Fig. 9.1
Treatment goals in cognitive therapy for PTSD (Ehlers and Clark 2000). Pointed arrows stand for “leads to.” Round arrows stand for “prevents a change in.” Dashed arrows stand for “influences”
First, it is suggested that individual differences in the personal meaning (appraisal) of the trauma and/or its sequelae (e.g., reactions of other people, initial PTSD symptoms, physical consequences of the trauma) determine whether persistent PTSD develops. For people with PTSD, the trauma and its aftermath have highly threatening personal meanings that go beyond what other people would find horrific about the situation. The perceived threat can be external or internal and leads to a range of negative emotions that are meaningfully linked with the type of appraisal. Perceived external threat can result from appraisals about impending danger (e.g., “I will be assaulted again”; “I cannot trust anyone”), leading to excessive fear, or a preoccupation with the unfairness of the trauma or its aftermath (e.g., “I will never be able to accept that the perpetrator got away with a minor sentence”), leading to persistent anger. Perceived internal threat often relates to negative appraisals of one’s behavior, emotions, or reactions during the trauma and may lead to guilt (e.g., “It was my fault,” “I should have prevented it”) or shame (e.g., “I am inferior,” “I am a bad person”). A common negative appraisal of consequences of the trauma in PTSD is perceived permanent change (e.g., “I have permanently changed to the worse,” “My life is ruined”), which can lead to sadness and hopelessness.
Second, it is suggested that the worst moments of the trauma are poorly elaborated in memory, namely, inadequately integrated into their context (both within the event and within the context of previous and subsequent experiences/ information). This has the effect that people with PTSD remember the trauma in a disjointed way. While they recall the worst moments, it may be difficult for them to access other information that could correct impressions they had or predictions they made at the time. In other words, the memory for these moments has not been updated with what the person knows now. This has the effect that the threat they experienced during these moments is reexperienced as if it were happening right now rather than being a memory from the past. For example, when John1 nearly drowned during a ferry disaster, he thought that he would never see his children again. Whenever he recalled this particularly distressing moment, he was not able to access the fact that he still lived with his children and reexperienced the overwhelming sadness he had experienced at that moment again and again.
Ehlers and Clark (2000) also noted that intrusive trauma memories are easily triggered in PTSD by sensory cues that overlap perceptually with those occurring during trauma, for example, a similar sound, color, smell, shape, movement, or bodily sensation. They suggested that cognitive processing that focuses on perceptual features of the experience (data-driven processing) leads to strong perceptual priming (a reduced threshold for perception) for stimuli (and their sensory features) that occurred at the time of the traumatic event. Through learned associations, the stimuli also become associated with strong affective responses. This increases the chances that similar cues evoke distressing reexperiencing symptoms after the trauma.
In line with a role of associative learning, reexperiencing includes strong affective responses that are clearly related to the trauma, without the person recognizing that a trauma memory has been triggered (affect without recollection). For example, Anna, whose trauma involved being chased by a bull, felt an overwhelming urge that she had to “get out of here” when going for a walk in the country and jumped into an icy river. She was unaware of what had triggered this urge. Her partner spotted that she had responded to a cow grazing at a distance. Together, the proposed memory processes (poor elaboration, priming, and associative learning) explain why trauma memories remain so threatening in people with PTSD and why parts of these memories can be easily triggered by sensory reminders.
Why do the negative appraisals and the problematic nature of trauma memories persist in PTSD? Ehlers and Clark proposed that the negative appraisals and emotions prompt dysfunctional cognitive and behavioral responses that have the short-term aim of reducing distress but have the long-term consequence of preventing cognitive change and therefore maintain the disorder. Common examples include rumination about the trauma, avoidance of trauma reminders, suppression of trauma memories, excessive precautions (safety behaviors), substance use, and hypervigilance.
