Cognitive Therapy for PTSD
Please note all client examples are fictional!
To understand the cognitive model of PTSD, unfortunately you will need to down several pints of espresso coffee and attempt to read some of the very complex theoretical papers written by Chris Brewin. The basic gist (or as much as I can get my head around it anyway) is that our brains process information differently during traumatic events. At a certain level of stress the hippocampus which is responsible for processing thought, context, time, location, and analytical thinking starts to go offline, leaving only an extremely active amydala which deals in emotional processing and sensory experience to process the event. As a result, trauma memories have a different feel to them from normal memories. They are easily triggered by sensory reminders of a trauma (e.g. particular colours, sounds, smells etc) and are sensory and emotional in quality. When a trauma memory is triggered it feels like the trauma is happening again and the physical sensations, emotions and meanings that the person experienced at the time are re-experienced intensely in the present. Many of my clients have described this as a highly confusing experience of having ‘one foot in the present and one foot in the past’ but for some it can take the form of a completely dissociative experience where they lose contact with the present altogether and start to act as though the trauma was recurring. The person can become hypervigiliant to threat and because it is such a horrendous experience, they may go to great lengths to avoid any reminders of the trauma.
This is a normal experience following a traumatic life or psychological integrity threatening event. Most people have these experiences for several weeks following a trauma. However, if a person has not started to recover spontaneously by about a month after a traumatic event, then they seem to be unlikely to make substantial improvements without intervention.
Ehlers and Clarke (2000) proposed an information processing based cognitive model as to why post traumatic stress persists. It is proposed that factors present at the time of the event (e.g. lack of control, intense fear, not understanding what was going on) impacts on how the person appraises the trauma (peri-traumatic appraisals) and it’s sequelae (post-traumatic appraisals). For example, a loud noise following a car accident may sound like the car and the people inside are being crushed to death. (It may be that the firefighters are actually cutting the roof off to get people out and that they are highly skilled and able to do this as quickly and safely as possible). The person’s peri-traumatic appraisal may be: ‘Me and my children are being crushed to death!’ However, because the memory returns as instrusive, sensory and terrifying it is difficult for the person to update their peri-traumatic appraisals with the new information (that they did not die and the noise was the sound of fire fighters rescuing them). Unsurprisingly, the person may go to great lengths to avoid reminders of the trauma and to push such memories from their mind (e.g. avoiding driving, substance use, thought control strategies). However, this serves only to maintain the sense of current threat by inhibiting information processing. Post-traumatic appraisals include new meanings about the self or others. I can easily count the number of people I’ve worked with with PTSD who do not believe that there is something mad, weak or otherwise defective about them that they are suffering from the condition (a big fat ZERO!) People also frequently report a sense that the world is unfair or that other people are not who they thought they were. (This is particularly true for interpersonal trauma such as assaults). Similarly, PTSD creates a host of ongoing difficulties for the individual as they feel different and distant from others, perhaps reduce valued and enjoyed activities and come to terms with tragedies that have unfolded as a result of the trauma (e.g. bereavement, disability, illness, financial loss etc.)
Trauma focused cognitive therapy is specifically focussed on trauma related cognitions at the time of the trauma (peri-traumatic appraisals) and following the trauma (post-traumatic appraisals). Peri-traumatic appraisals are seen as being stuck in time, accessed via the emotional memory system where imagery, emotion and the sensory processing dominate. The memory is decontextualized from from time and other information, so the meanings the person had at the time (e.g. I’m going to die) remain a present and persistent threat in the person’s mind.
A solid formulation is essential in helping the client to understand what they are going through. Often, this in itself begins to alter post-traumatic appraisals such as, “I’m crazy”, “I’m losing my mind” or “I will never recover”.” A good formulation sets the scene for starting trauma focused therapy and very importantly, it enables the client to feel understood and to have confidence in the therapist.
