Workshop Anke Ehlers - OxCADAT Resources



Workshop Anke Ehlers

Cognitive Therapy for PTSD, 2nd September 2020

Accompanying Materials

1. Impact of Event Scale Revised and PCL-5

2. Short versions of:

Posttraumatic Cognitions Inventory (PTCI)

Unwanted Memories (especially important: Nowness ratings)

Response to Intrusions Questionnaire and Safety Behaviours Questionnaire

4. Hot spot updating sheet (2 alternative versions with different layouts)

5. Record sheet for noting behavioural experiments

6. Understanding PTSD for patients

7. Information sheet for friends and family

8. Blueprint

9. Remote delivery guidance

Permission is automatically granted for clinical use. Before using the unpublished measures/ therapy materials developed by our group in any research studies, please contact Anke Ehlers for permission (anke.ehlers@psy.ox.ac.uk)

For more information see the OxCADAT Resources Website

(access is free, but you need to register to view the clinical resources)

Mailing address

Oxford Centre for Anxiety Disorders and Trauma

Department of Experimental Psychology

University of Oxford

The Old Rectory

Paradise Square

Oxford OX1 1TW

UK

anke.ehlers@psy.ox.ac.uk

IES-R

Weiss, D.S., & Marmar, C.R., 1996, in In J. Wilson & T.M. Keane (Eds.),

Assessing psychological trauma and PTSD (pp. 399- 411).

Below is a list of comments made by people after stressful life events. Please check each item, indicating how frequently these comments were true for you DURING THE PAST MONTH/WEEK.

| |Not at all |A little bit |Moder-ately |Quite a bit |Extremely |

|Any reminder brought back feelings about it. |0 |1 |2 |3 |4 |

|2. I had trouble staying asleep. |0 |1 |2 |3 |4 |

|4. I felt irritable and angry. |0 |1 |2 |3 |4 |

|6. I thought about it when I didn't mean to. |0 |1 |2 |3 |4 |

|8. I stayed away from reminders about it. |0 |1 |2 |3 |4 |

|10. I was jumpy and easily startled. |0 |1 |2 |3 |4 |

|12. I was aware that I still had a lot of feelings about it, but I |0 |1 |2 |3 |4 |

|didn't deal with them. | | | | | |

|14. I found myself acting or feeling like I was back at that time. |0 |1 |2 |3 |4 |

|16. I had waves of strong feelings about it. |0 |1 |2 |3 |4 |

|18. I had trouble concentrating. |0 |1 |2 |3 |4 |

|20. I had dreams about it. |0 |1 |2 |3 |4 |

|22. I tried not to talk about it. |0 |1 |2 |3 |4 |

|1. Repeated, disturbing, and unwanted memories of the stressful experience? |0 |1 |2 |3 |4 |

|3. Suddenly feeling or acting as if the stressful experience were actually happening again (as |0 |1 |2 |3 |4 |

|if you were actually back there reliving it)? | | | | | |

|5. Having strong physical reactions when something reminded you of the stressful experience (for|0 |1 |2 |3 |4 |

|example, heart pounding, trouble breathing, sweating)? | | | | | |

|7. Avoiding external reminders of the stressful experience (for example, people, places, |0 |1 |2 |3 |4 |

|conversations, activities, objects, or situations)? | | | | | |

|9. Having strong negative beliefs about yourself, other people, or the world (for example, |0 |1 |2 |3 |4 |

|having thoughts such as: I am bad, there is something seriously wrong with me, no one can be | | | | | |

|trusted, the world is completely dangerous)? | | | | | |

|11. Having strong negative feelings such as fear, horror, anger, guilt, or shame? |0 |1 |2 |3 |4 |

|13. Feeling distant or cut off from other people? |0 |1 |2 |3 |4 |

|15. Irritable behavior, angry outbursts, or acting aggressively? |0 |1 |2 |3 |4 |

|17. Being “superalert” or watchful or on guard? |0 |1 |2 |3 |4 |

|19. Having difficulty concentrating? |0 |1 |2 |3 |4 |

PTCI-s

On this page, you will find different thoughts that people may have after a traumatic experience. In this questionnaire we are interested in the way that YOU thought, IN THE LAST MONTH/ WEEK, in regard to the trauma. Please read each statement carefully and choose a number from the scale below which BEST DESCRIBES HOW MUCH YOU AGREED OR DISAGREED WITH THE STATEMENT in the last week.

|1 |2 |3 |4 |5 |6 |7 |

|Totally |Disagree |Disagree |Neutral/ neither|Agree |Agree |Totally |

|disagree |very much |slightly |agree nor |slightly |very much |agree |

| | | |disagree | | | |

| | |Totally | |Totally Agree|

| | |Disagree | | |

|1. |My reactions since the event mean that I am losing my mind. |1 |2 |3 |4 |5 |6 |7 |

|3. |If people knew what happened they would look down on me. |1 |2 |3 |4 |5 |6 |7 |

|5. |My life has been destroyed by the event. |1 |2 |3 |4 |5 |6 |7 |

|7. |If I think about the event, I will not be able to handle it. |1 |2 |3 |4 |5 |6 |7 |

|9. |If I stop being angry, what happened to me will be forgotten. |1 |2 |3 |4 |5 |6 |7 |

|11. |I have permanently changed for the worse. |1 |2 |3 |4 |5 |6 |7 |

|13. |Stopping feeling guilty is letting myself off the hook. |1 |2 |3 |4 |5 |6 |7 |

