1. Trauma-focused treatments are not suitable for complex/multiple trauma

One of the most common misconceptions we hear is that trauma-focused cognitive behavioural therapy is unsuitable for working with the experience of multiple or complex traumas. This observation is echoed in other studies, for example in van Minnen et al.’s (Reference van Minnen, Hendriks and Olff2010) finding that therapists perceive more barriers and are less likely to choose imaginal exposure for patients who have experienced multiple childhood traumas compared with a single incident trauma, particularly when they are also experiencing co-morbid depression.

Existing evidence does not support this misconception. For example, CT-PTSD remains effective when patients have experienced multiple traumas, with only a slight decrease in symptom reduction compared with single incident trauma (Ehlers et al., Reference Ehlers, Grey, Wild, Stott, Liness, Deale, Handley, Albert, Cullen, Hackmann, Manley, McManus, Brady, Salkovskis and Clark2013), although more time may be required in therapy. There is also evidence that a range of trauma-focused treatments are effective following childhood sexual abuse (Ehring et al., Reference Ehring, Welboren, Morina, Wicherts, Freitag and Emmelkamp2014) and for complex PTSD (a new diagnosis in ICD-11; World Health Organization; 2018), although further research is needed in this emerging field (Karatzias et al., Reference Karatzias, Murphy, Cloitre, Bisson, Roberts, Shevlin, Hyland, Maercker, Ben-Ezra, Coventry, Mason-Roberts, Bradley and Hutton2019). Treatment guidelines consistently recommend trauma-focused treatments, regardless of trauma type (e.g. American Psychological Association, 2017; International Society for Traumatic Stress Studies, 2019a; National Institute for Health and Care Excellence, 2018). Additional considerations are recommended for multiple trauma, such as allowing for more sessions and addressing barriers to engaging with trauma-focused treatment like substance misuse (National Institute for Health and Care Excellence, 2018), as well as for complex PTSD, for example the personalisation of treatment, including additional modules to address problems associated with complex PTSD (International Society for Traumatic Stress Studies, 2019b).

In CT-PTSD, there is a certain economy in addressing multiple traumas as the individual case formulation identifies links in meaning between different traumas (e.g. ‘no one can be trusted’, ‘I am worthless’, ‘people will look down on me if they knew what happened’), which can then be addressed together. Guided discovery leads to a re-evaluation of these appraisals, which is then used to update the most relevant linked hotspot. The therapist then facilitates generalisation to related hotspots from other traumas. Similarly, the formulation identifies appraisals and behaviours that maintain PTSD and co-morbid conditions such as depression or panic disorder, so that co-morbidity can be addressed in an integrated and focused way (see case examples in Ehlers and Murray, Reference Ehlers, Murray, Courtois and Ford2020; Ehlers and Wild, Reference Ehlers, Wild, Bufka, Halfond and Wright2020).

Therapists may also be concerned that trauma-focused treatments which involve reliving or narrative writing may not be suitable for very long or repeated traumas because recounting the whole trauma stories would take too much time in treatment or would be too distressing. However, the updating memories procedure does not require all details from the trauma to be recounted as it focuses on the moments of the patients’ traumas that are re-experienced and give rise to important threatening meanings about the self and the world. Hotspots are updated one at a time once their meanings are explored, and those with meanings that are straightforward to update (e.g. ‘I did not die’, ‘I can still walk’, ‘my body has healed’) can be addressed early in treatment without necessarily eliciting all other parts of the respective trauma. The emotional shift and reduction of re-experiencing after updating a hotspot may then motivate patients to disclose more details about others, e.g. those linked to self-blame and shame.

2. Stabilisation is always needed before memory work

A linked appraisal is that a stabilisation phase of treatment is always needed prior to a trauma-focused intervention, especially for those with multiple traumas. This misconception perhaps originates from Herman’s (Reference Herman1992a) phased model for working with complex PTSD. She recommended that a stabilisation phase should precede a trauma-processing phase, followed by a phase of ‘reintegration’ with important areas of life such as relationships, socialising and work. However, the interpretation that these phases should be followed in a strict linear fashion is itself a misunderstanding. Herman (Reference Herman1992b) emphasised that the phases of recovery are ‘oscillating and dialectical in nature’ and that ‘like any abstract concept these stages of recovery are a convenient fiction, not to be taken too literally’ (p. 155).