Traumatic memories lack a time-tag, therefore it is easy for the client to get caught up in the emotions and sensory experiences of the trauma. However, there are simple methods that can help substantially with reducing the intensity of the experience by helping the person to pay attention to the present. This can be done by either paying attention to or creating a strong sensory experience in the present that is not consistent with the traumatic event. These techniques are introduced early on. In fact I use them in the first session with most clients I meet who are experiencing flashbacks or intense intrusions because it can help to foster hope and give the client some mastery over the experience. They can also be taught to other staff (e.g. ward based staff, CMHT colleagues) and the client’s family/friends to help them better understand and respond to flashbacks.
It is helpful to find out as much as you are able to about the sensory experiences the client has during flashbacks, nightmares or intrusions (but take your time – people with PTSD find discussing trauma very upsetting and you will need to go at a gentle pace and allow them to develop trust in you before going too far). Identifying the dominant sensory experience can help guide which grounding/anchoring techniques to use.
Get the client to open their eyes (a lot of people close their eyes during flashbacks because they don’t want to see what is happening – remember, for the person it really seems like it is happening again) and look around the room. Some people like to have something to look at. This can be an object, preferably something that holds a positive meaning for the person. Helpful things can be something that reminds the person the trauma is over. For example, a picture of a close friend or family member or a pleasant event that happened since the trauma, or pictures of children who are now older. In the days of mobile phones having videos, clips of friends and families, or even you as the therapist can tackle both verbal and auditory senses. Some of my clients have had clips of their children or a party or a friend messing around in a way that makes them laugh. Others like to have a reminder – maybe they record themselves or get a friend or get you to record a message along the lines of: It happened a year ago, you survived, you are safe now etc. This can tackle both visual and auditory memories.
If the trauma happened a long time ago (e.g. when the client was a child) or the client experiences themselves physically as though the trauma was happening (e.g. being covered in debris, blood or something else) then it can be very helpful to look in the mirror. For some of my clients, I actually bring a mirror into the therapy room every time we meet, especially if we are going to do anything that may trigger an intense intrusion or flashback.
This could include listening to what is happening in the room if the client is able to tune into it. However, in my experience this can sometimes be difficult because noises at the time of a trauma are often extremely loud. Some people find loud music (through headphones if not in the room) can be helpful but make sure the music is carefully selected so that it does not trigger anything. Same goes for television – it may be more helpful for the client to have a series of DVDs they can watch to hand than just to switch on to a random channel which could have triggering material. Talking out loud can help – and asking other people to talk to the person can help. This is usually best done by gently reminding the person where they are, that the trauma is over, that they are safe. A soft and supportive voice is often all it takes.
Clients can use touch to orientate themselves to the here and now. This can be done by paying attention to what can be felt in the present. E.g. the feeling of your legs on the chair, your feet on the floor, your back against the back of the chair. You can ask the client to rub their legs or their arms (this can be especially helpful if the client experienced a physical threat and feared or experienced severe injury because it can help the client to see that their body is still whole, or what the actual damage was and how they are in the here and now). Clients may like to have an object they can both touch and look at (e.g. a stress ball). Other helpful things can be taking shoes off and rubbing feet against the floor or having a supportive person touch them (in an appropriate place – obviously!) Different therapists have different views on this, but I have no problem with using supportive touch (e.g. on the arm, or holding a client’s hand) to help keep a client in the here and now during trauma focused work. It goes without saying that you only do this if the client has agreed to it and finds it helpful. Bear in mind that this can be an extremely unhelpful approach if a client has experienced a sexual trauma because touch can also act as a trigger for a flashback. This is more complicated for male therapists working with female clients so tread carefully, but it can be helpful. It may be particularly helpful for clients’ close family and friends to use – but always and only with the client’s agreement.
Smells can be extremely vivid during flashbacks e.g. the smell of blood or burning rubber or the breath of an attacker. Smells can elicit strong memories: when you go back to your old school and experience the musty smell of the old locker room, what memories does that conjure up for you? So you can use strong smells to help the client orientate to the here and now. To see just how powerful this can be, close your eyes and try to create an image of something you are familiar with (e.g. your bedroom or living room). It’s pretty easy to do. Now smell something strong and try to do the same thing. What happens?
