Mood Anxiety and Personality

Clinical Academic Group (CAG)

Cognitive Therapy for PTSD

Nick Grey
Centre for Anxiety Disorders and Trauma
Oslo - August 2016
 Acknowledgements
Martina Mueller, Deborah Lee, Peter
Scragg, Kerry Young, Emily Holmes, Chris
Brewin, Ann Hackmann, Freda McManus,
Melanie Fennell, David Clark, Anke
Ehlers, Sheena Liness, John Manley, Jen
Wild, Idit Albert, Debbie Cullen, Alicia
Deale, Richard Stott, Rachel Handley.
 Learning Objectives
• Be able to assess for diagnosis of PTSD
• To understand a cognitive model of PTSD and how this
links to treatment
• To know when and when not to offer CT-PTSD
• To understand the key initial interventions used in CT-
PTSD
• To be able to provide a rationale for patients for
discussing the traumatic memories
• To know which memory-focused techniques might be
most helpful when
• To know how to use your full range of cognitive behaviour
therapy techniques to address cognitive themes in PTSD
 Accompanying Materials
• Reference list
• Chapters
• PTSD in a nutshell
• Published Questionnaires:
Posttraumatic Stress Diagnostic Scale (PDS)
Posttraumatic Cognitions Inventory (PTCI)
• Unpublished Materials:
Information Sheet for Patients
Session 1 note sheet
Worksheets
 ICD PTSD (F43.1)
• Arises as a response to a stressful event or
situation of an exceptionally threatening or
catastrophic nature, which is likely to cause
pervasive distress in almost anyone.
• Reliving of the trauma in intrusive memories or
dreams occurring against a persisting
background of a sense of ‘numbness’.
• Commonly fear and avoidance of cues and
reminders.
• Usually a state of autonomic hyperarousal.
• Usually within 6 months of the event.
 ICD 11 proposed definition of PTSD

This disorder follows exposure to an extremely threatening

or horrific event or series of events. It consists of 3 core
elements: (a) Reexperiencing: vivid intrusive memories,
flashbacks, or nightmares that involve reexperiencing in the
present, accompanied by fear or horror; (b) Avoidance:
marked internal avoidance of thoughts and memories or
external avoidance of activities or situations reminiscent of
the traumatic event(s); (c) Hyperarousal: a state of
perceived current threat in the form of hypervigilance or an
enhanced startle reaction. The symptoms must also last for
several weeks and interfere with normal functioning.
 DSM 5 Criterion A
• The person was exposed to the following event(s): death or
threatened death, actual or threatened serious injury, or
actual or threatened sexual violation in one or more of the
following ways:
• 1. Experiencing the event(s) him/herself
• 2. Witnessing the event(s) as they occurred to others
• 3. Learning that the event(s) occurred to a close relative or
close friend
• 4. Experiencing repeated or extreme exposure to aversive
details of the event(s) (e.g., first responders collecting body
parts; police officers repeatedly exposed to details of child
abuse)
 You need to know what you’re
dealing with
• “traumatic” experiences
• “flashbacks”
• “PTSD”
• Need for careful assessment
• Match re-experiencing symptoms to the
event
• Comorbidity is the rule rather than exception
• Other outcomes after trauma likely
 Falsetti (2009)
Characteristics with minimal
association to PTSD
• Severity of intrusions
• Frequency of intrusions
Characteristics associated
with recovery from PTSD
• Intrusions not assigned negative
meaning
• Thought control strategies such
as reappraisal and social control
Characteristics associated
with development and
maintenance of PTSD
• Sense of ‘nowness’
• Lack of context for intrusions
• Unwanted and uncontrollable
• Appear to be uncued
• Intrusions associated with
helplessness
• Intrusions associated with
panic attacks
• Negative meanings associated
to the intrusion (e.g. this
thought means I’m going crazy)
• Thought control strategies like
worry and rumination
“Ordinary”
Autobiographical Memories
• Awareness of remembering
• Emotions less strong
• Details have context
• Rarely spontaneous
• If spontaneous, close/ specific
match of triggers
Reexperiencing
• Limited awareness of
remembering, ”Nowness“ (no
time perspective)
• Original emotions (physiology,
behavior)
• Details without context, not
updated
• Easily triggered involuntarily
• Wide range of triggers, sensory
similarity, partial match
 Context for treatment
• Many people recover without help
• Treatment model developed for people
who become stuck in their recovery - focus
is on identifying and changing maintaining
factors
Cognitive Model of Persistent PTSD
(Ehlers & Clark, 2000)

