The previous post in this sequence reflecting on a trauma-focused CBT workshop looked in some detail at imaginal reliving/revisiting.  This seventh & final post more briefly describes "site visits" and "discrimination training".  Nick Grey, who ran the workshop, said that there are four ways that he works with trauma memories - and this is typical for the overall Ehlers and Clark treatment of PTSD.  Two of the ways I have already described - imaginal reliving and written narratives.  Additionally there are site visits and discrimination of triggers.

Nick commented that he tried do a "site visit", if practically feasible, with all clients.  I find this challenging to hear, as it's not something that I regularly manage with clients myself and I want to try to incorporate it more often into my own work with trauma.  Probably very much a second best, but an interesting option, is to use Google Earth to explore the site of the trauma with one's client.  A "Google Earth visit" is worth considering as a first step even if one plans to then go on to a full visit of the actual trauma site itself. (Nick commented in a later email that he is currently often using Google Street View) 

Nick said that revisiting the site could help therapeutically in a whole series of ways.  He listed seven bullet points: 1.) behavioural experiments - what is the client's fear or other "prediction" about what they feel might happen if they go back to the trauma site.  It can sometimes be helpful therapeutically to make this imagined "prediction" specific & explicit and then check out its truth or falsity in real life.  2.) watch out for safety behaviours - ways that clients may subtly avoid fuller "exposure" to feared experiences and so limit the benefits they could have achieved by facing their fear.  3.) relive & reconstruct - once at the site, typically one would ask the client to "talk me through what happened".  4.)  then v's now - are there any differences between how the site was in the trauma memory and how it actually is now on revisiting it?  5.) time-code on memory - coming back to the site can help to highlight that the memory is in the past.  6.) new information - coming back to the site (and talking through what happened) provides more cues to trigger fuller memories.  7.) new meanings - what additional or changed meanings emerge as new information becomes available from the site visit?  A list of these seven bullet points is downloadable both as a Word doc and as a PDF file.  

We also talked about "discriminating triggers".  PTSD sufferers are likely to have distress and flashbacks triggered by a broad range of different cues.  This problem may clear simply as a beneficial "side-effect" of the imaginal reliving, trauma writing & general processing work that is being done in therapy.  The usual aim would be to get people to a point where - like a more normal memory - it takes a narrow-focus, precise cue to trigger the memory rather than the more general range of stimuli that can act as triggers after trauma.  Nick commented that the triggered intrusions might involve emotion (or behaviour) without recollecting the memory itself.  He suggested that it might be worthwhile encouraging the client to use a diary and act as a bit of a detective to clarify what stimuli/situations are involved - often they are low-level physical cues such as colour, sound, movement or internal cues.  The aim is to discriminate NOW v's THEN, breaking the link between trigger and memory.  In the "Oxford guide to imagery in cognitive therapy" (p.125-6) they write "Ehlers et al have developed a template to help clients discriminate more clearly between the past and the present when intrusive imagery is activated.  The therapist draws two columns on the white board, and begins by making notes in the two columns of the similarities between the current situation and those present during the trauma.  Next in two differently coloured pens, lists are made of the ways in which the two situations differ.  This technique was invented as a therapy strategy for PTSD: however, it could be utilized in any other disorder where intrusive memory imagery is triggered ... usually the similarities are sensory features that are in fact harmless and coincidental.  The differences, however, are between intrinsically dangerous and safe aspects.  By focusing on the differences the client is usually able to feel calmer, and to feel better equipped to make discriminations if the old traumatic feelings and memories are triggered.  Having demonstrated this technique in the session, the therapist can suggest that, for homework the client deliberately seeks triggers for intrusive imagery associated with past memories: and then carefully attends to the similarities and differences between the current trigger situation and the past traumatic situation.  This typically results in the intrusive imagery being triggered less and less frequently."  A simple form that can be used for discrimination training - both in session with a therapist & as a homework sheet - is downloadable as a Word doc and as a PDF file.  It seems likely that for tricky, persistent triggers, it would be worth considering the use of "implementation intentions".  The recent paper - "Making self-help more helpful: A randomized controlled trial of the impact of augmenting self-help materials with implementation intentions on promoting the effective self-management of anxiety symptoms" - highlights the potential gains that are achievable with this kind of augmentation.  For "how to do it", see the two posts beginning with "Implementation intentions & reaching our goals more successfully". 

So, time to bring this sequence of seven blog posts on Nick Grey's fine PTSD workshop to close.  I'll finish with four brief points.  Firstly, although this workshop focused on memory-focused approaches, it's crucial to realise that tackling avoidance and helping with belief change are also key aspects of the therapy.  I wrote about this last year in the post "Guildford BABCP conference: Rolls Royce therapy & Anke Ehlers on PTSD" where I quoted Anke's remark that tackling "negative assessments" is likely to be the most important of these three overlapping aspects.  Secondly, if I was to add just one further facet to this PTSD therapy that I'm confident would reduce dropouts and improve outcomes still further, I would strongly encourage therapists to incorporate more organized sessional client feedback.  This would both involve having a clearer idea of typical improvement rates over the early therapy sessions so that one can react quickly if progress is stalling, and also obtaining in-session feedback on the working alliance so any problems/new information can be addressed immediately.  For more on this and the wide-ranging therapeutic implications see another post from last year - "Guildford BABCP conference: what shall we do about the fact that there are super-shrinks and pseudo-shrinks?" - and the section on therapist feedback in "Update on website traffic: my own favourite top 15 ... ".  Thirdly, it's interesting to note the way these trauma-focused therapy approaches can integrate with the blossoming of interest in narrative therapies - see, for example, "Angus & Greenberg's book 'Narrative in emotion-focused therapy" (first post): context."  And talking of books, my fourth & final point is that Nick Grey & colleagues are due to bring out a treatment manual based on the Ehlers & Clark model early in 2013.  I'm told the title is "Cognitive therapy for PTSD: a therapist's guide" (OUP Press).  If it's anything like as helpful as this workshop has been, then it will be well worth getting!