The initial focus of cognitive therapy with patients manifesting acute symptoms of increased arousal is on identifying the specific problems for which the patient is seeking help, and then establishing specific, mutually agreed upon treatment goals. If the treatment goal is to significantly reduce or eliminate the increased arousal symptoms, it should be made clear to the patient that achieving this goal could lead to a short-term exacerbation of PTSD symptoms (e.g., intrusive images or flashbacks of the traumatic event), but that the emergence of such symptoms would facilitate emotional processing of the trauma, and thus be beneficial to the patient’s long-term recovery.
If the patient responds to this caveat with some hesitation, it may be useful to conduct a cost-benefit analysis together with the patient, weighing the pros and cons of reducing or maintaining the increased arousal symptoms. If the patient decides that reducing the increased arousal symptoms is a desirable treatment goal, a two-pronged approach may be employed. This involves identifying and challenging the beliefs and schemas underlying the increased arousal symptoms (e.g., schemas of vulnerability and powerlessness), while simultaneously helping the patient to develop more adaptive coping strategies for daily functioning.