The Puzzle
Anxiety is about future threat. PTSD is to do with
memory for a past event.
Solution
Individuals are processing the trauma and/or its sequelae
in a way which poses a threat to self.
Implications for Therapy
Aim of therapy is to process the trauma so it is seen as
time-limited, past event which does not necessarily have
global implications for one’s future.
 What maintains current threat:
Threatening Meanings
• Negative appraisals of event and/or
sequelae
– Fact that it happened
– Own response behaviour in event
– Initial PTSD symptoms
– Perceived response of others
• Idiosyncratic: can confirm or shatter beliefs
What maintains current threat:
Nature of Trauma Memory
• Reliving; ‘nowness’
• Intentional recall poor
• Poor elaboration of memory
• Poor integration with other
autobiographical memories
• Disjointed, confused, gaps
• Unintentional triggering of memory
fragments by wide range of low level
cues
 What maintains current threat:
Coping Strategies
• Post-trauma behaviours and processing styles
as a response to perceived threat
• Type
– Avoid: thoughts, feelings, places, people
– Substance use; Rumination; Safety Behaviours
• Effect
– Directly increase symptoms: thought suppression
– Memory not processed
– Can’t change threatening meanings
 Persistent PTSD
(Ehlers & Clark, 2000)
Nature of Trauma Negative Appraisal of Trauma
Memory and/or its Sequelae

Matching
Triggers

Current Threat
Intrusions
Arousal Symptoms
Strong Emotions

Strategies Intended to Control Threat/Symptoms

 Treatment Goals
Ehlers & Clark (2000)
Trauma memory Appraisals of trauma and/or
sequelae
elaborate
identify and modify
Triggers
discriminate

Current threat
intrusions
arousal
Strong emotions
Reduce…

Dysfunctional behaviours/ cognitive strategies give up/alter

Trauma characteristics. Cognitive processing
Prior experience/ beliefs during trauma

Nature of Trauma Negative Appraisal of Trauma

Memory and/or its Sequelae

Matching
Triggers

Current Threat
Intrusions
Arousal Symptoms
Strong Emotions

Strategies Intended to Control Threat/Symptoms

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-20 -10 0 10 20 30 40 50 60 70 80 90 100
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You can do CT-PTSD in routine
clinical settings
• N=330; 57% interpersonal violence; 56%
women, 44% ethnic minority; ave 3 years
post trauma
• PDS
• 14/330 (4.3%) get worse
• RCT criteria (d=1.84; drop out 11%) vs
non-RCT (d=1.11; 16%)
• Drop out related to experiece (10 vs 18%)
 You can predict outcome...
Moderators (treatment works less well if present)

• Long-term unemployment/ severe social problems

• Never married
• Needs treatment for multiple traumas
• Past suicide attempts
• History of substance dependence
• Duration since trauma

Nonspecific predictors (higher scores if present, but does not affect

treatment effect)
• Comorbid depression
• Comorbid agoraphobia
• Comorbid pain
• Comorbid personality disorder
• Dissociation
 Therapy context
• Safe environment – practically (room, 90 min
sessions) and empathically
• Therapist comfortable with detail
• Up to 12 weekly sessions (plus up to 3 monthly
boosters)
• Tape of each session, patient listens to tape as
homework
• Weekly questionnaires to track improvement
• Belief ratings!
 Assessment
• Current problems and symptoms
• Description of event (& appraisals)
• Impact on life (& appraisals)
• Co-morbidity
• Prior trauma
• Goals
 Assessment tools
• structured interview
– CAPS; SCID
• questionnaires
– IES; PSS-SR; PDS; PTCI
 Cognitive assessment
• Cognitive themes
– Intrusions
– PTCI
– Worst moments / hotspots
– Most difficult since
– Self, world, others
– Misinterpretation of symptoms
• Maintaining factors
– Fragmentation of memory
– Rumination
– Avoidance
– Safety behaviours
– Numbing (inc substance use)
– Thought suppression
 Treatment Goals
Ehlers & Clark (2000)
Trauma memory Appraisals of trauma and/or
sequelae
elaborate
identify and modify
Triggers
discriminate