Helpful tools include include perfumes or hand creams and aromatherapy oils. (However, it may be necessary to change the smell every so often if it starts to get associated with an intrusion, so perhaps suggest to clients that they don’t choose their favourite smell!) Strong sweets (e.g. menthol drops) can tackle both taste and smell at the same time. I was introduced to Mackenzies smelling salts a while back. I am not joking when I say it is like being punched firmly on the nose but if someone is getting really stuck in a flashback, the intense smell can often bring them around. You can buy them in Boots for a few pounds. Try them if you dare!
With nightmares you need to think about how to adapt the bedroom to help the client ground themselves when they wake up. This could include a nightlight, photographs in easy sight, an ipod with suitable music on it. Also, it tends to help to get out of bed, do something else, calm down and wait until you are sleepy again before starting this.
Isn’t this just distraction?
It is important to note that the point of these exercises is NOT distraction. Clients are encouraged to turn towards their experience, recognise what is happening and then re-orientate themselves to the here and now. If someone is having a flashback, I do not want them to run away or push it out of their minds (because the more you try not to think about something, the more you think about it a la the white bear experiment). I want them to stop, I want them to orientate to the here and now and ideally I’d like them to work out what triggered the flashback or intrusion and see if they can understand it in a different way. For example, if a client sees a red, sticky substance on the floor and thinks that it is blood or gore, then I’d want them to stop, use grounding techniques and then once they are calm, I’d like them to look at the red sticky substance and discover that it is a blob of tomato ketchup. The primary aim is to help the client orientate to the here and now, not to push away or avoid flashbacks. We know that pushing these experiences away, tends to make them come back with a vengeance. However, orientating to the here and now and approaching the trigger helps the client to understand what is going on and update their mind that the past is in the past and they are now in the present.
I encourage my clients with PTSD that therapy can be as hard going as it is effective. So it is a really good idea for them to do as much as possible to help themselves be in as good a place as possible by eating well, building in pleasurable activities into their day, getting support of family and friends (if possible) and getting any medical conditions treated. I’d like to say it helps to have a good sleep routine, but my experience is that PTSD often comes with chronic sleep problems and clients may be chronically exhausted. Whilst trying sleep hygiene techniques won’t do any harm and may be helpful, I think it is also important to be realistic, that when your body is in a state of constant hyperarousal, good sleep just might not happen. Sometimes sleep problems are easier to address later in therapy once the client has established a better sense of safety. But certainly try and basics like limiting stimulants such as caffeine and nicotine, which often aren’t obvious to people.
I don’t bother with relaxation strategies for most people with PTSD because it is often just too difficult for them to do given the very high level of emotional arousal they experience. But I do encourage active relaxation such as doing pleasant activities and exercise.
Getting your life back
PTSD often comes with a much more limited range of work and social opportunities. Setting small but meaningful SMART goals can really help a person start to reclaim or rebuild aspects of their life. Simple things like starting to do old hobbies again, getting in touch with friends, reducing social isolation can be very helpful places to begin. As therapy progresses, more attention is paid to helping the client with depression, anxiety and rebuilding their lives using standard cognitive approaches.
Working with memories - Reliving
Edna Foa tackles this using prolonged exposure. The client is asked to recount the trauma in detail. A recording is made and the client is asked to listen to the recording on a daily basis. This approach draws on a behavioural rationale of exposing the person to the trauma, until they habituate to the threat and the fear reduces. It is primarily based on a behavioural exposure and habituation rationale. However, it is time consuming and peri-traumatic appraisals are often associated with emotions other than fear including shame, embarrassment, horror, sadness, anger etc. These emotions are less likely to respond to an habituation approach. Cognitive therapists have adapted this method to tackle peri-traumatic appraisals more directly (Grey, Young & Holmes, 2002). This includes asking the client to relive the trauma whilst enquiring about what the person is experiencing. This can allow peri traumatic appraisals to be identified and worked with. Some peri-traumatic appraisals update automatically in reliving. For example, someone who blames themselves for letting an attacker into their home might remember in reliving that prior to the trauma the attacker was a trusted friend or family member and that they thought he was paying them a friendly visit, just like he had many times before so it was completely natural for them to invite a friend in! Or a man who was forced to watch his wife being tortured who blames himself for not helping can realise that he was tied up at the time or that he had a gun to his head. I use reliving and restructuring within reliving and generally take 3-4 treatment sessions to do it in. I’ve not found it necessary to do any more reliving than that for a single trauma. My clients usually listen to a tape between sessions, but some (particularly those with more complex, repeated traumas) just won’t go there outside the safety of the therapy room and I can live with that.
