrative and to bring the written
2.4.1. Review of the Homework
material to the next session.
(a) The client hands over the recorded device to the
2.3. Session 3 (120 minutes) therapist, and the recording of this session is started.
If the audio-recording device has not been brought
2.3.1. Review of Homework back, start recording the session on another device.
(a) The client hands over the recorded device to the (b) Ask the client to reflect on thoughts and feelings
therapist, and the recording of this session is started. about the listening of the recorded session that was
If the audio-recording device has not been brought listened to since the last session.
back, start recording the session on another device. (c) The client reads aloud each of the written down
(b) Ask the client to reflect on thoughts and feelings added details that were remembered during the
about the listening of the recorded session that was listening of the most valued life event memories.
listened to since the last session.
(c) The client reads aloud each of the written valued 2.4.2. Cognitive Processing of Dysfunctional Beliefs in
narrative stories once, and reflects on the thoughts PTSD
and feelings that comes into the clients mind. (a) Present the role of cognitive processing of
dysfunctional beliefs in PTSD. Probe for the client’s
2.3.2. Emotional Processing of Valued Life Events understanding of the model and resolve
(a) Firstly, explain the purpose of the emotional misconceptions.
processing of most valued life event memories. The (b) Instruct the client to fill out the form Dysfunctional
purpose in this part of the treatment is to provide beliefs after traumatic events (see Appendix B).
experiential information that can be cognitively (c) Review the A-B-C sheet with the client. It consists of
processed in relation to trauma-related dysfunctional three parts: A-an activating event that sets of
cognitions during the remainder of the treatment, dysfunctional beliefs (first row), B-the beliefs that
counter numbing symptoms and increase the have been set of by the activating event (second row),
exposure tolerance to intrusion symptoms of PTSD. and C-the consequence of the belief (i.e., emotions
(b) Instruct the client to provide the most central event and behaviors, third row).
details of each of the most valued life stories that (d) Go through an example with the A-B-C sheet of one
were written down during homework and the former of the clients dysfunctional beliefs. Register
session. The central event details should include the activating events in the first row. The purpose here is
memory details encoded and stored through the five to teach the client how to identify internal and
senses, the event itself, other people’s behaviors, external activating events that set of dysfunctional
one’s own behavior as well as one’s own thoughts beliefs.
and feelings. (e) Instruct the client to register the dysfunctional belief
(c) Make notes of the most central details of each valued that has been set of by the activating event in the
life event. second row. After that, educate the client about the
(d) The client is instructed to make oneself comfortable, difference between thoughts and feelings, and about
to close the eyes, and to imaginally relive each the relationship between the activating events and
valued life event in detail for about 5-10 minutes. thoughts.
The therapist repeats to the client the written down (f) Instruct the client to register the consequences in the
most central valued life event details and asks the third row of the A-B-C sheet. Then ask the client to
client to focus on these details repeatedly for a summarize the written down consequences. After
prolonged time. Alternately, the client is asked to that, educate the client about the emotional and
provide more details that are incorporated into the behavioral consequences of dysfunctional thoughts.
same procedure. If other thoughts intrude into the Ask the client to include both emotional and
clients mind the therapist helps the client to stay behavioral consequences in the third row.
234 Nenad Paunovic: Behavioral-Cognitive Inhibition Therapy for Posttraumatic Stress Disorder: A Cognitive
Behavior Therapy Developed from the Behavioral-Cognitive Inhibition Theory

(g) Educate the client about the function of safety and beliefs sheet by choosing a dysfunctional belief to
avoidance behaviors in PTSD. Safety behaviors cognitively process. In the first row the activating event is
prevent the individual from testing dysfunctional registered. In the second row the dysfunctional belief is
beliefs. Avoidance and escape behaviors shuts down written down. Then the dysfunctional belief is cognitively
the trauma-related memory, the fear of current processed with the Challenging questions sheet and disputed
innocuous threat stimuli, and leads to negative with the answers from this sheet in the third row. Next, the
reinforcement (explain in simple language). dysfunctional belief is reviewed with regards to faulty
(h) Instruct the client to summarize how the A-B-C sheet thought patterns that are written down in the fourth row.