These maintain PTSD in three ways. First, some behaviors directly lead to increases in symptoms, for example, suppression of trauma memories leads to paradoxical increases in intrusion frequency. Second, other behaviors prevent changes in the problematic appraisals, for example, constantly checking one’s rear mirror (a safety behavior) after a car accident prevents change in the appraisal that another accident will happen if one does not check the mirror. Third, other behaviors prevent elaboration of the trauma memory and its link to other experiences. For example, avoiding thinking about the event prevents people from updating the memory of the worst moments with information that could make them less threatening, for example, that they did not die or are not paralyzed.
9.1.2 Empirical Studies Testing the Proposed Factors
Studies have (1) compared trauma survivors with and without PTSD on the factors specified in Ehlers and Clark’s (2000) model, (2) measured these factors soon after trauma and tested whether they predict PTSD later, and (3) tested them experimentally.
9.1.2.1 Negative Appraisals
Several studies have found strong empirical support for a relationship between PTSD and negative personal meanings (appraisals). Trauma survivors with PTSD endorsed negative appraisals of the trauma and its aftermath more strongly than those without PTSD (e.g., Foa et al. 1999). Negative appraisals correlate highly with the severity of PTSD symptoms. It is noteworthy that negative appraisals about the self (e.g., “What happened showed that I am a bad person,” “My reactions since the event show that I am going crazy”) correlate more strongly with PTSD severity than those about external danger (e.g., “The world is unsafe”) (e.g., Duffy et al. 2013). Negative appraisals also help identify who is at risk of chronic PTSD after trauma. Several prospective studies recruited trauma survivors soon after their trauma and found that early negative appraisals strongly predicted PTSD 6 months or 1 year later (e.g., Dunmore et al. 2001; Ehring et al. 2008). Again, negative appraisals about the self were the most predictive.
9.1.2.2 Memory Processes
There is evidence from prospective studies of trauma survivors that a predominance of data–driven processing during trauma (as opposed to conceptual processing) predicts subsequent PTSD (e.g., Ehring et al. 2008; Halligan et al. 2003). Similar results were found in studies that experimentally induced intrusive memories of analogue traumatic pictures in healthy volunteers (e.g., Sündermann et al. 2013). Bourne et al. (2010) showed that performing a distracting verbal task that interfered with conceptual processing of a trauma film predicted poor intentional recall, but more frequent unintentional retrieval, similar to the pattern of memory retrieval observed in PTSD.
The hypothesis that cues are strongly primed during trauma and therefore more easily spotted afterwards has also gained empirical support. In a series of experiments, volunteers saw unpleasant picture stories that included some neutral objects that were unrelated to the content of the stories and parallel neutral stories. When participants were later asked to identify blurred pictures, they were better at identifying neutral objects that they had previously seen during a trauma story than those that they had seen in a neutral story (for reviews see Brewin 2014; Ehlers et al. 2012). Similarly, Kleim et al. (2012b) found that accident and assault survivors with PTSD identified blurred trauma-related pictures, but not general threat pictures, with greater likelihood than neutral pictures. The lower perceptual threshold in identifying trauma-related pictures also predicted PTSD 6 months later.
There is some evidence that PTSD is related to slow extinction learning of conditioned associations between neutral stimuli and fear responses and poor discrimination learning. Individual differences in the degree to with which such learned associations generalize to related stimuli also seems to play a role in the persistence of PTSD symptoms (for a review see Ehlers et al. 2012).
The nature of trauma memories has been a matter of considerable debate (see Ehlers 2015, for a review). There is some evidence from questionnaire studies and analyses of trauma narratives that people with PTSD recall the trauma in a disorganized and incoherent way, for example, gaps in memory and/or problems remembering the temporal order of events (e.g., Halligan et al. 2003; Jelinek et al. 2009). Five prospective longitudinal studies showed that objective measures of trauma memory disorganization taken in the initial weeks after the trauma predicted the severity of PTSD symptoms at follow-up (see Ehlers 2015, for a review). It is less clear whether the observed memory disorganization is specific to trauma narratives in PTSD, as some studies found that people with PTSD also recall other events in a disorganized way.