A phase-based approach has high face validity and has been recommended in various expert consensus guidelines (e.g. McFetridge et al., Reference McFetridge, Hauenstein Swan, Heke and Karatzias2017), and underlies effective treatment packages (e.g. Bohus et al., Reference Bohus, Kleindienst, Hahn, Müller-Engelmann, Ludäscher, Steil, Fydrich, Kuehner, Resick, Stiglmayr, Schmahl and Priebe2020; Cloitre et al., Reference Cloitre, Koenen, Cohen and Han2002). However, there is limited evidence that phase-based approaches are superior to interventions that primarily focus on trauma processing, with critics arguing that they are an unnecessary use of clinical time, neither improving outcomes nor reducing drop-out (Baekkelund et al., Reference Baekkelund, Karlsrud, Hoffart and Arnevik2021; de Jongh et al., Reference de Jongh, Resick, Zoellner, van Minnen, Lee, Monson, Foa, Wheeler, Broeke, Feeny, Rauch, Chard, Mueser, Sloan, van der Gaag, Rothbaum, Neuner, de Roos, Hehenkamp and Bicanic2016; Oprel et al., Reference Oprel, Hoeboer, Schoorl, de Kleine, Cloitre, Wigard, van Minnen and van der Does2021). There is also great variability in what constitutes stabilisation, what interventions are offered and whether this is provided individually or in a group. There is recently a move towards considering ‘multi-component interventions’ encouraging individualised rather than phase-based approaches (Coventry et al., Reference Coventry, Meader, Melton, Temple, Dale, Wright, Cloitre, Karatzias, Bisson, Roberts, Brown, Barbui, Churchill, Lovell, McMillan and Gilbody2020).

CT-PTSD does not include a formal stabilisation phase and work on trauma memories in the form of imaginal reliving, narrative writing or constructing a timeline usually begins in session 2 of treatment. Session 1 includes psychoeducation and formulation (see oxcadatresources.com for a video on the first session of treatment), building the foundations of a collaborative and safe therapeutic relationship. There are instances when other interventions are also used prior to memory work to make sure that the patient can process the trauma memories in a productive way. For example, we always address risk as a priority, including risk to self, others and from others (including the perpetrator), and often adjust the order of interventions depending on individual needs and the formulation (see also point 10). If someone is very dissociative, we introduce trigger discrimination prior to updating memories work, and usually work on a written narrative first rather than reliving; verbally describing the event and writing it down at a pace that allows awareness of the present situation (i.e. being with the therapist in their office, years after the trauma) to be maintained at all times. Where people experience high levels of shame or a sense of enduring degradation or defeat associated with the trauma, we often address the related appraisals prior to memory work and develop some preliminary updates which can be introduced into the trauma memory immediately during reliving or narrative writing. Where people have lost a loved one during the trauma, the therapist and patient would talk about the person they lost, their relationship and what the person meant to them before reliving the trauma. However, we do not view these interventions as a formal stabilisation phase, rather as individualisation of treatment dependent on needs, guided by formulation.

Some of our patients are experiencing instability in their life circumstances, such as an imminent house move, financial difficulties, treatment for medical problems or an upcoming court case. Patients may prefer to wait until they have resolved these issues before beginning treatment, but we generally proceed if they consent and feel able to engage with treatment. The latest Crown Prosecution Service guidance on pre-trial therapy (2022) emphasises prioritising the wellbeing of the victim, giving informed choice regarding treatment, but not delaying therapy if it would be in their best interest. We have also noticed that some therapists delay treatment when symptoms are very severe and focus instead on symptom management. However, this can prevent patients receiving the effective elements of treatment which will have a greater impact on their symptoms. For example, sleep typically improves following work on the trauma memories (Woodward et al., Reference Woodward, Hackmann, Wild, Grey, Clark and Ehlers2017), so poor sleep should not be a reason to delay.