should be filled out with the reviewed example. After that a new belief is formulated in the fifth row/upper
Discuss eventual misconceptions or gaps in the box. Lastly, the emotional and behavioral consequences of
summary. the new belief are formulated in the fifth row/lower box. The
behavioral consequences should include a decrease in the use
2.4.3. Homework of safety and avoidance/escape behaviors. Help the client to
(a) Give the client the recording of the session to listen to identify safety/avoidance/escape behaviors and to counteract
at least twice until the next session. them.
(b) Instruct the client to fill out the A-B-C sheet when
distressing negative emotions are experienced at 2.5.5. Homework
least once daily (provided that such responses occur). (a) Give the client the recording of the session to listen to
(c) Instruct the client to review each sheet and to reflect at least twice until the next session.
on the relationships between activating events (A), (b) Instruct the client to fill out the Disputation of
beliefs (B), and consequences (C). dysfunctional beliefs sheet at least once daily as
(d) Instruct the client to bring all the registered A-B-C conducted with the example during the session.
sheets to the next session.
2.6. Session 6-7 (90 minute)
2.5. Session 5 (90 minutes)
2.6.1. Review of the Homework
2.5.1. Review of the Homework (a) The client hands over the recorded device to the
(a) The client hands over the recorded device to the therapist, and the recording of this session is started.
therapist, and the recording of this session is started. If the audio-recording device has not been brought
If the audio-recording device has not been brought back, start recording the session on another device.
back, start recording the session on another device. (b) Ask the client to reflect on thoughts and feelings
(b) Ask the client to reflect on thoughts and feelings about the listening of the recorded session that was
about the listening of the recorded session that was listened to since the last session.
listened to since the last session. (c) Instruct the client to review the filled out Disputation
(c) The client presents the filled out A-B-C sheets and of dysfunctional beliefs sheet. Help the client to
reviews the most distressing or important incidents. correct eventual faults in the registrations.
Help the client to correct any faults in the
registrations and discuss eventual misconceptions or 2.6.2. Exposure Inhibition
gaps in them. Describe the purpose and the procedure of exposure
inhibition of central trauma memories. The purpose is to
2.5.2. Introduce the Challenging Questions Sheet
inhibit as many central trauma memory elements as possible
Introduce The challenging questions sheet [16] to the with the help of the emotional processing of valued life event
client, explain how it is used and resolve eventual memories. The procedure is as follows:
misunderstandings. (a) Instruct the client to close the eyes, make oneself
comfortable, and use the information from session 3
2.5.3. Introduce Faulty thought Patterns when the emotional processing of valued life event
(a) Introduce Faulty thought patterns [16] to the client memories was conducted. Conduct this part of the
and review all of the faulty thought patterns in the session in the same manner as during session 3.
Faulty thought patterns information sheet with the Repeat the details from the most valued event
client. memories to the client and ask the client to be an
(b) Instruct the client to summarize the faulty thought active participant in the process when additional
patterns and correct eventual misunderstandings. memory details are remembered. Each valued life
event memory is imaginally relived for about 5-10
2.5.4. Introduce the Disputation of dysfunctional beliefs minutes. Chose the most valued life event memories
Sheet with an Example for this process. It is advisable that these memories
Educate the client about the Disputation of dysfunctional constitute different themes or areas so that different
 International Journal of Applied Psychology 2014, 4(6): 229-239 235

types of functional beliefs are activated and/or 2.7. Session 8-9 (90 minutes)
developed. Conduct this process for about 30
minutes. 2.7.1. Review of the Homework
(b) Conduct a single imaginal exposure of the trauma (a) The client hands over the recorded device to the
with the client. That is, a shortened version of therapist, and the recording of this session is started.
imaginal exposure to the trauma [15]. The imaginal If the audio-recording device has not been brought
exposure should usually take 5-10 minutes or until back, start recording the session on another device.
the trauma event narrative has been re-told once in (b) Ask the client to reflect on thoughts and feelings
detail. Probe for central details of the traumatic event. about the listening of the recorded session that was
The purpose is to activate the central trauma memory listened to since the last session.
elements in order to inhibit them in the next part of (c) Instruct the client to present and reflect upon the in
the session and/or between the sessions. vivo exposure homework.