Some of the inconsistencies in the literature may be due to the fact that not all parts of the trauma memory are equally disorganized. The hypothesis that trauma memories are disjointed from other autobiographical information concerns moments of the trauma that are reexperienced (Ehlers et al. 2004). There is indeed some evidence that the memory for the worst moments of trauma is particularly disorganized (e.g., Evans et al. 2007). People with PTSD experienced intrusive memories to a greater extent as more disconnected from their context than those without PTSD (e.g., Michael et al. 2005). In an experimental study, assault survivors PTSD took longer than those without PTSD to retrieve autobiographical information when imagining the worst moment of their trauma, but not another negative life event (Kleim et al. 2008).
9.1.2.3 Behaviors and Cognitive Responses That Maintain PTSD
Several studies found that the maintaining behaviors and cognitive responses highlighted in Ehlers and Clark’s model strongly correlate with PTSD (e.g., Duffy et al. 2013). Several prospective studies of trauma survivors found that rumination, suppression of trauma memories, and safety behaviors predicted chronic PTSD over and above what could be predicted from initial symptom levels (e.g., Dunmore et al. 2001; Ehring et al. 2008; Halligan et al. 2003; Kleim et al. 2012a).
Experimental studies investigated whether suppression of trauma memories and rumination play a causal role in maintaining PTSD symptoms. Most of the results are consistent with this hypothesis (for a review see Ehlers et al. 2012).
9.2 How to Do Cognitive Therapy for PTSD
9.2.1 Theory-Informed Individual Case Formulation
One of the basic ideas of cognitive therapy is that patients’ symptoms and behavior make sense if one understands how they perceive themselves and the world and what they make of it. Therapists need to “get into the patient’s head” (i.e., understand how patients perceive and interpret the world around them, what they think about themselves, and what beliefs motivate their behavior) before beginning the process of changing these cognitions. Cognitive therapy is a formulation-driven treatment. Treatment is tailored to the individual formulation and focuses on changing cognitions and cognitive processes that are directly relevant to the individual’s problems. In CT-PTSD, Ehlers and Clark’s cognitive model (2000) serves as the framework for an individualized formulation of the patient’s problems and treatment. This model suggests three treatment goals that are targeted in treatment (Fig. 9.1):
To modify excessively negative appraisals of the trauma and its sequelae
To reduce reexperiencing by elaboration of the trauma memories and discrimination of triggers
To reduce behaviors and cognitive strategies that maintain the sense of current threat
Therapist and patient collaboratively develop an individualized version of the model, which serves as the case formulation to be tested and revised in therapy. The maintaining factors are addressed with the procedures described below. The relative weight given to different treatment procedures differs from patient to patient, depending on the case formulation.
9.2.2 Therapeutic Style
Guided Discovery is central to the therapeutic style in cognitive therapy. Patient and therapist can be compared to a team of detectives that set out to test how well the patient’s perceptions and ideas match up with reality. Together, they consider the patient’s cognitions like hypotheses, exploring the evidence the patient has for and against them. A commonly used treatment technique is Socratic questioning. The therapist gently steers the patient towards considering a wider range of evidence or alternative interpretations by asking questions that help the patient consider the problem from different perspectives, with the aim to generate a less threatening alternative interpretation. For example, after being assaulted, Derek believed that he looked weak and was likely to be attacked again. In therapy, he considered the alternative hypothesis that his flashbacks gave him the impression that another assault was likely. Generating an alternative interpretation (insight) is usually not sufficient to generate a large emotional shift. A crucial, but sometimes neglected, step in therapy is therefore to test the patient’s appraisals in behavioral experiments, which create experiential new evidence against the patient’s threatening interpretations.
CT-PTSD follows these general principles, with some modifications. Therapists need to take extra care to establish a good therapeutic relationship with the patient (as many patients with PTSD feel they can no longer trust people) and make sure the patient feels safe in the therapeutic setting (as subtle trauma reminders can make the patient feel unsafe in many situations). CT-PTSD is a focused intervention that concentrates on changing cognitions that induce a sense of current threat after trauma. Careful assessment of the relevant appraisals is necessary. Patients may have other unhelpful negative thoughts that are not relevant to their sense of current threat and thus do not need to be addressed in treating their PTSD, unless they hinder the patient’s engagement and progress in therapy.