Overall, our experience is that most patients do not require a separate phase of stabilisation, and that additional interventions should facilitate work on updating trauma memories rather than replace them. Some of the interventions which form part of stabilisation packages may be included in CT-PTSD, typically interwoven with other interventions rather than as a distinct phase, and on a ‘needs-only’ bases. We recommend that treatment is individualised to specific needs rather than a ‘one size fits all’ approach. However, further empirical studies are needed on whether some patients with complex PTSD benefit from stabilisation prior to trauma-focused work and how such interventions might be best offered. We also do not believe that reintegration should wait until the end of treatment; in CT-PTSD, ‘reclaiming/rebuilding your life’ starts in session one and is part of every session, and contributes to changing appraisals of permanent change (e.g. ‘my life is over’) and feelings of hopelessness.

3. Talking about trauma memories is ‘retraumatising’

The term ‘retraumatisation’ is used in different ways. Strictly, it means being exposed to a further traumatic experience but clinicians commonly use it in the context of fearing that deliberately thinking about memories of past traumatic events is itself traumatic, and will cause symptom worsening. Undeniably, many of our patients become distressed when talking about their trauma memories, and some (not all) experience a temporary modest symptom exacerbation afterwards, so it is understandable that an empathic therapist may fear that they are somehow harming their patients. Yet, we know from research that engaging with, rather than avoiding, trauma memories through talking and/or writing is one of the most effective elements of treatment and that patients interviewed after reliving have reported it is ‘worth the pain’ (Shearing et al., Reference Shearing, Lee and Clohessy2011). We also know from randomised controlled trials that more patients experience a deterioration of symptoms in waitlist conditions than in trauma-focused treatments (e.g. Ehlers et al., Reference Ehlers, Hackmann, Grey, Wild, Liness, Albert and Clark2014; Jayawickreme et al., Reference Jayawickreme, Cahill, Riggs, Rauch, Resick, Rothbaum and Foa2014). Similarly, studies of patients treated in routine clinical care show that few people deteriorate over a course of trauma-focused CBT (e.g. 1.2% in Ehlers et al., Reference Ehlers, Grey, Wild, Stott, Liness, Deale, Handley, Albert, Cullen, Hackmann, Manley, McManus, Brady, Salkovskis and Clark2013; 0% in Gillespie et al., Reference Gillespie, Duffy, Hackmann and Clark2002), and it remains unclear whether this is due to treatment or new life events/stressors.

Introducing and managing work on trauma memories carefully is important in minimising any negative impact. Patients should be given information about how PTSD is maintained, including the role of unprocessed memories and avoidance, to give a clear rationale for why talking about memories can be helpful, so that they can give informed consent. Metaphors are particularly useful here. Work on trauma memories is conducted within a strong, collaborative therapeutic relationship where the patient feels in control of the process, is supported by the therapist and understands confidentiality. The therapist prepares the patient for the possibility of temporary distress and symptom exacerbation and helps them plan for after the session, for example, support from a loved one or a pleasurable activity. As well as the important processing of trauma memories, revisiting the trauma in imaginal reliving or narrative writing within these parameters also sends positive messages: that the trauma memories, associated meanings and distress are tolerable, that the patient can take control over the memories rather than be controlled by them and that the therapist will accept and appreciate the patient no matter what has happened. As people with PTSD already re-experience the past traumatic events in flashbacks and nightmares, in treatment we are simply asking them to engage with these memories in a more structured and supported way.