|15. |There is something wrong with me as a person. |1 |2 |3 |4 |5 |6 |7 |

|17. |The way I behaved/thought/felt during the event is unforgivable. |1 |2 |3 |4 |5 |6 |7 |

|19. |Nothing good can happen to me anymore. |1 |2 |3 |4 |5 |6 |7 |

UNWANTED MEMORIES OF THE TRAUMA

|1. In the last week, approximately how often did unwanted memories |Never |

|of the traumatic event pop into your mind? |Once |

| |Twice |

| |Every other day |

| |Once a day |

| |Several times a day |

| |Many times a day |

| | |

|2. How distressing were these memories? |0 -- 10 -- 20 -- 30 -- 40 -- 50 -- 60 -- 70 -- 80 -- 90 -- 100 |

| |Not at all Moderately |

| |Very |

| |strongly |

|3. To what extent did they seem to be happening now instead of |0 -- 10 -- 20 -- 30 -- 40 -- 50 -- 60 -- 70 -- 80 -- 90 -- 100 |

|being something from the past? |Not at all Moderately |

| |Very |

| |strongly |

|4. To what extent were you reliving your experience from the |0 -- 10 -- 20 -- 30 -- 40 -- 50 -- 60 -- 70 -- 80 -- 90 -- 100 |

|trauma? |Not at all Moderately |

| |Very |

| |strongly |

|5. To what extent did the memories seem to be isolated fragments |0 -- 10 -- 20 -- 30 -- 40 -- 50 -- 60 -- 70 -- 80 -- 90 -- 100 |

|that were disconnected from |Not at all Moderately |

|what happened immediately before and afterwards? |Very |

| |strongly |

|6. Many different things trigger memories of the trauma (please |0 -- 10 -- 20 -- 30 -- 40 -- 50 -- 60 -- 70 -- 80 -- 90 -- 100 |

|rate how strongly this applies to you) |Not at all Moderately |

| |Very |

| |strongly |

RIQ

What do you do when memories of the traumatic event pop into your mind?

Please circle the answer that applied best to you DURING THE PAST MONTH/WEEK.

|1. |I try to push them out of my mind. |Never |Sometimes |Often |Always |

|3. |I distract myself with something else. |Never |Sometimes |Often |Always |

|5. |I think about why the event happened to me. |Never |Sometimes |Often |Always |

|7. |I dwell on what other people have done to me. |Never |Sometimes |Often |Always |

|9. |I go over what happened again and again. |Never |Sometimes |Often |Always |

|11. |I numb my feelings. |Never |Sometimes |Often |Always |

SBQ

After a traumatic experience, some people take extra precautions to make their lives and that of significant others safer. Please indicate how often you take these precautions by circling the answer that best applied to you IN THE PAST WEEK.

| | |THIS APPLIED TO ME IN THE PAST WEEK |

|1. |I overprotect those close to me. |Never |Sometimes |Often |Always |

|3. |I check for the quickest way to leave the situation. |Never |Sometimes |Often |Always |

|5. |I plan what to do if things go wrong. |Never |Sometimes |Often |Always |

|7. |

|Worst Moments |Thought at the time, THEN |What would be the worst thing about that?|What I know NOW |How I can remind myself of what I know |

|(Hot Spot) | | | |NOW |

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BEHAVIOURAL EXPERIMENTS RECORD SHEET

|Date |1. Situation |2. Prediction |3. Experiment |4. Outcome |5. What have I learned? |

| | |What do you think will happen? |What will you do to test the prediction? |What actually happened? |What does this tell you? |

| | |How much do you believe it will, 0 - 100 %|Remember to | |How likely is it that your predictions |

| | |? How will you know if it has? |- let go of safety behaviours |Was the prediction correct? |will happen in the future - 0-100% ? |

| | | |and scanning for danger | |How can you build on this? |

| | | |- use “Then versus Now” when memories are | | |

| | | |triggered | | |

| | | | | | |

Understanding Post-traumatic Stress Disorder

A Normal Reaction to Abnormal Events

A traumatic event is an emotional shock. It is not easy to take in what has happened and to come to terms with it. After a trauma, it is quite normal to experience all kinds of unpleasant feelings, thoughts, and body sensations. These may take some time to die down. In the meantime, memories and images of the trauma, and thoughts about it, come into your mind even if you try to shut them out. These experiences may be confusing and even frightening. You may wonder if you will ever get over the trauma, if you are losing control of yourself, or even if you are going mad. These worries are entirely understandable.

Each person reacts to trauma in his or her own unique way. Nonetheless, there are common reactions which many people share. This handout describes some of these common reactions and how therapy will help. You may find that you have experienced, or are experiencing, many of them. Most people show many, but not all, of these reactions. Please read the handout carefully and see which parts apply to you.

The handout is yours to keep, so feel free to underline or highlight particular passages or make notes on the margin. It might be helpful to read it in small chunks, for example one section at a time, taking regular breaks. You will have an opportunity to discuss your reactions to the handout with your therapist when you next meet.

Effects of Trauma Memories on Your Mind and Your Body

Re-experiencing

People who have had a traumatic event often re-experience parts of the trauma. This can take several forms.

[pic]

Re-experiencing can happen when something reminds you of the trauma. This can automatically trigger emotions such as anxiety, sadness or anger and sensations from your trauma. Some triggers are obvious reminders of the original traumatic event (for example, returning to the site of a road traffic accident). Others are, however, hard to spot because only one part is similar to the trauma, for example, a particular colour, a certain smell, a change in the light, a shift in temperature, or a tone of voice.

