Returning to the scene of the trauma in PTSD treatment – why, how and when?

Moving forward with the loss of a loved one: treating PTSD following traumatic bereavement with cognitive therapy

Traumatic loss is associated with high rates of post-traumatic stress disorder (PTSD) and appears to inhibit the natural process of grieving, meaning that patients who develop PTSD after loss trauma are also at risk of experiencing enduring grief. Here we present how to treat PTSD arising from traumatic bereavement with cognitive therapy (CT-PTSD; Ehlers et al., 2005). The paper describes the core components of CT-PTSD for bereavement trauma with illustrative examples, and clarifies how the therapy differs from treating PTSD associated with trauma where there is no loss of a significant other. A core aim of the treatment is to help the patient to shift their focus from loss to what has not been lost, from a focus on their loved one being gone to considering how they may take their loved one forward in an abstract, meaningful way to achieve a sense of continuity in the present with what has been lost in the past. This is often achieved with imagery transformation, a significant component of the memory updating procedure in CT-PTSD for bereavement trauma. We also consider how to approach complexities, such as suicide trauma, loss of a loved one in a conflicted relationship, pregnancy loss and loss of life caused by the patient.

Key learning aims

To be able to apply Ehlers and Clark's (2000) cognitive model to PTSD arising from bereavement trauma.To recognise how the core treatment components differ for PTSD associated with traumatic bereavement than for PTSD linked to trauma where there is no loss of life.To discover how to conduct imagery transformation for the memory updating procedure in CT-PTSD for loss trauma.

Service support, work engagement and psychological wellbeing: validating an index of resource and infrastructure support for the delivery of CBT

BACKGROUND

Effective dissemination of cognitive behavioural therapy (CBT) has been assisted by clearly defined competencies, skills and activities, and validated scales used to measure therapist competence and adherence. However, there is no validated measure of the resource and infrastructure support therapists require to enable them to deliver CBT in line with best practice.

AIMS

This study aimed to validate an index of resource infrastructure and support for the delivery of CBT.

METHOD

This study took an existing questionnaire developed by Groom and Delgadillo (2012) and aimed to establish its psychometric properties through expert review and a pilot study.

RESULTS

This resulted in a shorter questionnaire with good content validity, internal consistency (α = 0.80) and temporal stability (r = 0.74, p < .00). The index consists of six components, and construct validity was demonstrated through positive association with measures of work engagement (r = 0.31, p < .00) and practitioner wellbeing (r = 0.47, p < .00).

CONCLUSIONS

The questionnaire provides a valid and reliable index of service support for delivering CBT, and is positively related to engagement and wellbeing among CBT practitioners.

Cognitive therapy for moral injury in post-traumatic stress disorder

Moral injury is the profound psychological distress that can arise following participating in, or witnessing, events that transgress an individual's morals and include harming, betraying, or failure to help others, or being subjected to such events, e.g. being betrayed by leaders. It has been primarily researched in the military, but it also found in other professionals such as healthcare workers coping with the COVID-19 pandemic and civilians following a wide range of traumas. In this article, we describe how to use cognitive therapy for post-traumatic stress disorder (CT-PTSD) to treat patients presenting with moral injury-related PTSD. We outline the key techniques involved in CT-PTSD and describe their application to treating patients with moral injury-related PTSD. A case study of a healthcare worker is presented to illustrate the treatment interventions.

KEY LEARNING AIMS

(1)To recognise moral injury where it arises alongside PTSD.(2)To understand how Ehlers and Clark's cognitive model of PTSD can be applied to moral injury.(3)To be able to apply cognitive therapy for PTSD to patients with moral injury-related PTSD.

Behavioural Experiments in Cognitive Therapy for Posttraumatic Stress Disorder: Why, When, and How?

Behavioural experiments are an integral component of cognitive therapy (CT) for posttraumatic stress disorder (PTSD), but they can be overlooked due to practical constraints and therapist concerns. Here we describe why behavioural experiments are an important part of CT, where they fit into different elements of treatment for PTSD, how to design and implement effective experiments including coping with unexpected outcomes, and how to incorporate behavioural experiments when therapy is delivered remotely. Clinical case examples are used to illustrate a range of idiosyncratic and creative behavioural experiments.

Treating posttraumatic stress disorder remotely with cognitive therapy for PTSD

Delivering trauma-focused cognitive behavioural therapy to patients with PTSD during the COVID-19 pandemic poses challenges. The therapist cannot meet with the patient in person to guide them through trauma-focused work and other treatment components, and patients are restricted in carrying out treatment-related activities and behavioural experiments that involve contact with other people. Whilst online trauma-focused CBT treatments for PTSD have been developed, which overcome some of these barriers in that they can be delivered remotely, they are not yet routinely available in clinical services in countries, such as the UK. Cognitive therapy for PTSD (CT-PTSD) is a trauma-focused cognitive behavioural therapy that is acceptable to patients, leads to high rates of recovery and is recommended as a first-line treatment for the disorder by international clinical practice guidelines. Here we describe how to deliver CT-PTSD remotely so that patients presenting with PTSD during the COVID-19 pandemic can still benefit from this evidence-based treatment.

Can visiting the site of death be beneficial for bereaved families after terror? A qualitative study of parents' and siblings' experiences of visiting Utøya Island after the 2011 Norway terror attack

Background. After the 2011 terror attack on Utøya Island, a collective visit was organized for bereaved families. There is limited knowledge whether bereaved families can benefit from such visits after terror. Objective. This study aims to explore how bereaved families experienced visiting the site of death after the 2011 terror attack. Method. As part of in-depth interviews, 22 parents and 16 siblings were asked whether they had visited Utøya and, if so, how they experienced the visit. Participants' responses were analysed using thematic analysis. Results. The results showed that for the majority of the bereaved, visiting Utøya had been important in processing their loss. Three key themes emerged as to what they considered important with the visit: 'seeing the actual place of death', 'seeking factual information', and 'learning to know the island'. These factors were associated both with beneficial reactions (e.g. accepting the reality of the loss increased cognitive clarity) and with distressing reactions (e.g. intrusive thoughts, re-enactment images), but the benefits had outweighed the distress. Having the opportunity for multiple visits seemed to optimize the benefits. Conclusion. Bereaved families should be offered the opportunity to visit the site of death after terror.

Clients' Experiences of Returning to the Trauma Site during PTSD Treatment: An Exploratory Study

Background:Visits to the location of the trauma are often included in trauma-focused cognitive behavioural therapy (TF-CBT) for post-traumatic stress disorder (PTSD), but no research to date has explored how service users experience these visits, or whether and how they form an effective part of treatment.Aims:The study aimed to ascertain whether participants found site visits helpful, to test whether the functions of the site visit predicted by cognitive theories of PTSD were endorsed, and to create a grounded theory model of how site visits are experienced.Method:Feedback was collected from 25 participants who had revisited the scene of the trauma as part of TF-CBT for PTSD. The questionnaire included both free text items, for qualitative analysis, and forced-choice questions regarding hypothesized functions of the site visit.Results:Overall, participants found the site visits helpful, and endorsed the functions predicted by the cognitive model. A model derived from the feedback illustrated four main processes occurring during the site visit: “facing and overcoming fear”; “filling in the gaps”; “learning from experiences” and “different look and feel to the site”, which, when conducted with “help and support”, usually from the therapist, led to a sense of “closure and moving on”.Conclusions:Therapist-accompanied site visits may have various useful therapeutic functions and participants experience them positively.