Treating posttraumatic stress disorder remotely with cognitive therapy for PTSD

Figures & data

Figure 1. Ehlers and Clark (2000) cognitive model of PTSD with treatment goals (reprinted with permission from Ehlers, 2013).

Table 1. Commonly used process measures in CT-PTSD.

Process Measure	Purpose
Post-traumatic Cognitions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) or a shortened version that can be given weekly (e.g. Kleim et al., 2013).	To assess trauma-related appraisals linked to feelings of overgeneralised fear, anger, guilt, shame, permanent change, alienation or persistent degradation.
Responses to Intrusions Questionnaire (RIQ; e.g. Clohessy & Ehlers, 1999).	To assess unhelpful responses to intrusive memories, such as rumination, suppression and numbing.
Safety Behaviours Questionnaire (SBQ; e.g. Dunmore, Clark, & Ehlers, 2001).	To assess excessive precautions the patient may take to minimise perceived risk.
Unwanted Memories Questionnaire (e.g. Michael, Ehlers, Halligan, & Clark, 2005).	To assess qualities of intrusive memories that contribute to the sense of current threat such as their “nowness”.

Figure 2. Maintenance cycle showing how the patient’s strategies for dealing with unwanted memories cause her symptoms to persist.

Table 2. Reclaiming life activities that can be carried out remotely.

Exercise	Finding your trainers again Going for a walk/run/cycle Health and fitness apps Taking the dog for a walk	Exercising at home using online videos, video game consoles or DVDs Yoga, Pilates Dancing
Self-care	‘Me time’ Relaxation activities Meditation/wellbeing apps Prayer/religious activities Buying yourself a treat Buying/making your favourite food	Taking a bath Getting back to your old beauty/grooming routine Trying a new style of clothes, hair or make-up Healthy eating Improving your sleep routine
Interests & Hobbies	Reading Creative writing, blogging Drawing, Arts and Crafts Learning a new skill/language (using the internet, books, or apps) Taking/organising photos Listening to or making music/playing an instrument Researching future holiday destinations	Cooking/baking (e.g. from your old recipes) DIY Gardening, growing seeds Crosswords/puzzles/quizzes Singing, joining an online choir Researching a topic of interest Watching TV or films that you used to enjoy
Social & Relationships	Planning a meal or activity with your family/partner/housemates/friends (in person, virtually, or both as required) Arranging to meet a friend or friends for virtual coffee/drink/dinner Catching up with work colleagues Checking in on neighbours/those who are vulnerable Playing a game online with a friend	Contacting someone you haven’t spoken to in a while (e.g. phone, email, messaging) Dating apps Online classes or discussion groups on social media Sending someone a card, letter or gift Activities with children (e.g. sports day, treasure hunt, make a movie, build something, board games) Organise an online quiz
Work	Researching job or volunteering opportunities Creating a pleasant workspace at home Online training courses or learning new skills to help to you improve/progress in your job role Updating your CV Starting/progressing/finishing a project or assignment	Evening classes, college, or university courses via distance learning Talking to your manager about how they can support you Seeking advice and help around money/benefits/employment Planning your work and career goals

Table 3. Essential practicalities for the in person and remote updating trauma memories procedure.

