This is the third in a series of posts triggered by Nick Grey's workshop on memory-focused approaches in CBT for adults with PTSD.  In the second post yesterday, I wrote about " ... treatment structure".  In today's post I want to step back for a moment and get a broader perspective.  These trauma-focused treatments have much wider applicability than just for DSM-IV-TR congruent, single episode traumas, and it's this wider applicability that's a major reason for me doing this workshop.

The question of appropriate client assessment and monitoring can open a bit of a can of worms here, or a cornucopia of possibilities if you'd prefer a more upbeat spin. I can think of at least four types of therapeutic situation where I might want to be using adaptations of trauma-focused cognitive therapy, but where assessment might best look more broadly than just using straightforward type I trauma questionnaires like the IES-R. So one such situation is with PTSD symptoms that are triggered by life events that don't typically qualify for a PTSD diagnosis - usually this would mean that they don't fit with criterion A which states the sufferer should have been "exposed to a traumatic event in which both of the following were present: 1.) experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2.) the person's response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behaviour)."  Fascinatingly, PTSD symptoms in the community often don't require this kind of initiator - see the classic Gold et al paper "Is life stress more traumatic than traumatic stress?" with its abstract reading "This study explored the definition of a traumatic stressor, as it currently stands in the DSM-IV-TR, and the relationship between this definition and psychological symptomatology. Four hundred and fifty-four college undergraduates completed measures assessing psychopathology and exposure to trauma. Individuals were then divided into two groups, those who reported a traumatic event that was consistent with the DSM Criterion A1 definition and those who reported a traumatic event that was inconsistent with the definition. Surprisingly, the latter group reported significantly greater severity of PTSD symptomatology than those who reported a Criterion A1 PTSD event. In addition, significantly more people in the DSM trauma-incongruent group met criteria for PTSD than those in the DSM trauma-congruent group. Nearly two-thirds of the DSM trauma-incongruent group identified the death or illness of a loved one as their traumatic experience. The results are discussed within the context of the ongoing controversy over PTSD Criterion A1." Mol, Arntz et al showed a similar picture in a large adult population, see "Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study." It might be absolutely appropriate to use a measure like the IES-R in this common trauma-incongruent PTSD, but - where death of a loved one is the trigger - it may well be that it would be more helpful to conceptualise the symptoms as traumatic grief and use a more appropriate scale like Prigerson et al's questionnaire described in their paper "Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss." A copy of the "Traumatic grief inventory" is downloadable from further down the "Relationships in general" page of this website. Grief is a huge subject area in its own right and the overlap with PTSD is widely appreciated - see, for example, Anke Ehlers' paper "Understanding and treating complicated grief: What can we learn from posttraumatic stress disorder?"

In further posts about this workshop on memory-focused approaches in CBT for adults with PTSD, I talk in more detail about the use of written trauma descriptions and - extending the current post - I look at further applications involving anxiety & depression, personality disorders, and complex type II traumas.