Once you have identified the triggers with the help of your therapist, your automatic emotional reactions will make better sense. You will also learn to realise that you are responding to a memory rather than the present situation. This will help you to realise more and more quickly that there is no current danger when you encounter the triggers, and bring down your emotional reactions.

Your therapist will also explain to you that your re-experiencing symptoms are the result of how traumatic events are laid down in memory. They are stored in a “raw”, unfinished form and are not fully processed (put together) like other memories from your life. This has the effect that the trauma memories appear to happen in the “here and now” rather than being something from the past.

In therapy, you will learn to experience your traumas as past events. You will do this by working through what happened and what it means to you with your therapist. This will be done in a controlled way that does not overwhelm you, but lets you process your experience. When this is accomplished through therapy, you will no longer feel like you are back in the trauma when you remember it - reliving it as if it was happening again. Instead, when you remember your traumatic experiences, it will feel like something that happened to you in the past.

Physical arousal

Another common reaction to trauma is physical arousal, for example, feeling jittery or agitated, overly alert, trembling, being easily startled and having trouble sleeping. You may have trouble getting to sleep, or you may wake repeatedly during the night, or sleep restlessly, or have troubled dreams.

Feeling tense and jumpy all the time may lead to feelings of irritability, especially if you are not getting enough sleep. You may find yourself snapping at people close to you, or losing your temper for trivial reasons. Symptoms of arousal are our body’s response to danger.

When we are in danger, our body prepares us for running away or fighting by releasing more adrenaline in our blood, which makes our heart pound and our muscles ready for action. The same thing happens when we are afraid or startled.

Another bodily reaction to extreme danger in animals and humans is to freeze. You may have noticed that, when approached by a dog, a cat will crouch down and keep very still when it is afraid. The same thing happens to many people during trauma, or when they are suddenly reminded of it. It may make you feel as if you are no longer in your body, as if the world around you is unreal or as if you are unable to move or have feelings (these responses are called dissociation, see below).

After a very frightening trauma, your body may stay constantly on the alert, prepared for instant action, even though this is no longer necessary. The trauma has forced you to realize that there is danger in the world, and you are all set to deal with it. It is as if your body has failed to realize that the danger is past. It continues to react as if you were still under threat and might need at any moment to fight, flee or freeze. This is why you may feel constantly on guard, vigilant, tense, irritable or have difficulties sleeping.

Once you work with your therapist through your trauma memories and the meanings they have for you and learn to respond differently to reminders of the event, your arousal and sleep problems will decrease.

Dissociation

Dissociation is common during and after trauma. It involves feeling distant from the ‘here and now’. It can range from daydreaming and being on automatic pilot to seeing yourself do things as if from the outside (an ‘out-of-body’ experience). It can be triggered by obvious and subtle trauma reminders, like memories and other reactions from the trauma. You may find yourself “blanking out” or “switching off” when reminders of what happened occur.

Dissociation is our brain’s response to stress and protects us from getting overwhelmed by it. It is not a sign that you are going mad or ‘losing it’. Even people who have not had a trauma dissociate from time to time, for example during periods of stress or when very tired. Your therapist will help you gain control over your dissociation.

Difficulty concentrating

You may also find that you have trouble concentrating. This is another common experience after a trauma. It is frustrating and upsetting to be unable to concentrate, pay attention to, or remember what is going on around you. This experience too may lead to a feeling that you are not in control of you mind. It is important to remember that these difficulties are part of your PTSD. They are a result of intrusive and distressing feelings and memories about the trauma, poor sleep and high arousal. In therapy, you will find that when your re-experiencing symptoms become less severe, you dwell less on what has happened, and your sleep improves, this will also improve your concentration.

Common Emotions and Thoughts After Trauma

After trauma, people live with strong emotions which can sometimes feel overwhelming. Behind the emotions are the trauma memories and thoughts about what the trauma means to you. Most people experience a range of different emotions. The emotions you feel make sense if we look at the thoughts behind them. See which ones apply to you.

Fear and anxiety

Fear and anxiety after trauma are very common. They are reactions to having been in or having witnessed a dangerous, life-threatening situation.

A trauma often leads to changes in people’s views of the world and their sense of safety. After experiencing trauma, it takes a while to feel secure again. You may feel that life is full of risks, and that you can never be sure when disaster will strike. This heightened sense of danger may be partly because the trauma has made you more aware of real risks. It may also be because the memory of your trauma has led you to overestimate and exaggerate how dangerous life is.

Let us take the trauma of a road traffic accident as an example. Although you knew road traffic accidents happen, you may never really have believed that one would happen to you. After a crash, it is as if an accident is waiting to happen at every roundabout and junction, and around every corner. Even as a passenger, you cannot afford to take your eyes off the road for an instant. In actual fact, an accident is not more likely than it was before. But in your mind it seems extremely likely that history will repeat itself. Naturally enough, these changes in how you see things lead to heightened fear and anxiety. In therapy, you will have the opportunity to discuss and reduce your heightened sense of danger with the help of your therapist.

Because fear and anxiety are distressing, people often attempt to reduce them by trying to avoid places, people and other reminders of the trauma or by distracting themselves from upsetting memories and thoughts. These strategies may well help you to feel better in the short term, but in the longer term they will actually slow down recovery and keep the problem going. This point is explained in more detail below.

Feeling low

Another common reaction to trauma is sadness, or feeling down or depressed. You may have lost important parts of your life due to your traumas. This could be a death, changes to your body, the loss of friendships, work or hobbies. You may also have lost interest in people and activities you used to enjoy. You may feel low in energy, hopelessness, have frequent crying spells, or feel numb inside.