Importantly, the main problematic appraisals that induce a sense of current threat are usually linked to particular moments during the trauma. The patient’s evidence for their problematic appraisals typically stem from what they remember about their trauma. Disjointed recall makes it difficult to assess the problematic meanings by simply talking about the trauma and has the effect that insights from cognitive restructuring may be insufficient to produce a large shift in affect. Thus, work on appraisals of the trauma is closely integrated with work on the trauma memory in CT-PTSD.
9.2.3 Individual Case Formulation and Treatment Rationale
At the start of treatment, therapist and patient discuss the patient’s symptoms and treatment goals. The therapist normalizes the PTSD symptoms as common reactions to an extremely stressful, overwhelming event and explains that many of the symptoms are a sign that the memory for the trauma is not fully processed yet.
The therapist asks the patient to give a brief account of the trauma and starts exploring the personal meanings (“What was the worst thing about the trauma?” “What were the worst moments and what did they mean to you?”). The Posttraumatic Cognitions Inventory (PTCI, Foa et al. 1999) can help with identifying cognitive themes that will need to be addressed in treatment. The therapist also asks the patient about the content of their intrusive memories and their meaning, as the moments that are reexperienced are often omitted from trauma narratives and the intrusions point to moments that are important for understanding the sense of current threat.
The therapist asks the patient what strategies they have used so far to cope with their distressing memories. Suppression of memories, avoidance, and numbing of emotions (including substance use) are commonly mentioned, as well as rumination (dwelling on the memories). The therapist then uses a thought suppression experiment (asking the patient to try hard not to think about an image such as a green rabbit or a black and white cat sitting on the therapist’s shoulder) to demonstrate that suppressing mental images has paradoxical effects. After discussing this experience, the therapist encourages the patient to try to experiment with letting intrusive memories come and go during the next week (an exception to this homework assignment are patients who spend much time ruminating about the trauma, as they need to learn the distinction between intrusive memories and rumination first).
The therapist then uses the information gathered so far to develop an individual case formulation with the patient. This formulation contains the following core messages (in individualized form, using the patient’s words as much as possible):
1.
Many of the patient’s current symptoms are caused by problems in the trauma memory. Therapy will help the patient in getting the memory in a shape where it no longer pops up as frequent unwanted memories and feels like a memory of the past rather than something that is happening now.
2.
The memory of the trauma and what happened in its aftermath influences the patients’ current view of themselves and the world. The patient perceives a threat; a threat from the outside world, a threat to their view of themselves, or both. In therapy, the therapist and patient will discuss whether these conclusions are fair representations of reality and consider the possibility that the trauma memory colors their perception of reality.
3.
Some of the strategies that the patient has used so far to control the symptoms and threat are understandable but counterproductive and maintain the problem. In therapy, the patient will experiment with replacing these strategies with other behaviors that may be more helpful.
The graphic presentation of the treatment model shown in Fig. 9.1 is usually not presented to the patient, as it is quite complex. Instead, different parts of the model, such as the vicious circle between intrusive memories and memory suppression, or the relationship between beliefs about future danger, safety behaviors, and hypervigilance may be drawn out for the patient to illustrate particular maintenance cycles that the patient is trying to change.
9.2.4 Modifying Excessively Negative Appraisals of the Trauma and Its Sequelae
9.2.4.1 Reclaiming Your Life Assignments
People with PTSD often feel that they have permanently changed for the worse and have become a different person since the trauma (e.g., Dunmore et al. 2001). Related to this perceived permanent change, patients with PTSD often give up activities and relationships that used to be important to them. This usually goes beyond avoidance of reminders of the traumatic event and may include activities that were previously a very significant part of the patient’s life. Some activities may not have been possible in the immediate aftermath of the event and have just dropped out of the patient’s repertoire. Giving up these activities maintains the perception of permanent change by providing confirmation that they have become a different person and that their life is less worthwhile since the trauma.