The client goes through the memory and identifies particular hot spots where their emotion is strongest and what their appraisals were at the time. These may spontaneously update and the client may realise a different explanation. If (as is more usually they case) they do not spontaneously update, then all the usual tools of CBT like socratic questioning, finding alternative thoughts and using behavioural experiments can be used to reappraise peri-traumatic meaning. Finding out information (e.g. looking at newspaper articles from the time, asking a medic to explain why medical staff in A&E conducted painful procedures that the client took to mean they didn’t care or that they were torturing him) to help the client understand what happened and make sense of it is very helpful.
When the client has reappraised their hotspots, reliving can be repeated and at the “hot” moments, the therapist can interrupt the client and ask them, “What do you know now?” and the client can insert the new information or alternative perspective into their trauma memory. This can be done verbally. Other clients use more rescipting techniques. For example, they might bring their adult self, a compassionate image, a supportive partner or even the therapist into a childhood trauma to take care of the traumatised child and confront abusive adults. However, this is more in fitting with a developmental trauma approach than straight forward PTSD (Weertman & Arntz, 2007)
Reliving should never be attempted by someone who isn’t suitably qualified or who doesn’t have adequate supervision. It is a technically challenging and highly emotive approach to use.
Working with Memories - Narrative methods
A similar approach to reliving except that the client writes a narrative of their trauma, inserting updates as appropriate as a way of making sense and building the traumatic experience into their story to put it in time and context.
Do therapists get traumatised?
Occasionally but very rarely! Personal communication from Martina Mueller (Oxford Cognitive Therapy Centre expert on PTSD) is that she conducted a study with a doctoral student interviewing therapists about their experience of this approach and found that far from being traumatised by it, most therapists talked about the strong bond and warmth they feel towards their clients. My experience has been that it is not traumatic, but on the contrary, it is a deep privilege to be allowed to be with someone in the darkest moments of their lives. Judith Herman (1997) talks about the need to bear witness to the trauma. This in itself can undermine the shame and aloneness that many people with PTSD experience.
Of course, we should all look after ourselves, watch our caseloads (I avoid having more than 2 people using this sort of technique at the same time and try to balance seeing a client for this kind of work in one half of the day with an easier other half of the day). I don’t go straight home from work after trauma work – I need headspace, for me, that’s working out but we all have our own ways. Supervision is obviously invaluable. If I’m facing a particularly difficult session or series of sessions, I will make arrangements with a supervisor or supportive colleague who understands the approach to call them afterwards or to at least know that they are available should I feel the need to debrief.
The above information is primary focused on straight forward one off traumas. Many clients seen by clinical psychologists will have experienced repeated developmental traumas. This complicates the issue and care needs to be taken to ensure the person is in a safe place to do the work, has enough emotion tolerance and regulation skills before starting. Extra care needs to be taken. There is some excellent work emerging on using a gradual approach to this (Cloitre et al., 2010).
PTSD is changing - or at least, we are seeing it differently
In the DSM-V, PTSD will no longer be classed with the anxiety disorders because it is now widely recognised that it tends to come with a complex array of emotions including fear, shame, disgust, horror, anger etc.
Shame is a major issue for particular types of trauma, particularly sexual trauma (but certainly not limited to it). Anywhere that people feel that they are to blame for a dreadful event can lead to great shame for the person. There is some very interesting work emerging on this led by Deborah Lee looking at using a compassionate mind approach to enable a person to take a compassionate stance towards themselves There's a chapter in Grey (2009) on this.
Nick Grey - Case Book of Cognitive Therapy for Traumatic Reactions
Cloitre - Treating Survivors of Childhood Abuse
Judith Herman - Trauma & Recovery (Not specifically CBT but an excellent book!)
Clark & Ehlers (2000)
Grey et al. (2002) - Cognitive Restructuring within reliving
Weertman & Arntz (2007) - Imagery Rescripting
Chris Brewin's dual representation theory