4. Some traumas shouldn’t be relived

Therapists sometimes express anxieties about working with certain types of trauma. We have heard misconceptions that imaginal reliving should not be used with sexual assault memories (even though Foa’s early work and trials on prolonged exposure therapy as well as Resick’s early work on cognitive processing therapy focused on women who developed PTSD after rape, e.g. Foa and Rothbaum, Reference Foa and Rothbaum1998; Foa et al., Reference Foa, Hembree, Cahill, Rauch, Riggs, Feeny and Yadin2005; Resick and Schnicke, Reference Resick and Schnicke1992; Resick et al., Reference Resick, Nishith, Weaver, Astin and Feuer2002), traumatic bereavements, childhood traumas, if there are gaps in the memories or a patient had lost consciousness, following multiple or very long traumas, where the patient’s worst fear had come true (e.g. someone died in the trauma), or where the trauma was a patient’s fault.

Our experience is that PTSD associated with all types of trauma can be addressed with CT-PTSD and that reliving or a written narrative is nearly always possible. Some adaptations may be required. For example, memories which are disjointed or contain a lot of gaps can benefit from being mapped out with a timeline first. Imaginal reliving of the parts of the memory which can be recalled can still be helpful, although written narratives can be easier if the memory is very fragmented. Finding information to explain gaps and to access a plausible scenario for what occurred can be helpful, such as using reports from others or an early site visit. For example, patients traumatised by treatment in intensive care units (ICU) typically have incomplete and confused memories due to periods of sedation. They often find ICU diaries, medical records and accounts from loved ones useful in understanding what happened and how this relates to their memories, particularly when they experienced delirium (Murray et al., Reference Murray, Grey, Wild, Warnock-Parkes, Kerr, Clark and Ehlers2020). Very early childhood memories can be unclear, disjointed and primarily sensory, but reliving and updating can still be used. The content and mode of updating need to be appropriate and accessible to the age the person was at the time of the trauma. For example, a young child may need simple messages that they are safe and the trauma is not their fault. Imagery rescripting can be useful to help update the meanings linked to these memories. For example, their older self entering the scene to deliver these messages, comfort the child with a hug and take them to a place of safety (similar to the protocol described by Arntz and Weertman, Reference Arntz and Weertman1999).

Updating a memory where the worst expected outcome has happened is possible. The purpose of cognitive work is to address excessively negative meanings, not to pretend that something bad has not happened. Sometimes there has been a tragic outcome to a trauma, like a death or permanent physical injury. Here, we look for associated personal meanings that keep the sense of current threat going like ‘the person is still suffering’, ‘I am alone forever without them’, ‘I let them down and did not do enough to prevent their death’, ‘my life no longer has a purpose’, or ‘people will find me disgusting’ and address meanings which are distorted. Similarly, with genuine responsibility or moral injury, we do not seek to absolve an individual of blame but to identify where beliefs have become distorted or generalised (e.g. ‘because I did this, I am a monster’ or ‘no-one can be trusted’). We also help people accept responsibility where it is due and consider with them how to move forward (Murray and Ehlers, Reference Murray and Ehlers2021). Even when there is no clear updating of a meaning, we can try to help put a ‘time-tag’ on the memory to show that it is a ghost from the past rather than happening now as it feels. For example, a patient whose worst fear was that they would be raped, and this is what occurred, could still benefit from updating their memory with the reminder that ‘this is in the past, it is over, no one is touching me now’. As before, we would also check for associated meanings and update these as appropriate.

5. CT-PTSD is a talking therapy

Of course, talking is involved, but we think of CT-PTSD as a ‘doing’ therapy, as all good CBT should be. Experiential techniques are generally part of every session, whether that is reliving, creating written narratives, updating trauma memories, transforming images, practising stimulus discrimination, conducting surveys, behavioural experiments or a site visit. Between sessions, patients are engaged in reclaiming/rebuilding your life assignments, behavioural experiments and other tasks. Treatment should be active and involved and create new experiences that help change the threatening meanings of the trauma and its aftermath. A related misconception is that cognitive therapy only involves the verbal restructuring of cognitions. In fact, testing hypotheses experientially has been a cornerstone of cognitive therapy since its inception (Beck et al., Reference Beck, Rush, Shaw and Emery1979), and a wide range of techniques to address memories and behaviours, as well as beliefs, are important elements of CT-PTSD.