In Person & Remote Delivery		Purpose
Give rationale (e.g. to help put the trauma in the past; update the most distressing moments so they no longer feel like they’re happening now)		Increases understanding and engagement with the trauma-focused work.
Elicit and address concerns about reliving or narrative writing		Guides adaptations (e.g. conducting imaginal reliving for a part of the trauma in the first instance rather than the whole story) and informs behavioural experiments to test patient’s concerns, if necessary (e.g. testing predictions that the patient will not be able to stop crying, for example, if they talk through their trauma).
Agree where in the trauma story to start and stop. Generally, start before the main traumatic event and continue until the person felt safer, or the worst parts are over.		Provides clarity for the patient. Stopping reliving or narrative writing at a point where the patient felt safe ensures the patient is not left in moments of heightened distress and helps to demarcate the end of the traumatic event, wherever possible.
Allocate enough time to finish reliving or narrative writing.		This ensures you do not finish at the worst moment of the trauma associated with heightened distress, but rather have time to finish the trauma story at a point where the patient felt reasonably safe.
Be aware of avoidance		Spotting signs of avoidance (e.g. skipping over parts of the trauma) can help you to engage patients with their memory of the trauma in future reliving/narrative writing/updating and ensures that memory updating will be maximally effective for patients.
Identify worst moments (‘hot spots’)		Identifying the worst moments helps identify the worst meanings that are maintaining distress and symptoms.
Take ratings of distress and newness		These ratings show levels of distress and how much the memory seemed as though it was happening now rather than being in the past. When updating information is linked to worst moments, we would expect shifts in these ratings.
Identify updating information		This information will help to make the meanings less threatening and distressing. Information may emerge from knowledge about how the event unfolded (e.g. the outcome was better than expected) or from cognitive restructuring of meanings.
Include updates early		For outcomes that were better than expected (e.g. ‘I survived’; ‘I am still living with my family’) include such updating information in early reliving/narrative writing since this helps to reduce distress and increases hope and motivation.
Insert updates in narrative writing in a different colour		This helps to reinforce the updating information and helps to reduce distress.
Ask for feedback		Helps you to understand the patient’s experience and gives you information to make adaptations, if necessary.
Capture updates in a written flashcard or a photo		This helps patients to easily access updates. Flashcards and photos can be accessed on their phone.
Plan activity (e.g. a reclaiming life or self-care activity) the patient will do after the session		Rewards patients’ efforts, ensures they will move onto a cognitive or behavioural activity that is not trauma-focused, and may reduce opportunities for rumination.
Adaptations for Remote Delivery
Check the patient has privacy		This helps to create a safe place for the patient to engage with the trauma memory.
Elicit any concerns the patient has about remote work		Provides the opportunity to address specific concerns and may likely increase the sense of safety with remote therapy.
For video conferencing sessions, ask the patient to show you their reminders of the here and now		Allows you to refer to specific reminders to bring the patient’s attention back to the here and now if they begin to dissociate.
For video conferencing sessions, routinely give patients the choice of reliving or writing a trauma narrative together		Increases the patient’s sense of control. If writing a trauma narrative, share screen. Patient or therapist can type the narrative. Use your voice and reminders of the here and now if the patient over-engages with the memory.
For telephone sessions, conduct narrative writing		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. The narrative can be written in session or for homework and emailed to you in advance of the call. To increase emotional engagement, especially when updating hot spots, ask the patient to read the narrative out loud or read it out to them if they prefer.

Table 4. Then vs Now trigger discrimination table developed for one of the patient’s triggers (ambulance siren).

	THEN	NOW
Similarities	Ambulance on road	Ambulance on road
	Sirens	Sirens
Differences	9 am in the morning	7 pm at night
	Father can’t breathe	Father is breathing
	My father could barely speak	I can hear my dad chatting on the phone
	My father is uncomfortable and in pain	My father is comfortable
	Hearing the ambulance suggested danger, something terrible might happen to my dad	Hearing the ambulance means the paramedics may be able to help someone else. My dad is safe.

Table 5. Questions asked in the blueprint.

How did my problems develop? What kept my problems going? What did I learn during treatment that helped? What were my most unhelpful thoughts? What are the helpful alternatives/updated thoughts? How will I deal with any setbacks in the future?

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress Disorder. Behaviour Research and Therapy, 38(4), 319–345.

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Ehlers, A. (2013). Trauma-focused cognitive behavior therapy for posttraumatic stress disorder and acute stress disorder. In G. Simos & S. G. Hofmann (Eds.), Textbook of CBT for anxiety disorders (pp. 161–189). New York: Wiley.

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Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D., & Orsillo, S. (1999). The post-traumatic cognitions inventory (PTCI). Development and validation. Psychological Assessment, 11, 303–314.

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Kleim, B., Grey, N., Hackmann, A., Nussbeck, F., Wild, J., Stott, R., … Ehlers, A. (2013). Cognitive change predicts symptom reduction with cognitive therapy for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81, 383–393.

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Clohessy, S., & Ehlers, A. (1999). PTSD symptoms, response to intrusive memories, and coping in ambulance service workers. British Journal of Clinical Psychology, 38, 251–265.

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Dunmore, E., Clark, D. M., & Ehlers, A. (2001). A prospective study of the role of cognitive factors in persistent posttraumatic stress disorder after physical or sexual assault. Behaviour Research and Therapy, 39(9), 1063–1084.

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Michael, T., Ehlers, A., Halligan, S., & Clark, D. M. (2005). Unwanted memories of assault: What intrusion characteristics predict PTSD? Behaviour Research and Therapy, 43, 613–628.

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