(c) Conduct an emotional processing of valued life event (d) Instruct the client to review the filled out Disputation
memories as during the first part of the session for of dysfunctional beliefs sheets. Help the client to
about 30 minutes. The valued life event memory correct eventual faults in the registrations, and
elements become integrated into the trauma memory cognitively process the material.
network and inhibits them.
2.7.2. Exposure Inhibition
2.6.3. In Vivo Exposure
The client is instructed to conduct the exposure inhibition
Describe the purpose and the procedure of in vivo process as during the previous session. This time, the
exposure to the client [15] and add how this is supposed to emotional processing of valued life events should take about
work out in terms of the BCI-theory. Plan with the client how 10 minutes before and 10 minutes after trauma exposure, and
in vivo exposure is going to be conducted (preferably once the single trauma exposure should take about 5-10 minutes.
daily or as often as possible). See if the client can be
confronted with the most distressing situations immediately, 2.7.3. Valued Behavioral Activation
or if moderately distressing situations are going to be Instruct the client to choose the most important parts of the
confronted first. Ask the client to stay in each situation valued narrative storytelling and the emotional processing of
between 40-60 minutes, or until the anxiety or fear valued life events from all sessions that represent the most
diminishes at least 50-70 %. Use SUDs (Subjective Units of valued behavioral activities. Then help the client to plan to
Distress) to measure the level of anxiety or fear before, engage in most valued behavioral activities in the present.
during and after in vivo exposure (0 = no anxiety/fear, 50 = Identify eventual safety and avoidance behaviors that may
moderate anxiety/fear, 100 = extreme anxiety/fear). Plan the pose as obstacles. Help the client to plan to cope successfully
implementation of in vivo exposure so that safety and in the relevant situations. Lastly, set goals with the client on
avoidance behaviors are dropped. The reason why in vivo how the plan should be implemented.
exposure to most distressing situations may be viable for
many clients is that in vivo exposure in this context has a 2.7.4. In Vivo Exposure
different theoretical rational compared to standard in vivo
Plan together with the client the next in vivo exposure
exposure. In this context it is assumed that the exposure
exercises and instruct the client to stay in the situations
inhibition during the session has developed an inhibitory
between 40-60 minutes, or until the anxiety or fear
memory network in relation to the trauma that may help the
diminishes at least 50-70%. Use SUDs to measure the level
client to immediately confront the previously most
of anxiety or fear before, during and after in vivo exposure.
distressing in vivo exposure situations.
The client also prepares for how to block any safety and
2.6.4. Challenge Dysfunctional Beliefs avoidance behaviors during the in vivo exposure.
Instruct the client to continue to challenge dysfunctional 2.7.5. Challenge Dysfunctional Beliefs
beliefs with the help of the Disputation of dysfunctional
Instruct the client to continue to challenge dysfunctional
beliefs sheet as conducted before.
beliefs with the help of the Disputation of dysfunctional
2.6.5. Homework beliefs sheet as conducted before.
(a) Give the client the recording of the session to listen to 2.8. Only in Session 9 (the last 15 minutes)
at least twice until the next session.
2.8.1. Review Treatment Progress and Find Areas for Further
(b) Instruct the client to conduct in vivo exposure at least
Improvement
twice between 40-60 minutes until the next session.