Current threat
intrusions
arousal
Strong emotions
Reduce…

Dysfunctional behaviours/ cognitive strategies give up/alter

Trauma characteristics. Cognitive processing
Prior experience/ beliefs during trauma

Nature of Trauma Negative Appraisal of Trauma

Memory and/or its Sequelae

Matching
Triggers

Current Threat
Intrusions
Arousal Symptoms
Strong Emotions

Strategies Intended to Control Threat/Symptoms

 Initial interventions
• Normalization/Education
– Symptoms, emotions, strategies
– Procedures, situation etc
• “Reclaim life”
– Activities previously valued/enjoyed
– Strengths / resilience
– ‘time-code’ in memory
• Thought suppression
 Treatment Goals
Ehlers & Clark (2000)
Trauma memory Appraisals of trauma and/or
sequelae
elaborate
identify and modify
Triggers
discriminate

Current threat
intrusions
arousal
Strong emotions
Reduce…

Dysfunctional behaviours/ cognitive strategies give up/alter

 Why work with trauma
memories?
• access meanings
• restructure meanings
• behavioural experiment
• memory reconstruction / elaboration
Ways of being memory focused
• Talking about what happened
• Reliving
• Written narratives
• Timelines
• Stimulus discrimination (then vs. now)
• Site visit

• So both imaginal and in vivo ‘exposure’

 Rationale for reliving
• conveyor belt
• overfull cupboard
• jigsaw puzzle
• new type of memory

• (habituation)
 How to do reliving I
• Patient
– As realistic as possible
– First person
– Present tense
– All senses
– Start before and end when safer
• Therapist
– Manage expectations
– Supportive
– Watch for avoidance behaviour
– Cue in information
– Ratings of emotions and vividness
– Focus on significant emotional content
 How to do reliving II
• After
– Any changes?
– Anything surprising?
– Holding back?
– Worst moments and meanings?
• Listen to tape
• Written account
 Situation Cognition Emotion

Y-fronts removed at They’re going to shoot me Terrified

gunpoint and kill me.

Get an erection when I must have wanted this to Ashamed

penetrated happen. I must be gay.

Left on floor at end I should’ve known this Guilty

would happen. It’s my
fault.
 Situation Cognition Emotion Update (“what I
know now”)

Y-fronts removed at They’re going to Terrified They don’t shoot

gunpoint shoot me and kill me. I don’t die.
me.

Get an erection I must have wanted Ashamed It’s a normal

when penetrated this to happen. I physiological
must be gay. response. It doesn’t
mean I wanted it to
happen. It doesn’t
mean I’m gay.

Left on floor at end I should’ve known Guilty It’s not my fault. I

this would happen. I couldn’t’ve known
t’s my fault. what was going to
happen. [They] are
to blame. They are
bad people.
 Updating trauma memory I
• The worst didn’t happen
• Belief: “I’m going to die

Situation Thought / Feeling / Restructuring

meaning at time emotion at “what do you know now? Emotion Emotion
of trauma time of trauma In reality what is the rating rating
case?” before after

See gun I’m going to die Fear I don’t die 50 5/10

Guy comes round I’m going to die Fear 50 0

side and says
“Abacha man we I won’t see my Sadness I see my son again 50 0
don’t want you here.” son again.