Our experience in supervision has been that surveys, out-of-office behavioural experiments and site visits are the least commonly used techniques, often relating to practical obstacles combined with therapist concerns about unexpected outcomes or patients experiencing flashbacks. We find surveys are powerful, particularly in addressing shame-related beliefs, and we encourage their regular use. As with reliving (Shearing et al., Reference Shearing, Lee and Clohessy2011), research has shown that site visits can be anxiety-provoking, but patients find them rewarding and beneficial (Murray et al., Reference Murray, Merritt and Grey2016), suggesting that some of these therapist concerns may be unfounded. Some therapists also report that they do not carry out site visits if patients have already revisited the scene of the trauma. We find site vists are helpful even when the trauma occurred in a much-visited place, including their own home, as patients are often using safety behaviours or avoiding some aspects of the experience and do not naturally use strategies during site visits that lead to new learning (piecing together the trauma memory, looking for new information, trigger discrimination, behavioural experiments). Video examples of how to carry out all the different techniques mentioned here, including various types of behavioural experiments can be found at www.oxcadatresources.com.

CT-PTSD also addresses the physical nature of PTSD. Re-experiencing symptoms are not only experienced in the cognitive domain; the whole body may re-experience the trauma. For example, patients may find themselves frozen in fear when a memory is triggered, or sweating, shaking, or vomiting, just as at the time of the trauma. It follows that our memory updates are not only verbal and cognitive, but physical as well. For example, for someone who was trapped and unable to move peri-traumatically, a verbal update ‘I can move now’ would be paired with physical movement during reliving, such as standing, waving the arms, and walking around. Talking alone may be insufficient for the physical elements of the trauma memory to be updated.

6. PTSD can’t be treated remotely

The COVID-19 pandemic forced many therapists to work remotely, sometimes for the first time, and perhaps to collect evidence against this misconception. The development and testing of internet-delivered trauma-focused PTSD treatments (including CT-PTSD; Ehlers et al., Reference Ehlers, Wild, Warnock-Parkes, Grey, Murray, Kerr, Rozental, Beierl, Tsiachristas, Perera-Salazar, Andersson and Clark2020; Wild et al., Reference Wild, Warnock-Parkes, Grey, Stott, Wiedemann, Canvin, Rankin, Shepherd, Forkert, Clark and Ehlers2016) has shown preliminary evidence of effectiveness (Kuester et al., Reference Kuester, Niemeyer and Knaevelsrud2016), suggesting that remote delivery is possible. Wild et al. (Reference Wild, Warnock-Parkes, Murray, Kerr, Thew, Grey, Clark and Ehlers2020) detailed how to carry out CT-PTSD remotely showing that, with some flexibility and creativity, all the usual treatment strategies are possible. For example, when practising trigger discrimination, therapists are encouraged to source possible triggers (audio and visual files) before the session, email them to the patient during the session, and listen or look at them together using a shared screen (if video-conferencing), listing the similarities and differences on a shared Word document. Behavioural experiments can be carried out with the patient over the telephone. Site visits can be virtual, using Google Street View, or with the patient attending the site (potentially with a trusted friend or family member) and speaking on the telephone to the therapist. There are training materials about remote delivery available on www.oxcadatresources.com.

7. Dissociation rules out work on trauma memories

A common concern is that patients will dissociate during memory work, often leading therapists to avoid addressing trauma memories with patients who show signs of dissociation or first implementing long stabilisation phases. Research does not support the need for these changes. Hoeboer et al. (Reference Hoeboer, De Kleine, Molendijk, Schoorl, Oprel, Mouthaan, Van der Does and Van Minnen2020) and Halvorsen et al. (Reference Halvorsen, Stenmark, Neuner and Nordahl2014) found no evidence that pre-treatment dissociation moderates the effectiveness of trauma-focused treatments. In other words, techniques like memory updating still work when someone is prone to dissociation.