Your thoughts may circle about what you lost in the trauma or negative thoughts about yourself, other people or how about your life is changed. You may also think that life is no longer worth living and that plans you had made for the future no longer seem important or meaningful. With therapy, as you work through the memories of your traumas and your thoughts about them and start rebuilding your life again, you will find that your mood will also improve.

If you feel low, you may sometimes even have thoughts of hurting yourself and suicide. If you have such thoughts, please discuss them with your therapist so they can help.

Feeling guilty and ashamed

Trauma often leads to feeling guilty or ashamed. These feelings may be related to self-blaming thoughts about something you did, or did not do, in order to survive or cope with the situation. After trauma, is common for people to go over what happened in their minds. You may find yourself going over steps you might have taken to prevent the trauma from occurring, or different ways you might have reacted. Feelings of shame are also often linked to thoughts about being judged by other people if they knew what happened.

Self-blaming thoughts are a real problem, because they can lead to feeling helpless, depressed and bad about yourself. In therapy, you will discuss these thoughts with your therapist, and learn to be less hard on yourself. You will discover that your reactions were understandable and you had good reasons for the way you behaved at the time. You will learn that most other people are more understanding and sympathetic than you think.

You may also blame yourself for not having been able to put the trauma behind you and get back to normal. Perhaps you see this as a sign of weakness or inadequacy. Hopefully the information in this handout will be helpful for your symptoms as a normal, human reaction to intolerable stress.

Unfortunately, sometimes other people such as family, friends or other people who you met after the trauma are unhelpful. They may wrongly place responsibility on those who have been hurt or victimized, rather than on those who have done the hurting. Or they may not understand the nature of post-traumatic stress and give you the message that you should be pulling yourself together and getting on with life. It is important to understand that they are wrong, and their opinion does not mean that you are to blame.

Feeling angry

Anger is also a common reaction to trauma. There can be a lot to be angry about. Experiencing a trauma is unfair. You may be angry with other people because the hurt you, abused you, disrupted your life or hurt someone close to you. Or because they betrayed you or let you down during or after the trauma. You may also be very frustrated about the problems that the trauma has caused in your everyday life. You may find yourself dwelling a lot about the unfairness and find it hard to put this behind you. Therapy will help you with this.

Feelings of anger may also be stirred up by people, places or situations that remind you of the trauma, even if they had nothing to do with it. Many people also find they are experiencing anger towards those they love most: family, friends, their partners, and their children. Sometimes you may lose your temper with the people who are most dear to you. This may be confusing and upsetting, but it is an understandable response after trauma.

Sometimes you may feel so angry that you want to hit someone or swear. If you are not used to feeling so angry and irritable these feelings may feel foreign to you, and you may not know how to deal with them.

In therapy, you will be able to explore your anger and what you are angry about in a safe environment with your therapist who will understand and support you. You will learn that the anger is often triggered by subtle reminders of the trauma, and by your thoughts about the unfairness of the trauma, and you will learn ways of dealing with these memories and thoughts.

Self-image and negative thoughts about other people and life

Your self-image can also suffer as a result of a trauma. You may tell yourself: “I am a bad person, and bad things happen to me”, or “If I had not been so weak and stupid, this would not have happened”. Or you may be hard on yourself for not coping better with what has happened. People often say that the trauma has changed them completely. They say, for example: “Before the trauma I could cope stress and I could get along with others. And now I am afraid most of the time, do not trust anyone and cannot cope with even trivial problems”. Other people may feel the trauma was the “last straw” and seems to prove things they had long suspected, for example that they cannot trust themselves or that they are inferior to others.

Both the trauma itself and the feelings you experience afterwards can be a source of such self-criticism and self-doubt. This is a very understandable reaction. You may also have negative thoughts about other people and about life in general. The world may suddenly seem a very dangerous place. You may feel that you cannot trust anyone.

A recent trauma may also stir up memories of past negative experiences because some of the physical aspects overlap (e.g., an angry voice, pain) or the meanings (e.g., being vulnerable, helpless or in danger). This may make it difficult to think of any experiences in the past that were not negative. You may even believe that you will ever feel happy again, or get back to normal, or enjoy life. But you will. It is possible to put these painful experiences behind you.

Your therapist will discuss your negative thoughts with you, and encourage you to test how accurate they are. Through the discussions and the experiences you will have in therapy, you will get a new, more positive perspective and improve your self-image.

Feeling cut off from other people

Many people with feel cut-off or distant from others after a trauma, including the people they really care about. It is difficult to have positive feelings and be in the “here and now” with your partner, family or friends when trauma memories and thoughts about the trauma intrude in your mind. Memories of the trauma may also bring on feelings of being numb, being outside your body or the world around you being unreal, which interferes with feeling close to others. You may also have thoughts that the trauma has permanently changed you and that you are now different from other people – thoughts that you do not deserve love and support. This may lead to you avoiding contact with others and withdraw from your relationships.

As work through your trauma memories and thoughts with your therapist and gradually engage more with other people again, this will reduce your feelings of being cut off and improve your relationships with your significant others.

Ways of Coping with Trauma

Coping with the effects of trauma and the symptoms of PTSD is hard. People understandably use many different strategies to control their distress. Some of these help only in the short-term and actually stand in the way of recovery.