Hit, kicked, hear I’ll be killed Fear I survive 30 0

bang.
 How to tell ‘hotspots’ in reliving
• Affect change
• Avoidance
– Change in tense & person
– Leave parts out
– Go through parts quickly
• Ask for worst moments
 It’s not only fear...
• Holmes, Grey & Young (2005); Grey & Holmes (2008)
• Several worst moments in a trauma
– Mean = 4.8 (2.4); range 1-11
• Intruding images are usually of hotspots
– 78% of all images match hotspots
– 86% of main intrusive images match hotspot
• It’s not just fear
– Full range of emotions experienced in hotspots
– Only 42% emotions in one study were fear, helplessness or horror. 52% in
other study.
• Cognitive themes also vary
– More than half of hotspots are related to psychological threat rather than
physical threat
– E.g. I’m useless, it’s my fault, I’m all alone vs. I’m going to die
 Updating trauma memory II
• “I’m trapped”
• Physical movement to update
• (not all meanings shown in table)

Situation Thought/meaning Feeling Update

Fingers inside me I’m dirty and Disgust It’s not my choice. I don’t want
horrible to be here, it’s him, I’m not dirty
and disgusting, he was doing
something disgusting.

Inside my mouth I’m trapped, I Fear and

can’t do anything helplessness I was trapped then but I’m not
now [stand up, move arms].
 How much reliving?
Ehlers et al Ehlers et al
(2003) (2005)
Sessions 10.5 + 2.7 9.0 + 2.4
Sessions with any 3.5 3.3
reliving
Total minutes of 90 83
reliving over treatment

• Reliving integrated with cognitive and behavioural work

over treatment
• Reliving used to identify and restructure key meanings
• Doesn’t include other forms of memory work in session,
or any homework done
 Is CT-PTSD acceptable?
• Drop out rates

• Trials (Ehlers et al, 2003, 2005, 2014)

– 0/28; 1/34; 1/30; 1/31 (2.4%)

• Routine NHS care (Ehlers et al, 2013)

– 46/330 (14%)
 UPDATING TRAUMA MEMORIES
Step 1: Accessing the worst moments of trauma

• Revisiting trauma
• Function 1: Access problematic meanings and
change them in the memory (rather than as a mere
intellectual insight).
• Function 2: Generate information that helps put
meanings in perspective (e.g., reconstruct
sequence of events, access “forgotten” details)
• Function 3: For some patients, behavioural
experiment to test beliefs about catastrophic
consequences
UPDATING MEMORIES PROCEDURE Continued
Step 2: Identify information that provides evidence against
appraisals of worst moments or predictions made at the time
a. may be information from course of the event, e.g.,
- outcome was better than expected (e.g., patient did not die, is not paralyzed)
- contradictory information from course of event (e.g., compliance with
perpetrator because he had knife)
- realization that an impression, perception was not true (e.g., toy gun),
sometimes expert advice needed (e.g., car explosions, electric shock)
b. may be result of systematic cognitive restructuring
 UPDATING TRAUMA MEMORIES- continued
STEP 3: Insert the updating information into the relevant part of the
trauma memory:

- Produce an updated version of written narrative, with new

meanings (“I know now that...”);
- Incorporate restructured meanings into reliving while holding
hotspot in mind by one or more of the following (whatever most
convincing)
- verbal reminders
- images
- incompatible actions
- incompatible sensations

