Staff Perspective: I'm Having the Thought That Cognitions are Important in Trauma Work

Staff Perspective: I'm Having the Thought That Cognitions are Important in Trauma Work

Dr. Andy Santanello

Here is a very obvious and non-controversial statement: the thoughts that trauma survivors have about themselves, the world, and other people have an important impact on their recovery. Regardless of the model you use to help survivors of trauma to recover from their experiences, you are absolutely going to be addressing thoughts at some level. Treatments such Cognitive Processing Therapy address thoughts directly with socratic dialogue. Other treatments such as Prolonged Exposure Therapy or Eye-Movement Desensitization and Reprocessing may target unhelpful thinking more indirectly. This is important because research is beginning to demonstrate that maladaptive posttrauamtic cognitions right after a traumatic event predict posttraumatic symptoms (PTS) a year later (O’Donnell, Elliott, Wolfgang, & Creamer, 2007), that posttraumatic cognitions are important in maintaining PTS (Shahar, Noyman, Schnidel-Allon, , & Gilboa-Schechtman, 2013) and that changes in these cognitions may precede reductions in symptoms (Schumm, Dickstein, Walter, Owens, & Chard, 2015).

As a trauma clinician, you also know that sometimes (maybe more than just sometimes) trauma survivors may have trouble letting go of unhelpful beliefs. In some cases, even when clients can clearly articulate the reasons that their unhelpful thoughts are not accurate and are not helpful, those thoughts continue to stick around. These thoughts might decrease in frequency and intensity, but do they ever really go away? When they pop up again, are they any less unhelpful or distressing? Maybe. And then again, maybe not.

It turns out that there might be more to the story when it comes to posttraumatic cognitions. In a recent study, Benfer, Rogers, and Bardeen (2020) investigated the influence of cognitive fusion on the impact of posttraumatic cognitions. Cognitive fusion, relating to one’s thoughts literally thereby contributing to excessive “entanglement” with the content of these thoughts, can have a very powerful influence on the experience of thoughts. For example, if you related to the thought, “I am horribly ugly” , in a literal way, it might seem like a “truth” about “how you are.” If it is true that you are horribly ugly and being horribly ugly is a problem for you, then you need to do something about it. This is cognitive fusion. In contrast, if you said to yourself, “I am having the thought that ‘I am horribly ugly’”, you might be able to notice that thought as just a thought. What is there to do with thoughts except to allow them to drift into and out of your mind? In the study referenced above, it turned out that trauma survivors who were more highly fused with their posttraumatic cognitions tended to report more severe PTS independent of the frequency of these thoughts. The authors of the study were quick to point out that these results need to be replicated and that observing the relationships between fusion, posttraumatic cognitions, and PTS in the context of treatment research is an important next step.

Until then, it might be interesting to note there could be an important, perhaps fundamental, difference between a posttraumatic cognition and “having a posttraumatic cognition”.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Andy Santanello, Psy.D., is a licensed, clinical psychologist and Military Behavioral Health Psychologist at the Center for Deployment Psychology. Dr. Santanello joined CDP after over a decade of service in the Veterans Health Administration where he was a staff psychologist in the Trauma Recovery Program.


Benfer, N., Rogers, T.A., & Bardeen, J.R. (2020) Cognitive fusion potentiates the effect of maladaptive posttraumatic cognitions on posttraumatic stress symptoms, Journal of Contextual Behavioral Science, 17, 55-61.

O’Donnell, M. L., Elliott, P., Wolfgang, B. J., & Creamer, M. (2007). Posttraumatic appraisals in the development and persistence of posttraumatic stress symptoms. Journal of Traumatic Stress, 20(2), 173–182.

Schumm, J. A., Dickstein, B. D., Walter, K. H., Owens, G. P., & Chard, K. M. (2015). Changes in posttraumatic cognitions predict changes in posttraumatic stress disorder symptoms during cognitive processing therapy. Journal of Consulting and Clinical Psychology, 83(6), 1161–1166.

Shahar, G., Noyman, G., Schnidel-Allon, I., & Gilboa-Schechtman, E. (2013). Do PTSD symptoms and trauma-related cognitions about the self constitute a vicious cycle? Evidence for both cognitive vulnerability and scarring models. Psychiatry Research, 205(1–2), 79–84.