(c) Instruct the client to dispute dysfunctional beliefs by (a) Review with the client what has been accomplished
the Disputation of dysfunctional beliefs sheet as with regards to each of the components of the
conducted before. treatment program: valued narrative storytelling,
236 Nenad Paunovic: Behavioral-Cognitive Inhibition Therapy for Posttraumatic Stress Disorder: A Cognitive
Behavior Therapy Developed from the Behavioral-Cognitive Inhibition Theory

valued emotional processing, cognitive techniques, unknown or whether they operate in interaction with
exposure inhibition, in vivo exposure and valued each other. The purpose of the content and the structure
behavioral activation. of the presented treatment program in this article is to
(b) Review shortly in which areas the client needs to describe how it has been applied in recent clinical work
focus on future therapeutic work and how this is with PTSD patients by the author with success.
going to be planned and implemented. (c) The behavioral-cognitive inhibition therapy includes
commonly used procedures in CBT for PTSD such as
2.8.2. Homework psychoedcucation/normalization, exposure, behavioral
(a) Give the client the recording of the session to listen to activation and emotional/cognitive processing.
at least twice until the next session. However, these components/techniques are utilized
(b) Instruct the client to conduct in vivo exposure at least differently in relation to new treatment components for
twice between 40-60 minutes until the next session. PTSD (valued narrative story telling and emotional
(c) Instruct the client to dispute dysfunctional beliefs by processing of valued life moments) as compared to
the Disputation of dysfunctional beliefs sheet as evidence-based treatment protocols for PTSD.
conducted before. Another possible critique of this treatment package is that
(d) Instruct the client to implement valued behavioral it may consist of too many treatment components. According
activation according to the treatment plan. to this position this could render such a treatment difficult to
teach and to implement because there are too many
2.8.3. Say Goodbye to the Client and Communicate a Sincere
components to keep a track on. However, such a view is
Wish for Further Improvement
based on a component argumentation that may be
appropriate with regards to some treatments such as stress
3. Discussion inoculation training (SIT) [24]. SIT consists of the following
components: (a) breathing retraining, (b) relaxation training,
The behavioral-cognitive inhibition therapy for PTSD that (c) role-playing successful coping in anxiety provoking
has been presented in the current article is based on the situations, (d) thinking about and changing behaviors by
behavioral-cognitive inhibition therapy [1]. It consists of the successfully coping in stressful situations after going
following parts: normalization of PTSD symptoms, valued through the entire situation in imagination, (e) learning to
narrative storytelling, emotional processing of valued talk to oneself by recognizing negative or unhelpful
memories, cognitive techniques, exposure inhibition, in vivo statements of themselves and replacing them with more
exposure and valued behavioral activation. The package of helpful internal “talking”, and (e) stopping negative thoughts.
techniques constitute an integrated approach that has been SIT was not developed from the emotional processing theory
specifically developed from the behavioral-cognitive as exposure therapy was. SIT is based on managing
inhibition theory presented in fig. 1. anxiety-provoking situations and can be considered a coping
Since the purpose of the present article is only to present technique therapy consisting of multiple components. Also,
and describe the recently developed behavioral-cognitive the thought stopping technique may be counterproductive
inhibition therapy for PTSD, no systematic review of because the avoidance of trauma-related stimuli is
evidence-based therapies for PTSD in relation to this therapy considered to be a maintaining factor in PTSD.