Each treatment session contains a discussion of what the patient can do to reclaim their life and corresponding homework assignments are agreed. In the first session, the rationale for these assignments is introduced. If patients have lost much of their former lives since the trauma, it is best to refer to “rebuilding your life.” The therapist refers to the patient’s treatment goals, which usually include an improvement in their ability to work and to have satisfying relationships. The initial discussion aims to map the areas where patients would like to reclaim their lives and to agree on an achievable first step in one of these areas, and the first homework is agreed. This intervention helps install hope that therapy will help the patient get back on track. It is also helpful for the therapist to get an idea of the patient’s life and personality before the trauma so that they can build on their previous strengths and interests.
9.2.4.2 Changing Meanings of Trauma by Updating Trauma Memories
CT-PTSD uses a special procedure to shift problematic meanings (appraisals) of the trauma, termed updating trauma memories. This involves three steps:
Step 1: Identifying threatening personal meanings. To access the personal meanings of the trauma that generate a sense of current threat, the moments during the trauma that create the greatest distress and sense of “nowness” during recall (hot spots, Foa and Rothbaum 1998) are identified through imaginal reliving (Foa and Rothbaum 1998) or narrative writing (Resick and Schnicke 1993) and discussion of the content of intrusive memories. The personal meaning of these moments is explored through careful questioning (e.g., “What was the worst thing about this?” “What did you think was going to happen?” “What did this mean to you at the time?” “What does this mean to you now?” “What would it mean if your worst fear did happen?”). It is important to ask direct questions about patients’ worst expected outcome, including their fears about dying, to elicit the underlying meanings, as this guides what information is needed to update their trauma memory.
Imaginal reliving and narrative writing both have particular strengths in working with trauma memories, and the relative weight given to each in CT-PTSD depends on the patient’s level of engagement with the trauma memory and the length of the event. In imaginal reliving (Foa and Rothbaum 1998), patients visualize the traumatic event (usually with their eyes closed), starting with the first perception that something was wrong and ending at a point when they were safe again (e.g., the assailant left; being told in hospital that they were not paralyzed after an accident). Patients describe (usually in the present tense) moment by moment what is happening in the visualized event, including what they are feeling and thinking. This technique is particularly powerful in facilitating emotional engagement with the memory and accessing details of the memory (including emotions and sensory components). In our experience, it usually takes about 2 to 3 imaginal relivings of the traumatic event to access the hot spots sufficiently to assess their problematic meanings, although it may take longer if patients suppress their reactions or skip over difficult moments because, for example, they are ashamed about what happened.
Writing a narrative (Resick and Schnicke 1993) is particularly useful when the traumatic event lasted for an extended period of time and reliving the whole event would not be possible. The narrative covers the whole period and is then used to identify the moments or events with the greatest emotional significance so that their meaning can be explored further. Narrative writing is also particularly helpful for patients who dissociate and lose contact with the present situation when remembering the trauma or those who show very strong physical reactions when remembering the trauma (e.g., patients who were unconscious during parts of the trauma may feel very faint). Writing a narrative on a whiteboard or computer screen with the support of the therapist can help introduce the necessary distance for the patient to take in that they are looking back at the trauma rather than reliving it. Narrative writing is also especially helpful when aspects of what happened or the order of events are unclear, as it can be easily interwoven with a discussion about possible scenarios. Reconstructing the event with diagrams and models and a visit to the site of the trauma (which provides many retrieval cues) can be of further assistance in such instances. The narrative is useful for considering the event as a whole and for identifying information from different moments that have implications for the problematic meanings of the trauma and for updating the memory (see steps 2 and 3). After therapy, patients at times find it helpful to refer back to their updated narrative when memories are triggered, for example, around anniversaries of the trauma.
In our clinic, the majority of patients start with a few imaginal relivings, and the information generated during reliving is then used to write a narrative. The remaining patients only write a narrative with the help of the therapist and do not do reliving, for the reasons stated above.