4. After all identified hotspots have been updated, probe for further
hotspots with “diagnostic” complete reliving
 Dissociation
• compartmentalization of experience; a
type of attention
• daydreaming, numbing, spacing out,
unreal or dreamlike, out-of-body
experiences, flashbacks
• dissociation during traumatic event
• dissociation as a symptom after traumatic
event
 Dealing with Dissociation
• Prevents processing of new information
• Provide information / normalisation
• Grounding strategies – to maintain awareness of ‘here and
now’
– triggers, first sensations
– object, image, phrase
• Reliving work
– Identify moment of dissociation
– imagery techniques
– graduated: eyes open, written
– Using grounding objects and updated info on to tape
• Precautions / action plan for self-harm
 When not to offer CT for PTSD
• When person doesn’t have PTSD
• When person can’t process info (drunk,
depressed, head injury) how to adapt
• When person is at risk of imminent harm
• When person is more pre-occupied with
other issues
Why not into the memory work?
• Practical factors
• Therapist factors
• Patient factors
 Reliving: therapist factors
• Becker et al (2004)
– 83% of 207 psychologists never opted for exposure
therapy to treat their PTSD patients.
• Van Minnen et al (2010)
– imaginal exposure seen as more credible than
medication or supportive counselling but underutilized
– Majority of professionals undertrained.
– Fears of symptom exacerbation and drop out.
• Your Concerns?
• How to test?
 Effects on the therapist
• Countertransference
• Emotional exhaustion / ‘compassion fatigue’
• Secondary PTSD / ‘vicarious traumatization’
• Change in belief systems
– Watch behaviours
• But see Elwood et al (2010)
• Secondary posttraumatic growth
 Looking after yourself
• Supervision
– Formal; informal
• Caseload mix
• Use CBT…
• General strategies
– Diet, exercise, social contact, moderate alcohol use,
etc.

• Craig & Sprang (2010): “utilization of evidence-based

practices predicted decreases in compassion fatigue and
burnout, and increases in compassion satisfaction”
 Written narrative
• In session and / or homework
• Particularly helpful when:
– Confusion re. temporal order
– Prolonged duration trauma
– Strong dissociation
 Example of narrative
• “They are holding me down and one of
them penetrates me. I can feel pain. I get
an erection. I feel really bad and think that
this must mean that I am gay and want
this to happen. But I know now in reality that this
is a normal physiological response and it does not
mean that I am gay or wanted it to happen. They
continue…”
 Updated Memory
I’m driving along the middle lane, the van is losing stability, it makes a violent
veer to the right – why does it do that? I feel confused and scared. Now I
know the tyre had blown out and we were driving on the wheel. I try to get
it to drive steady and come back to the middle lane. I’m fighting with the
steering with all my strength – completely pull it, we’ve picked up speed ,
we’re heading straight for the embankment, John said, “This is it!” and we
both thought, “this is it, we’re going to die. I felt I had no control over the
van. I didn’t know what was happening. I was 100% convinced I was
going to die. I thought, “ I’m making a mess of it” and thought John would
have done better. I now know I had more control than I thought and I
made the situation safer by pulling in out of the way of the other traffic. I
avoided another collision and it could have been a lot worse for John and I
if we’d been hit by the other transit or the central barrier. We veer to the
embankment. I feel I’ve lost control. We hit the embankment, the
windscreen smashes, we’ve been thrown all over the place, I thought I
was going to die. I now know I didn’t die, I’d got the van out of danger, it
had swung round, gone up the side, pivoted on the front passenger side
edge and come to a stop on the edge of the road, looking towards the
traffic.
 Reliving vs Narrative
Reliving Narrative
• More direct access to • Confusion about
emotions temporal order
• Access important – Loss of consciousness
details – Alcohol / drugs
• “Felt change” in • Long trauma
meaning – to identify hot spots in
long sequence of events
• Strong dissociation
– no contact to present
reality
 Prolonged duration
• Written narrative
• Relive worst periods
– What intrusions
– Hardest to write about
 Multiple events
• Identify key re-experiencing symptoms, key
meanings, and contexts
• Start with developing a timeline
• What to go for first
– What intrusions?
– Client preference
• More than one at a time?
– Common cognitive themes
– Explicitly encourage generalization
• Narrative Exposure Therapy
 Timeline
• Facts, context (social, occupational etc), i.e.
key events not just trauma
• Re-experiencing symptoms
• Beliefs
• Where to start and stop
– Birth? When traumas began?
– When traumas ended? Present day? Future?
• Be flexible and creative
– ‘enlarge’ sections, use photos etc
 Treatment Goals
Ehlers & Clark (2000)
Trauma memory Appraisals of trauma and/or
sequelae
elaborate
identify and modify
Triggers
discriminate