has been conducted. A more systematic review of The behavioral-cognitive inhibition therapy is not based
evidence-based approaches for PTSD, primarily exposure on an anxiety management paradigm. Rather, it is based on
therapy and cognitive processing therapy, would take up to the behavoral-cognitive inhibition theory and the following
much space and compromise the descriptive purpose of the aims: (a) developing valued narratives in order to become
present article. However, such a review is warranted in the experientially more aware of one’s valued directions in life,
future if the utility of the behavioral-cognitive inhibition (b) emotionally process valued life event memories in order
therapy becomes successfully applied by other psychologists to process emotions incompatible to the trauma, (c) utilize
and psychotherapists in addition to the author. That is, the the valued memories in order to cognitively process
behavioral-cognitive inhibition therapy is yet to be trauma-related beliefs and inhibit central trauma memories,
rigorously tested as a treatment for PTSD in clinical settings. and (d) become highly motivated to implement valued
The main limitations of the behavioral-cognitive behavioral activation. Thus, the whole treatment package is
inhibition therapy are as follows: theory-driven and the treatment components are highly
(a) This treatment protocol has not yet been clinically interconnected. Furthermore, since a significant proportion
applied by other psychologists or psychotherapists of the treatment package focuses on valued memories and
besides the author. However, the purpose of this article valued behavioral activation, it ought to be much more
is to function as a guideline to other psychologists and motivational-inducing than only techniques whose purpose
psychotherapists in order to test the clinical value of the is to manage anxiety in the short-term. Thus, the author
behavioural-cognitive inhibition therapy for PTSD. proposes that the behavioral-cognitive inhibition therapy
(b) The relative efficacy of each treatment component is will not constitute a multi-component problem since: (a)
 International Journal of Applied Psychology 2014, 4(6): 229-239 237

several of the treatment components share the same multi-component mechanism approach is herewith
theoretical rational (valued narrative story telling, emotional presented.
processing of valued life events and valued behaioral It is appropriate to first test the behavioral-cognitive
activation), and (b) because of the former it may be viewed inhibition therapy for PTSD in a series of case studies. The
as consisting of three main components: valued based purpose is to get enough clinical experience in order to adjust
interventions, trauma-focused interventions, and cognitive the theory and treatment protocol so that the next step can be
techniques. planned and implemented.
Another relevant topic to discuss is proposed mechanisms The next step is to test the behavioral-cognitive inhibition
in evidence-based cognitive-behavioral therapies for PTSD. therapy with an evidence-based therapy for PTSD. Since
In cognitive processing, both an exposure component and exposure therapy is regarded as the cognitive-behavior
cognitive techniques are included. However, the exposure therapy with the strongest evidence in the treatment for
component consist only of written accounts. In a randomized PTSD, it is suggested that it is compared to the
study the full protocol was compared with two other behavioral-cognitive inhibition therapy in a randomzied
protocols that either consisted of written accounts only and controlled trial. In such a trial it is of utmost importance to
cognitive therapy alone [24]. The written account didn’t add ensure that the treatment integrity is maximized for both
to the efficacy of the cognitive component, and the written conditions. It is also important to include a wait-list control
account alone was inferior to cognitive therapy alone. Thus, condition. Firstly, it is hypothesized that the
by focusing on changing the meaning (i.e., dysfunctional behavioral-cognitive inhibition therapy will be equally
beliefs in PTSD) that maintain PTSD, the cognitive therapy effective in treating the intrusion symptoms in PTSD as
alone was able to effectively treat PTSD and associated exposure therapy. Secondly, it is hypothesized that the
psychopathology. behavioral-cognitive inhibition therapy is going to be more
In exposure therapy for PTSD it is proposed that effective in treating the numbing symptoms and the non-fear
emotional processing is the main mechanism of change [15]. related dysfunctional beliefs that are supposed to maintain
Emotional processing is defined as being emotionally PTSD, e.g. the type of beliefs that currently constitute a part
engaged during imaginal and in vivo exposure exercises of of the DSM-V criteria of PTSD. It is crucial to control for
the trauma memory and feared trauma-inducing situations. that exposure therapy does not contain any cognitive
However, it has also been proposed that the main mechanism interventions that may effectively change dysfunctional
of change in exposure therapy is the change of meaning of beliefs in PTSD except those that are related to the exposure
the trauma and central cognitions that are proposed to be interventions. That is, the post-exposure discussion at the
involved in the maintenance of PTSD. An indication of end of the sessions should only be devoted to discussions
emotional processing is habituation. That is, decreases of about aspects directly related to the exposure interventions
anxiety or fear within and/or between sessions as a result of (i.e., fear-related cognitions). They should not contain any
exposure. However, habituation is not a mechanism, but only discussions or manipulations that are related to
an indication of anxiety/fear decline over time. In fact, a lot non-fear/anxiety related cognitions in PTSD. Thirdly, it is
of cognitive restructuring may be conducted after the hypothesized that the behavioral-cognitive inhibition therapy
exposure component during the sessions when the exposure (a) will be viewed by the client’s as much more important for
process is discussed. The client may then utter dysfunctional them for their future life in terms of valued directions, (b)
cognitions that can be discussed and worked through. that valued memories will be significantly more detailed and
To summarize, the main mechanisms of change that are concrete than after exposure therapy, (c) that the clients will
considered to be involved in evidence-based engage in significantly more valued behavioral activities
cognitive-behavioral therapies for PTSD are (a) emotional than in exposure therpay, and (d) that the
processing of the trauma memory, and/or, (b) a change of behavioral-cognitive inhibition therapy will be viewed as
meaning of the trauma. significantly more attractive and less distressing than
In behavioral-cognitive inhibition therapy the following exposure therapy.