Step 2. Identifying updating information. The next step is to identify information that provides evidence against the problematic meanings of each hot spot (updating information). It is important to remember that some of the updating information may be about what happened in the trauma. It can be something that the patient was already aware of, but has not yet been linked to the meaning of this particular moment in their memory, or something the patients has remembered during imaginal reliving or narrative writing. Examples include knowledge that the outcome of the traumatic event was better than expected (e.g., the patient did not die, is not paralyzed); information that explained the patient’s or other people’s behavior (e.g., the patient complied with the perpetrator’s instructions because he had threatened to kill him; other people did not help because they were in shock); the realization that an impression or perception during the trauma was not true (e.g., the perpetrator had a toy gun rather than a real gun); or explanations from experts of what happened (e.g., explanations about medical procedures).
For other appraisals, cognitive restructuring is necessary, for example, for appraisals such as “I am a bad person,” “It was my fault,” “My actions were disgraceful,” or “I attract disaster.” Cognitive therapy techniques such as Socratic questioning, systematic discussion of evidence for and against the appraisals, behavioral experiments, discussing of hindsight bias, pie charts, or surveys are helpful. Imagery techniques can also be helpful in widening the patient’s awareness of other factors that contributed to the event or in considering the value of alternative actions. For example, assault survivors who blame themselves for not fighting back during the trauma may visualize what would have happened if they had. This usually leads them to realize that they may have escalated the violence further and the assailant may have hurt them even more.
Step 3. Active incorporation of the updating information into the hot spots. Once updating information that the patient finds compelling has been identified, it is actively incorporated into the relevant hot spot. Patients are asked to bring the hot spot to mind (either through imaginal reliving or reading the corresponding part of the narrative) and to then remind themselves (prompted by the therapist) of the updating information either (a) by verbally (e.g., “I know now that …”), (b) by imagery (e.g., visualizing how one’s wounds have healed; visualizing the perpetrator in prison; looking at a recent photo of the family or of oneself), (c) by performing movements or actions that are incompatible with the original meaning of this moment (e.g., moving about or jumping up and down for hot spots that involved predictions about dying or being paralyzed), or (d) through incompatible sensations (e.g., touching a healed arm). To summarize the updating process, a written narrative is created that includes and highlights the new meanings in a different font or color (e.g., “I know now that it was not my fault”).
9.2.4.3 Changing Appraisals of Trauma Sequelae
For some patients, a main source of current threat comes from threatening appraisals of the aftermath of the traumatic event. For example, some patients believe that intrusive memories are a sign they are going crazy (e.g., Ehlers et al. 1998). Their failed attempts to control the intrusions are seen as further confirmation of their appraisals. Others interpret some people’s responses after the event as signs that no one cares for them or understands them or that other people see them as inferior (e.g., Dunmore et al. 2001). Such appraisals are modified by the provision of information, Socratic questioning, and behavioral experiments.
9.2.5 Memory Work to Reduce Reexperiencing
9.2.5.1 Imaginal Reliving and Narrative Writing
The updating trauma memories procedure described above helps elaborate the trauma memory. Retrieving the memory and talking about it helps making it appear less vivid and intrusive. Patients may describe that some of the sensory impressions from the trauma fade away (e.g., colors or taste fading). When the hot spots have been successfully updated, patients usually experience a large reduction in reexperiencing symptoms and improvement in sleep.
9.2.5.2 Identification and Discrimination of Triggers of Reexperiencing Symptoms
Patients with PTSD often report that intrusive memories and other reexperiencing symptoms occur “out of the blue” in a wide range of situations. Careful detective work usually identifies sensory triggers that patients have not been aware of (e.g., particular colors, sounds, smells, tastes, touch). To identify these subtle triggers, patient and therapist carefully analyze where and when reexperiencing symptoms occur. Systematic observation in the session (by the patient and the therapist) and as homework is usually necessary to identify all triggers. Once a trigger has been identified, the next aim is to break the link between the trigger and the trauma memory.
Related posts:
EMDR Therapy for Trauma-Related Disorders
Psychological and Social Theories of PTSD
Considerations in the Treatment of Veterans with Posttraumatic Stress Disorder
Trauma as a Public Health Issue: Epidemiology of Trauma and Trauma-Related Disorders
What Works for Whom?
Neurobiological Findings in Post-traumatic Stress Disorder
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