However, the experience of having a dissociative flashback is unpleasant for our patients and severe dissociation is likely to disrupt work on the trauma memories and prevent the integration of new information, so dissociation should be addressed in therapy. In CT-PTSD, patients are encouraged to identify and focus their attention on reminders of the ‘here and now’ to bring their awareness back into the room if they begin to dissociate. These might include objects with a positive association, photos, strong smells or tastes, or something to squeeze or hold. Having these handy is important during memory work for patients who dissociate, especially when working remotely. Moving around and hearing the therapist speak are also a useful reminders of the present. Trigger discrimination is taught and practised prior to work on the trauma memories for dissociative patients, alongside recognition and awareness of first signs of dissociation and its triggers.

Some adaptations to memory work may be appropriate with dissociation. For example, a written narrative is usually less immersive than imaginal reliving, so may be preferable, particularly when therapy is remote. The therapist can also reduce the intensity of reliving by asking the patient to keep their eyes open, speak in the past tense and by asking frequent questions. Continual movement can be helpful during memory work, such as walking on the spot, using a fidget spinner, or throwing a soft ball backwards and forwards, to keep the patient’s attention in the here and now and prevent freezing. The therapist can closely monitor the patient for signs of dissociation and intervene rapidly to bring their attention back into the present if needed.

A subgroup of patients with PTSD may experience long periods of dissociation (e.g. finding themselves in places without knowing how they got there). Careful identification of triggers (especially sensory triggers) and early signs of dissociation (e.g. starting to feel unreal) and use of the trigger discrimination technique with reminders of the here and now can help these patients stay in the present and thus reduce risk. Involvement of partners or family in helping patients spot triggers and signs of dissociation is helpful in early stages of therapy.

In summary, dissociation need not be a barrier to memory-focused interventions in CT-PTSD, nor is a long stabilisation phase required (see point 2). However, it is an important problem to address in therapy and some adaptations to trauma-focused techniques may be indicated.

8. PTSD is about fear

While early CBT models and studies of PTSD focused on conditioned fear responses, trauma-focused cognitive behavioural therapy programmes deal with the full range of negative emotions that can occur during and after traumatic events, including guilt, shame, anger, humiliation, betrayal, disgust, helplessness, hopelessness, horror and so on. Evidence suggests that only about half the emotions in the worst moments of traumatic memories are fear-based (Grey and Holmes, Reference Grey and Holmes2008). It follows that the meanings linked to these emotions are varied and idiosyncratic, so our approaches to understanding and addressing these meanings must also be personalised to each patient.

Often fear-based meanings like ‘I’m going to die’ are easy to spot, but we often find that further meanings are revealed if we ask follow-up questions like ‘what was the worst thing about that for you?’, or ‘what does that mean about you as a person?’. We try to avoid making assumptions about what might be distressing for an individual. For example, believing you are going to die is often associated with fear, but a further meaning may be uncovered like ‘I’m letting my family down by allowing this to happen’ associated with shame, or ‘I’m never going to see my children again’ associated with sadness. This is important because all of these different meanings will need to be updated to achieve a full emotional shift; not just ‘I survived, I’m alive’, but also ‘I didn’t allow this to happen, it wasn’t my fault’ and ‘I see my children every day’.

We also look for ways to consolidate these new meanings and not just in the verbal-cognitive domain; as described in point 5, trauma memories are also experienced physically and in imagery, so we update in those domains as well. For example, moving around to show that is now possible, looking at recent photos to consolidate an update like ‘I see my children every day’, touching a scar to show that a wound has now healed, re-reading survey results to consolidate a new meaning like ‘other people do not think I am to blame’, or accessing an image such a person who has died in a peaceful place to represent an update like ‘they are not in pain anymore’.