Pushing memories away

Trauma memories and the emotions and strong body feelings that come with them are upsetting and may make you feel out of control. It is very understandable and natural to try to push them away and try very hard to distract themselves. Unfortunately, trying to push flashbacks and memories out of your mind does not stop them from coming back and may even make them more persistent. Your therapist will help you to find other way of dealing with them.

Dwelling on the trauma and its after-effects

After a trauma, many people end up dwelling on thoughts and questions about it, for long periods of time. When your thoughts go round and round in circles, we call this kind of thinking rumination. You can often spot rumination by noticing the kinds of thoughts you are having. Thoughts like “Why?”, “What if?” and “I should…” are often signs of ruminating. You will probably find dwelling hard to stop. Rumination is unhelpful as it makes us feel bad and also makes it harder to move forward with our lives. In therapy you will learn to spot unhelpful rumination and how to deal with it.

Scanning for danger, avoidance and extra precautions

After trauma, many people feel at risk. You may find that you are scanning for danger in your everyday life, avoid people, places or situations that reminds you of the trauma, or take unnecessary extra precautions to stay safe. You may also avoid thinking about the trauma and may be blocking off or avoiding the feelings that are triggered by reminders. Scanning, avoidance and extra precautions are strategies to protect yourself from things that you feel have become dangerous, and from thoughts and feelings that seem overwhelmingly distressing.

In therapy, you will work with your therapist on reclaiming your life and on mastering situations that you have avoided.

Using alcohol or other substances

Memories of trauma and the emotions and physical arousal linked to them are painful and exhausting. It is understandable that many people try to block out the memories, numb their feelings or make it easier to fall asleep by using alcohol, cannabis or other substances. While these substances may give a short-term relief, they usually make PTSD symptoms worse. For example, you may sleep worse and have bad dreams. Longer-term use of the substances may also lead to problems with dependency and affect your motivation to do things that are important for rebuilding your life. In therapy, as put your trauma memories in the past, they will become less distressing. This will help you with reducing your substance use. It is important that you are not intoxicated when you attend your therapy sessions as this will interfere with the work you are doing in therapy.

Dissociation and numbing your emotions

You have read above that dissociation can be automatically triggers by stress and reminders of the trauma and protects us from becoming overwhelmed. Some people have also learned to “bring on” dissociation when they feed stressed, such as “blanking out” or “switching off”. Feeling emotionally numb (the loss of the ability to feel anything very much, including affection and pleasure) another common way of trying to cope with painful feelings and thoughts about the trauma. While this helps them from feeling overwhelmed at that moment, it can lead to problems in relationships with others and does not help overcoming the trauma. If this applies to you, your therapist will help you to find other way of dealing with your distress and live in the “here and now”.

Conclusion

In this handout you have read about common reactions to trauma. You will have had an opportunity to identify those that particularly fit how you have been feeling.

This is why the problems you are experiencing are called “post-traumatic stress disorder”. They are a sign that you have not yet been able to come to terms with what happened to you. It is as if the trauma continues to happen over and over again in the here and now. Through therapy you will come to understand how this happens, and you will learn ways of dealing with your upsetting thoughts and feelings, gaining perspective on your traumatic experiences and how they have affected you, and rebuild your life. This will help you to take the heat out of your memories and to put your traumas in the past, where they belong.

Understanding

Posttraumatic Stress Disorder

For Families and Friends

Introduction

This leaflet is probably in your hands right now because someone you are close to has been through an extremely upsetting or frightening experience (a trauma) and as a result is living with the symptoms of posttraumatic stress disorder (PTSD). Watching a loved one suffer in this way can be confusing, distressing and sometimes even frightening for you too. You may feel lost as to how to help and support them while they receive treatment for these problems.

The aims of this leaflet are to:

▪ help you understand what they (and you) are experiencing and why

▪ help you realise that these are normal and common reactions

▪ explain what treatment involves and how you might help

The person who has experienced the trauma has been given a more detailed leaflet that may be helpful for you to read as well. Similarly it is probably helpful for them to read this one too.

What is Posttraumatic Stress Disorder?

PTSD is a common reaction to traumatic events where a person feels extremely frightened, helpless or horrified about what they experience. Common examples of traumas are being assaulted, severe accidents, natural disasters or bombings. Even if traumatic events do not lead to actual injury, they can be extremely frightening. What makes it traumatic is how it felt to the person going through it at that time. For example, if they thought they were going to die during the event, however unlikely this may seem with hindsight, the event will be traumatic.

Such stressful events come as a big emotional shock and it is normal to be very churned up afterwards. Often these reactions fade with time. But for some people things stay the same or even get worse. They are often very worried by the thoughts, feelings and physical symptoms that they are experiencing and try to avoid the things that make them feel that way or remind them of the trauma. Things just seem stuck. Sometimes people fear that they are going mad or ‘losing it’, however, this is not the case, these are typical trauma reactions.

Even though it is very well meaning most people we treat say that they don’t like it when others say “I know how you feel” or compare the traumatic event to some experience of their own. Usually it is better to simply listen to what your loved one says when they are feel able to talk about their experience.

PTSD symptoms are many and vary from person to person. However, some reactions that friends and families often observe are described below:

Fear and Anxiety

After a traumatic event the world seems like a much more frightening place, as if there is danger around every corner. It takes a while to put danger in perspective when it has been experienced first hand. As a result, you may notice that the person you are close to tries to overprotect you and others and goes out of their way to avoid risk. They may, for example, phone you often or ask you to take special care when you go out. They may be jumpy and jittery, especially when reminded of what happened.

This may be frustrating or even frightening for you. You may find it hard to know what to do when they are scared. You can help them by gently reminding them that the traumatic event is in the past and that they are safe now.