mechanisms may be responsible for changing the trauma
memory and a recovery in PTSD: (a) a change in valued
memories from overgeneralized memories to the Appendix A
development of concrete valued stories [4], (b) emotional
processing of valued life moments that inhibit numbing Valued narrative storytelling sheet
symptoms [20], (c) inhibition of the trauma memory Instruct the client to read each statement below and to
elements by the emotional processing of valued life write down events on separate sheets of paper that illustrate
memories. The mechanism in exposure therapy is inhibition, one’s most valued life experiences in each of the following
not extinction [25], (d) valued behavioral activation that life areas:
inhibit numbing symptoms, and (e) a change in meaning of 1. Valued relationships: “I value most the following
valued memories, the capacity to emotionally process valued relationships in my life…”
emotions, dysfunctional beliefs in PTSD, the trauma 2. Valued accomplishments or skills: “I value most the
memory and valued behavioral activities. Thus, a following accomplishments or skills in my life…”
238 Nenad Paunovic: Behavioral-Cognitive Inhibition Therapy for Posttraumatic Stress Disorder: A Cognitive
Behavior Therapy Developed from the Behavioral-Cognitive Inhibition Theory

3. Valued activities: “I value most the following 8. _____ People think about me in a negative way.
activities that i have participated in in my life…” My thoughts: ________________________________
4. Valued appreciative responses from others: “I value 9. _____ I think negatively about other people.
most the following appreciate responses from others My thoughts: ________________________________
in my life…”
5. Valued affectionate responses from others: “I value 10. _____ It was my fault that the trauma event occurred.
most the following affectionate responses from My thoughts: _______________________________
others in my life…” 11. _____ It was other peoples fault that the traumatic
6. Valued loving moments with significant others: “I event occurred.
value most the following loving moments with My thoughts: ________________________________
significant people in my life…”
12. _____ I am unable to be close to other people.
7. Valued trustworthy individuals: “I value most the
My thoughts: ________________________________
following trustworthy individuals in following
ways…” 13. _____ I am unable to feel good about myself.
8. Valued intimate moments with life partners (current My thoughts: ________________________________
and/or past): “I value most the following intimate 14. _____ I am unable to feel positive emotions.
moments with my current or former life partner…” My thoughts: ________________________________
9. Valued intimate moments with friends: “I value most
the following intimate moments with friends…”
10. Valued self-efficacy events: “I value most the ACKNOWLEDGEMENTS
following events in terms of that i handled them
effectively…” The author wishes to acknowledge the many years of
11. Valued self-esteem related events: “I value most the encouragement and positive reinforcement from professor
following events that have given me most self-worth Sten Rönnberg that has influenced a spirit of creativity and
in life…” faith very important in this type of developmental work. A
12. Other valued life events: “I value most the following remarkable influence from a behavior therapist that has
events in following ways…” eventually led to the present article despite that many years
has passed since he encouraged many of my ideas in a
conservative academic climate.
Appendix B
Dysfunctional beliefs after traumatic events
Please read each question and rate it on the left with a
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