9. Exposure needs to be graded

Many therapists use graded exposure to approach trauma reminders and memories. This is a core technique in many trauma-focused treatments for PTSD, including prolonged exposure (Foa and Rothbaum, Reference Foa and Rothbaum1998; Foa et al., Reference Foa, Hembree and Rothbaum2007). It originated from behavioural models of phobias which emphasise achieving habituation to fear-provoking situations. In a cognitive approach to PTSD, the aim is to test trauma-related appraisals, which include beliefs of the likelihood of future harm or negative reactions of other people, so behavioural experiments are used to provide the best test of an appraisal. This approach can be less time-consuming than graded exposure. Rather than work through a hierarchy of feared situations, staying in each one long enough for anxiety to habituate, a test of the underlying belief (e.g. ‘I will be attacked again if I drop my guard in public’) via one or two behavioural experiments (e.g. going with the therapist to a busy shopping centre and deliberately dropping your guard by closing your eyes) may be sufficient to learn that the feared outcome does not occur. Of course, patients need to be willing to engage in an experiment, and support from the therapist (e.g. modelling the experiment first) is important, which is why we often do behavioural experiments during therapy sessions. Incidentally, the importance of testing feared predictions has also been highlighted in contemporary exposure therapies for PTSD as well (e.g. Craske et al., Reference Craske, Treanor, Conway, Zbozinek and Vervliet2014).

Although we do not grade experiments, timing them is important. We usually find it helpful to do memory updating and trigger discrimination work first to reduce re-experiencing during challenging experiments and so that the ‘then versus now’ technique can be used during the experiment if memories are triggered. The latter is needed so that the patient is able to process that the predicted outcome did not occur during the experiment.

There is also a subtle difference in exposure to the trauma memory in different trauma-focused treatments. In CT-PTSD, the purpose of narrative writing or imaginal reliving is to access the important personal meanings associated with the worst moments of the trauma and then update these. Unlike prolonged exposure, where reliving is a major part of most sessions, this is usually required only two or three times in CT-PTSD, with more time spent addressing the meanings associated with the memory and generating updating information using cognitive interventions. Updating is started as soon as possible, rather than repeated detailed reliving sessions without updates.

10. CT-PTSD is protocolised and inflexible

We commonly hear this misconception, along with requests for a session-by-session protocol for delivering CT-PTSD. Therapist surveys of attitudes to protocols reveal mixed feelings; while many see the utility of empirically derived guidance, others view them as restrictive and detrimental to the therapeutic relationship (Addis and Krasnow, Reference Addis and Krasnow2000). CT-PTSD is not a session-by-session protocol; it differs for every patient, depending on their individual formulation and needs. We appreciate that this can be challenging for therapists when they first learn the treatment. The core elements of treatment are similar for everyone, starting with psychoeducation, formulation, and reclaiming/rebuilding your life, before working on trauma memories and meanings, but there is a lot of flexibility about when and how to deliver certain treatment elements. For example, with a patient who experienced a sexual assault and feels very ashamed about the trauma, we may work first (before reliving the memory) on shame-related appraisals such as ‘people will think I let it happen because I didn’t fight back’ by introducing some psychoeducation about the freeze response and conducting a survey. This helps to provide potential updating information (e.g. ‘I didn’t fight back because I froze, which is a natural, instinctive reaction to threat. In the survey, no-one thought I had “let it happen” or blamed me’), which can then be linked to the relevant hotspots in trauma memory in the first reliving or narrative writing session. For a patient who cannot sleep because lying in bed triggers disjointed, confusing memories of their trauma in hospital, we may use stimulus discrimination to address lying down as a trigger and develop a detailed timeline of their time in hospital to fill in the gaps in their memory, create a more coherent narrative, and identify hotspots which are being re-experienced. We may do a site visit early in treatment to help piece together the disjointed memory and to speak to hospital staff who can provide valuable information about what occurred.

In this way, we keep close to Ehlers and Clark’s (Reference Ehlers and Clark2000) cognitive model, always guided by the individual formulation and the patient’s goals, whilst delivering treatment adaptably and creatively. This approach is sometimes termed ‘flexibility within fidelity’ (Whittington and Grey, Reference Whittington and Grey2014).