Flashbacks and memories

Flashbacks (very strong memories where it seems like the event is happening again) are common after a trauma. Memories of the event seem to come out of the blue into the mind during everyday activities and can feel uncontrollable, overwhelming and terrifying.

During treatment the person you are close to will be encouraged not to push these memories away or avoid reminders of the event. In fact, they will be encouraged to think about what happened in detail with their therapist in order to sort through these memories and put them away. You can help by reminding the person you are close to that they are safe, the danger has passed and that it is normal to have these kinds of memories whilst they are still recovering.

Sleep problems

Sleep problems are very common after a trauma including difficulties getting to sleep, waking during the night, nightmares and cold sweats, and waking early in the morning. It is as if the body has remained on “red alert”, ready to flee, fight or freeze in the face of the danger that was present at the time of the trauma. This makes sleep difficult as it is hard to relax. Once asleep, nightmares related to the trauma are common and the fear that comes with them can make a person wake drenched in sweat or even shouting or screaming.

These problems may keep you awake too if you share a room! It is important to look after yourself and make sure you get rest when you can. You can help them by keeping a normal bed time routine and, if they do wake up upset, reassuring them that they are safe.

Anger

Anger is a common reaction to trauma; it is normal to feel angry when someone or something causes us harm or distress. As a result, you may notice that the person you are close to is angrier in general and more snappy and irritable with those they love most, including you.

As the person you are close to discusses their anger in treatment things should start to improve. It may help you to remind yourself that usually it is not really you they are angry at.

Feeling sad and low

Feeling sad and low is common after a trauma especially when someone died or was permanently injured in the event. It is normal to feel low when we lose something and many people feel they have lost the person they used to be or their hopes for the future. As a result, you may notice that the person you are close to is very tearful and may even talk about hurting themselves or wanting to die.

This can be upsetting and frightening but with treatment, as they start to think about the traumatic event differently, things will start to improve. You can help them by encouraging them to be active and to do the things they used to enjoy or be interested in, little-by-little.

Loss of interest

Loss of interest is linked to feeling sad and low and can be particularly upsetting for friends and family. You may notice that the person you are close to does not seem to seek out your company as often or no longer wants to participate in the hobbies or pastimes that you shared before the trauma. Spouses and partners may notice a loss of interest in sex and children may notice that their parent doesn’t seem to play with them anymore.

These problems can put a strain on relationships but it is important that you know that the symptoms are not due to your relationship itself but rather are caused by the trauma. Again, you can help them by encouraging them gently to slowly engage in the things they enjoyed before the trauma happened.

Seeming distant or unloving

Appearing distant or “cut off” from loved ones and difficulties concentrating are common reactions to trauma. It is normal to have difficulty experiencing positive emotions and focussing on the here and now when constantly flooded by fear and anxiety from a terrifying experience. They may feel like they don’t deserve your affection and support. As a result it can seem like the person you are close to no longer cares, is unloving or can’t be bothered to listen to you.

These symptoms may be confusing, upsetting or frustrating but it may be helpful to know that the person you are close to does not care any less about you; they just can’t feel warm and happy emotions right now. You can help by reassuring them that you are there for them and that you still care about them.

Alcohol and drugs

Some people use alcohol or other drugs to help them cope with their reactions to a trauma (such as fear or sleeplessness) or to try to block out what has happened to them because it just feels so awful to think about it. But this doesn’t help fix the problem and can be disruptive to relationships, family life, work and finances.

During treatment the person you are close to will be asked to cut back on these things and that can be tough. You can help by praising them when they do cut back. It may be helpful to encourage them by not drinking yourself.

What does treatment involve?

The person you are close to is receiving a special treatment for PTSD (cognitive therapy) which we know is really helpful for the kind of problems described above. The treatment has two main strands:

▪ Sorting out the memory; talking about the traumatic experience in detail and working through the negative thoughts and feelings about the trauma, both then and now that have stopped the individual carrying on as normal.

▪ Reclaiming your life; helping the individual get back to the activities and life that they had before the trauma occurred.

This treatment can be tough because it involves talking about the very things the person with PTSD most wants to forget about. It’s a bit like cleaning a wound; it stings whilst it is getting cleaned but it heals better afterwards. As a result, you may notice that things don’t seem much better at first; sometimes the memories are even stronger in the first couple of weeks. It’s hard work, but things will gradually get better.

In the course of therapy, they will work with the therapist on doing things that they have avoided since the trauma (e.g., driving after a road traffic accident; leaving the house after dark after an assault). Some of the work will need to be done between treatment sessions, and it will take the person you are close to a lot of courage to work on these assignments.

You can help by encouraging the person you are close to keep going. Sessions can be emotionally tiring so they may arrive home tired! Your support and understanding will be helpful to them. They may want to tell you about the sessions or just need your help to find time and space to work through important treatment tasks during the week. You may be asked to accompany them on some of these tasks. When doing so, it will be important to remember how hard this is for them, even if they did not have any problems doing these things before the trauma.

It takes real courage to face the things we are frightened of and love and support from friends and relatives can make all the difference in the world.

What can I expect from the future?

Things may well go back to how they were before the trauma, but sometimes this is not possible because of ongoing physical problems or bereavement that happened as a result of the trauma. With time it is usually easier to come to terms with these changes more, even though there may always be a natural sadness.

On the other hand, sometimes things change in really positive ways. People can learn and grow through trauma and tragedy and this can shape the way they want to live in the future. Sometimes they learn new ways of coping with emotions such as anger or sadness that bothered them even before the trauma occurred; they may find it easier to talk about their feelings or relate to others who feel upset or distressed.