Current threat
intrusions
arousal
Strong emotions
Reduce…

Dysfunctional behaviours/ cognitive strategies give up/alter

 Dealing with Intrusions
• Intrusion can be affect without recollection
• Identify the triggers
– Diary
– Detective work for matching stimuli: often low-
level physical cues such as colour, sound,
movement or internal cues (Batman)
• Discriminate NOW vs THEN
– Break link between trigger and memory
 Discriminating triggers
• Trigger exact bit of memory
– Variety of cues, one at time
• Discriminate then (similarities) vs. now
(differences)
• Behavioural experiment
• Practise
THEN NOW
• Dark – can’t see • Dark – can’t see
• Feel bad • Feel bad
• Group of people • One person
• People attacking • People helping
• Couldn’t open eyes • Can open eyes
• Outdoors • Indoors
• Hand broken • Hand OK
• Knife in mouth • Chewing gum in mouth
• Can’t move • Can move
THEN NOW

• Touched in particular way • Touched in same way

• Couldn’t move • Can move

• Didn’t want it to happen • I’ve chosen to be with [partner]
• No choice what he did • I have control over what
happens
• Couldn’t speak • Can speak
• I was very very ill • I’m healthy
• He’s sick, not normal • [partner] is normal
• Just 20 then • 30 now
 Stimulus Discrimination
• https://www.youtube.com/watch?v=m0Je6
z24wP4
• Using technology in session
 Revisiting the site
• Relive and reconstruct
• Time-code on memory
• Then vs. now
• New information
• New memories and meanings
• Behavioural experiment
• Watch for safety behaviours
 Site visits
• Google street view
• Other sources: internet,
friends/family/colleagues, photos, official
records, people still there
• ‘Virtual Iraq’ in US
 Virtual site visit
• https://www.youtube.com/watch?
v=LPfdbyA3198
 Treatment Goals
Ehlers & Clark (2000)
Trauma memory Appraisals of trauma and/or
sequelae
elaborate
identify and modify
Triggers
discriminate

Current threat
intrusions
arousal
Strong emotions
Reduce…

Dysfunctional behaviours/ cognitive strategies give up/alter

 Cognitive techniques
• Socratic questioning
• Evidence for and against
• Advantages / disadvantages
• Pie charts
• Surveys
• Information from other sources, e.g., police,
significant others, statistics
• Guided imagery
 Overgeneralized threat
• “bad things can happen at any time”
• Avoidance
• Other Safety Seeking Behaviours
– Checking / hypervigilance
• If I keep alert I’ll stay safe
– Not alone / over protect others
– Avoid risks / extra precautions
 Addressing overgeneralized
threat
• Feels more dangerous due to trauma
memory
• Objective risk not changed
• Evaluate / calculate actual risk (sequential
probabilities)
• Identify selective attention to danger cues
and role of hypervigilance
• Behavioural experiments
 Sequential probabilities
• Chance I’ll have an accident - ‘feels’ 80%
• Times per week driven down that road: 10
• How long lived there: 4 years
• Years x weeks x occasions: 4 x 50 x 10 = 2000
• Number of accidents: 1
• Probability: 0.05%
• How feel isn’t a good guide and is fueled by the nature of the
memory.
• Any change in actual likelihood of accident because had one?
– Safety behaviours: e.g. looking in mirror may increase
probability
• Can ask about other accidents and also get DoT official statistics
 Anxiety and threat

Anxiety is proportional to the perception of danger; that is

perceived perceived
likelihood X “awfulness”
it will happen if it did
___________________________
perceived
coping ability
+ perceived
rescue
when it does factors
 How I am now Partner How I’d like to be How I used to be

Taking no risks at Very risky behaviour.

