Cognitive Therapy for Posttraumatic Stress Disorder

Anke Ehlers, London, United Kingdom

In the immediate aftermath of traumatic events, many people experience symptoms of posttraumatic stress disorder (PTSD). Many recover in the following months, but a significant subgroup develops chronic PTSD. Factors explaining the maintenance of the disorder are at the core of Ehlers and Clark’s (2000) recent cognitive model of chronic PTSD. The model specifies three maintaining mechanisms. First, people with chronic PTSD show excessively negative appraisals (“personal meanings”) of the trauma and / or its sequelae that lead to a sense of current threat. Second, the nature of the trauma memory explains the occurrence of reexperiencing symptoms. Third, the patients’ appraisals motivate a series of dysfunctional behaviours and cognitive strategies (such as thought suppression, rumination, safety-seeking behaviours) that are intended to reduce the sense of current threat, but maintain the problem by preventing change in the appraisals and trauma memory, and / or lead to increases in symptoms.
On the basis of the model, we have developed a new version of CBT that has three goals. First, the idiosyncratic negative appraisals of the trauma and / or its sequelae are identified and changed. Therapeutic techniques include reliving of the event to identify hot spots and associated meanings, socratic questioning, and behavioural experiments. Second, the trauma memory is elaborated.  “Personal meanings” of the trauma are updated with information that corrects impressions and predictions from the time of the event, using a range of techniques such as updated trauma narratives, imaginal reliving including updated meanings, in vivo reconstruction of the event, and imagery modification. In stimulus discrimination training, the patient learns to discriminate triggers of reexperiencing symptoms from the stimuli that were present during the trauma. Third, the patient is encouraged to drop maintaining behaviours and cognitive strategies. Results from four randomised controlled trials and two audits of National Health Service clinics indicate that the treatment is highly effective and acceptable to patients. The workshop starts by outlining the cognitive model. Case examples will be given to illustrate the different aspects of the model. Next the techniques used in the treatment are described and illustrated with clinical material and videotapes.