What you can hope for is that the person you are close to is much better able to deal with the memories of the event and re-engaging with the things they enjoyed before all this happened. And your support through treatment can make all the difference.

Looking after you

Supporting someone with these difficulties can be very demanding. You may feel quite exhausted if you have been doing so for a very long time before they started treatment. So it is important to make sure you have the support and care of others and time out for relaxation and fun.

You may have experienced or witnessed the same traumatic event as the person you are supporting and have your own difficulties to deal with it. If you recognise the symptoms mentioned above in yourself you may wish to consider visiting your GP for help.

Thank you for caring for your friend or family member and for reading this leaflet. We hope it has been helpful.

YOUR BLUEPRINT

1. HOW DID YOUR PROBLEMS DEVELOP?

It might help to think about:

■ What was your trauma?

■ What did you think was happening at the time?

■ How did this make you feel?

■ Was information missing that you know now?

■ Did you avoid thinking about the trauma and what happened afterwards?

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2. WHAT KEPT YOUR PROBLEMS GOING?

It might help to think about:

■ What stopped you being able to put the memory together and in the past?

■ Did you try to push the memory of what happened out of your mind?

■ Did you dwell on a moment without joining it up with things you know now?

■ Did you try hard to avoid reminders of the trauma?

■ Did you give up things you used to enjoy before the trauma?

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3. WHAT DID YOU LEARN DURING TREATMENT THAT HELPED?

It might help to think about:

■ What did you do to help update the memory of your trauma?

■ Did you go through your story in a lot of detail?

■ What did you learn to do when an unwanted memory came to mind?

■ What did you learn about dwelling?

■ How did you change that thinking pattern?

■ What experiments did you do to deal with your fears about reminders?

■ Did you visit the place where the trauma happened?

■ What did you do to reclaim/rebuild your life?

■ What sessions were particularly helpful?

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4. WHAT WERE MY MOST UNHELPFUL THOUGHTS? WHAT ARE THE HELPFUL ALTERNATIVES/UPDATED THOUGHTS?

It might help you to think about:

■ What were your hot spots and what new information did you find to update them?

■ What beliefs about yourself changed because of the trauma and what are your updated beliefs?

■ What beliefs about other people changed because of the trauma and what are your updated beliefs?

■ What thoughts linked to guilt, shame or anger did you have and what are your updated thoughts?

■ What thoughts did you have about being permanently different and what are your updated thoughts?

|MY UNHELPFUL THOUGHTS |UPDATED THOUGHTS |

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5. HOW WILL YOU CONTINUE TO BUILD ON WHAT YOU HAVE LEARNT?

It might help you to think about:

■ What plans have you made to keep making progress?

■ What homework will you continue with?

■ What experiments will you need to keep doing to remind you of new information?

■ What are you planning to do to further reclaim/rebuild your life?

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6. HOW WOULD YOU DEAL WITH ANY SETBACKS IN THE FUTURE?

People sometimes experience temporary setbacks when they come across strong reminders of their trauma. Things like anniversaries, court cases, meeting people involved in their trauma or another trauma can bring back trauma memories, emotions, thoughts and feelings for a short time.

It might help you to think about:

■ How have you learnt to deal with triggers of your trauma memories?

■ Would you avoid thinking or talking about the trauma?

■ What would you do if you noticed you were dwelling on the worst moments?

■ Could you seek help if necessary?

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Cognitive Therapy for PTSD (CT-PTSD): Guidance for Conducting Memory Work Remotely

(Version 3)

CT-PTSD is a trauma-focused cognitive behaviour therapy (TF-CBT), recommended by the National Institute for Health and Care Excellence (NICE) as a treatment for PTSD (NICE, 2018). A key part of this treatment is use of techniques that are memory focused.

When working remotely with people with PTSD, using Skype, Zoom etc. you can use the same treatment components in their typical order. The technique used first most commonly is the updating memory procedure. This starts with accessing key meanings of the trauma, either through ‘reliving’ (i.e., revisiting the trauma by asking the person with PTSD to describe events in the sequence in which they happened and in an emotionally engaged way) or through writing out a detailed moment-by-moment account (narrative writing). The distressing meanings are then updated with what the patient knows now. Other memory focused techniques include using a timeline/lifeline, trigger discrimination (THEN vs. NOW) and a virtual or in vivo site visit. All of these can also be used in remote treatment, with similar considerations for their use as in direct face-to- face treatment. The memory focused techniques are the best way to identify key trauma-related meanings. The change in these meanings is the best predictor of PTSD symptom change.

As in face-to-face CT-PTSD, when working remotely always

• Assess for history of dissociation in response to trauma reminders. If present:

o Work on dissociation first, identifying triggers for dissociation and introducing reminders of the here and now (objects, images, smells, physical movements [‘grounding’]). Be sure to have the person show you these reminders before you start reliving or narrative writing.

o Introduce THEN vs NOW discrimination tools early on in treatment to help patients break the link between triggers in the present and the past trauma.

o A written narrative of the trauma(s) will be the best initial memory focused work.

• Make sure you give a rationale and explain that therapy aims to update the most distressing moments so that they no longer feel as if they are happening now.

• Use reliving, a written account and description of the patient’s intrusive memories to identify key meanings to address.

• Update the trauma memory with helpful information and new meanings as soon as possible (e.g. "I survived, I did not die"). Ensure patients can draw on this information after the phone or Skype session by capturing the meaning of the updates in a written flashcard or in a photo they can access on their phone.