all. Never leave the No sense of danger
house?
 Appraisals of what happened
• What did or didn’t do
– guilt
• The kind of person you are or aren’t
– shame
• What others did or didn’t do
– anger
 Shame and guilt
• shame: a sense of oneself as defeated,
deficient, exposed, failure, worthless,
inadequate (see Gilbert, 1997)
• humiliation focuses on harm done by
others; in shame focus is on the self
• guilt is about what you do but shame is
about who you are (for guilt see Kubany
work)
 Risk factors for shame/guilt
• pre-existing vulnerability / prior history
• negative outcome
• personalisation
• breach of intimacy barrier
• lack of external sources of information
• duration of event
• actions / judgements
• making decisions - impossible choices
 Why guilt in PTSD
• About
– Fact event happened at all
– Fact person survived
– What did / didn’t do during event
– Failure to overcome symptoms
• Cognitive biases – leading to overestimation of personal
responsibility
– Hindsight bias
– Discount other explanations and positive actions
– Superhuman standards
– Violation of personal standards
– Emotional reasoning
 Working with guilt
• Hindsight bias
– socratic questioning; national lottery
• Responsiblity
– pie chart; child & cooker
• Violation of personal standards
– “I should / shouldn’t”; label emotional
reasoning
• Imagery – from observer perspective
 Exploring guilt
• What other explanations might there be?
• Who else was involved?
• How much power did you actually have to influence what happened
• How did things appear to you at the time?
• What was the reason for you acting as you did, at the time?
• How could you have known what was going to happen?
• How much time for reflection and choosing the best course of action
did you have?
• What was your emotional and physical state at the time?
• What did you do that was helpful?
• If this was another person, what more would you expect of them?
How would you explain their behaviour?
• Apart from your feelings, what else might you take into account
when considering how you acted?
Pie chart
company he keeps

Mike

new girlfriend

old boyfriend

person who pulled

trigger
me
 Why shame in PTSD
• what happened
• how reacted at time
• development of symptoms
 Shame

Misinterpretations about:
• How others will perceive the trauma
• How others will perceive one’s actions during
the trauma
• How others will view one’s symptoms

Important to address because:

• Shame causes people to withdraw or avoid
and can therefore maintain symptoms
 Identifying shame
• Behaviour in and out of session
– Feel “awkward, silly, exposed”
– Labels “weak, useless, inadequate”
– Look away, freeze, aggression
• Questionnaires
• Information sheet
• Trauma characteristics
 Impact on therapy relationship
• Good relationship
– Threat of ‘discovery’ (of something bad) so
keep safe by withdrawing
– ‘if I really tell you then it’ll spoil it all’ –
contaminate the relationship
• Aggressive patients
– I’m not going to be shamed –anything to
prevent
– “describe what you were feeling just then”
 Initial interventions
• Therapist reaction: empathic, trustworthy etc
• break secrecy, active validating approach,
bring up topic
• Normalize & educate
• refocusing attention (stops internal shame
spiral)
• focus with effort outside self
 Working with shame
• identify internal bully, foster compassionate
friend (Paul Gilbert stuff)
• hanging up phone on bully, foster self-affirmation
• cognitive techniques: meaning, schema, core
beliefs etc
• discuss with others
– Evidence re what will others think
• surveys
 Survey
1. If you were walking in London late at night and
you saw a man crouched on the ground in a foetal
position trying to protect himself while a group of
other men were kicking and punching him, what
would you think of the man who was being
beaten?
2. Would you think he was weak?
3. Would you think he was inferior?
4. Would you think less of him?
5. What would you think of the 12 men who were
attacking him?
 Dealing with anger
• Empathy first
• Who/what angry at
– Wants to be heard
– Allow time to discuss / vent
– Letter
• Present frustration
– Problem solving
– Reclaim life
Anger at behaviour of others
during and after trauma
– Examine and restructure distortions taking all
context and info into account
– Explore explanations for person’s behaviour –
challenge assumptions re malicious intent if
appropriate
– CT re standards (should’s)
• black/white thinking, rigidity
– Humiliation (Gilbert)
 Giving up anger
• Who wins?
• Conscious decision to stop someone else
controlling your life (forgive?)
• Challenge assumptions re. letting anger go
– “if you weren’t angry what would that mean to
you?”
– E.g. it will be forgotten, he will have got away
with it etc
 Kleim et al (2013)
• Ehlers et al (2013) routine NHS care (n=330)

• Negative trauma-related appraisals and PTSD

symptoms both decreased significantly during treatment
• Change in negative appraisals predicted symptom
change in the following week, independent of a general
decrease of each variable over time.
• This prediction was not significant in the other direction:
PTSD symptom change did not predict negative
appraisal change in the following week
• Change in meanings most important

• Can change meanings in various ways

• Accessing the memory helps you identify

and update meanings
 Restructuring images
• Peritraumatic vs secondary
• Veridical vs non-veridical
• Fragments lack context
• Context spontaneously from reliving
• Context from imagery techniques
– Run past worst point
– Watch from new perspective
– Explore actions not taken
– Bring in other information
– Enter body – dissociation
– Incorporate spiritual viewpoint
– THEN vs. NOW
 Permanent change
• What is and what isn’t permanent
• Depression
• Physical injuries / pain
• Losses
• Identify and work with meanings
 Life is full of crap (80%) - BDI 40
• Accident • Job going well
• New partner
– Financial
– Relationship’s existence
– Physical injuries – Committed to her
– PTSD • I’m able to commit and love
• Loss of enjoyment • Nice home
• Have Car
• Loss of convenience
• Cadets
• Divorce – Making a difference to lives
• Financial aspects – Them getting pleasure
• Work • Divorce settled
• • Treatment
Life feels hard
• Pleasurable activities
– Films, books, music, countryside
• Distilled moments of enjoyment
 Physical injuries
• Predictor of poorer treatment response
• Meaning of injury (now and future)
• Can maintain ongoing threat?

• Social phobia treatment techniques

• Address distorted sense permanent change
• Grief work for losses
 Bereavement
• Blocks natural grief process
• Dead person is “stuck” at time of trauma
(nowness of memories, appearance of
dead body) and meaning of that
• Regrets about things said/ not said
• Often need to discuss beliefs about
afterlife

• “Complicated grief”
 Interpretation of
Physical Sensations / Panic Attacks
• Can interfere with willingness to do reliving
• Often needs to be addressed before trauma
memory work
• Information about trauma memory or assumed
damage to body during trauma often helpful
• Vicious cycle of panic, behavioural experiment
• Set up reliving as experiment
 Blueprint
1. How did your problems develop?
2. What kept your problems going?
3. What did you learn in the course of therapy
that was helpful?
4. What were the most unhelpful thoughts? What
are the alternatives?
5. How could you build on what you learned?
6. If you experience another traumatic event in
your life, what would you do differently and
how would you try to manage it?
 Overall structure of treatment
• Make sure it is PTSD
• Provide safe environment
• What’s stopping recovery
• Initial interventions – normalising ++
• Memory-focused work
• Work on meanings
• Work on behaviours
• [interweave these]
• Keeping well
 Overall structure of treatment
Session Likely activity
Diagnostic assessment

#1 (cognitive assessment) Outline of event, normalize, reclaim life, rationale for reliving
#2 Reliving; identify hotspots and meanings
#3 Address one cognitive theme at a time
#4 Reliving with restructuring / updating trauma memories

#5 Continue to address cognitive themes and update memory

#6 In vivo exposure / Discriminating triggers (then vs. now)

#7 Continue to work on cognitive themes, triggers and update memory as

required
#9 On ave. when site visit occurs
• Reclaim life a strand through every session
#10 Start blueprint if not already done so
• 12 weekly sessions – and follow up
• Not all techniques with everybody or in exactly this order – flexibility based on
personal model of PTSD
 Learning Objectives
• Be able to assess for diagnosis of PTSD
• To understand a cognitive model of PTSD and how this
links to treatment
• To know when and when not to offer CT-PTSD
• To understand the key initial interventions used in CT-
PTSD
• To be able to provide a rationale for patients for
discussing the traumatic memories
• To know which memory-focused techniques might be
most helpful when
• To know how to use your full range of cognitive behaviour
therapy techniques to address cognitive themes in PTSD
 Mood Anxiety and Personality
Clinical Academic Group (CAG)

nick.1.grey@kcl.ac.uk
www.kcl.ac.uk/cadat
www.national.slam.nhs.uk/cadat
@CADATLondon
@nickdgrey