• When re-experiencing symptoms are associated with multiple traumatic events it can be useful to draw a timeline of life events with the person prior to reliving or narrative writing. The timeline starts from birth and extends to the patient’s current age. The patient indicates the age at which traumatic as well as positive life events occurred on the timeline. The therapist will also ask the patient to indicate which trauma are associated with re-experiencing symptoms in the present as this gives clues about the trauma to work on first.

• Complement updating memory work with the THEN versus NOW trigger discrimination.

• Be aware of avoidance. Patients may avoid engaging in memory work by holding back their feelings during reliving or if working remotely, by closing their eyes during stimulus discrimination practice or doodling during reliving. It is important to ask patients if they have been doing anything to avoid parts of the trauma story or the sounds or images you may be working with in trigger discrimination.

• Memory focused work is one part of CT-PTSD. Ensure you use other techniques such as reclaiming/rebuilding your life and behavioural experiments etc. Encourage clients to use THEN versus NOW discrimination when reexperiencing is triggered during behavioural experiments.

Special considerations for remote memory focused work

• Routinely give people the choice of reliving or writing a trauma narrative together in video sessions.

• When using the telephone for sessions (rather than Skype etc.), we recommend developing a written narrative rather than imaginal reliving. The narrative can be written down in session, either by the patient or the therapist and shared by e-mail. Alternatively, the patient may start it as homework, if they feel able to do so. It can then be emailed to the therapist in advance of the call. Narrative writing is recommended for phone calls because we think it is important for the therapist to be able to see emotional reactions during reliving, which is not possible during a phone call.

• When writing a narrative in session, the therapist or client can write the narrative. Give your client the choice of who writes the narrative. You can use the ‘share screen’ function while writing. Include updates to the worst meanings of the trauma, the hot spots, in the narrative in a different colour.

• If it is necessary to increase emotional engagement it can be helpful to ask the person to read the narrative out loud to you.

• When using images, audio files and videos sourced online to use as triggers in stimulus discrimination, email these to patients to access in your remote session or use screen share to work together on the same trigger.

• Use Google Street View to visit the site of the trauma. You can use the screen share function to do this in Zoom or on Skype.

• Extend the compassion you extend to clients to yourself. Take a break after speaking to clients and try to keep a clear distinction between your work and private life. Please be sure to put your remote therapy tools (laptop, images/other triggers you’ve sourced for clients) away after your calls, preferably in a different room.

Structure of the session

• Allocate enough time to set reliving or other memory-focused technique up properly, ensuring patients have reminders of the here and now (also called grounding objects) in their environment.

• Allocate enough time to finish reliving or narrative writing and ensure you do not finish at the worst moment of the trauma (unless this has been sufficiently updated and it is no longer maximally distressing to patients and no longer carries a heightened sense of nowness).

• Avoid conducting reliving just before the end of the session.

• Plan what activity (e.g., a reclaiming life or self-care activity) the person will do after the call

• Always ask for feedback at the end of a session, and especially about any memory focused techniques used.

Further Resources

For training videos on how to conduct CT-PTSD, including reliving and updating, narrative writing, Then vs Now, conducting a Site Visit and Virtual Site Visit, creating a trauma timeline, and working with dissociation, see the PTSD videos at . You will need to register as a therapist to access the videos. There is no charge. The videos and other materials on the OxCADAT website assume that therapists using the materials have already had general training in cognitive behaviour therapy.

The PTSD NICE guideline, including adaptations for complex presentations, is available at .uk/guidance/ng116.

Acknowledgements

This document was created by the team at the Oxford Centre for Anxiety Disorders and Trauma. The work was supported by the Wellcome Trust, NIHR Senior Fellowships and the Oxford Health NIHR Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

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You will discover from this handout that the feelings, thoughts and body sensations you are experiencing are a normal reaction to stress. They are signs that your body and your mind are working to come to terms with your traumatic event(s).

You may find that you are having “flashbacks”, when images, sounds or other sensations from what happened suddenly pop into your mind. Sometimes flashbacks can be so vivid that you may feel as if the trauma is happening all over again.

• [pic] You may also find that you are re-experiencing the trauma in nightmares.

[pic] You may re-experience the trauma emotionally, including bodily reactions, without having images of the trauma or nightmare.

Feeling angry in PTSD can be linked to:

• Memories of what happened. These can be triggered in situations that have nothing do with the trauma.

• Dwelling on the unfairness of the trauma and how others have treated you.

• Frustration about difficulties in everyday life.

• High arousal and poor sleep may make you more irritable than usual so that you may react more strongly to small things than before the trauma.

• You may also feel that nobody really understands what you are going through.

Avoidance and extra precautions are very common after trauma as they can help reducing distressing feelings in the short-term. But they are often not the best longer-term strategy for getting over trauma.

• It is difficult to avoid one’s own thoughts and feelings successfully. They keep coming back, and indeed trying to avoid them actually makes them more frequent and persistent and increases the sense of being out of control.

• Scanning, avoidance and extra precautions are usually a result of predictions that something terrible will occur, for example, that your feelings will overwhelm you, or that you will be attacked again. They make perfect sense when you believe you are going to be harmed. But they also stop you from discovering that your fears may be exaggerated, and that the world is not as dangerous as it seems. As a result, your life may become more and more restricted.

The main message of this handout is this:

The feelings, thoughts and body sensations you have been experiencing are entirely normal. They are a natural, human reaction to extreme stress.

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