Contents
Stage 2: increase the safe base, secure haven and soothing system
Frame
Client presents having had a RTA and presents some weeks\months later for 12 sessions of CBT
Client Empathy
The client has had something very frightening happening to them, they thought they were going to die. There is more than likely to be a big difference in terms of how they acted at the time, and how they might think back over the incident.
Client effects
Cognitive
Beliefs about themselves may be challenged: I can look after myself, I am safe, Others are not to be trusted
Behavioural
Safety Behaviours whilst driving, hyper vigilance
Avoidance
Emotions
Anxiety: It could happen again, I’m not safe
Anger: How could I\they be so stupid
Depression: World might shrink on the trauma effects of I’m not safe (world or I am dangerous)
Symptoms
Hyperarousal
Flashbacks
Rumination
Meta cognitions about trauma\sequalae
Client preparation
We will assess your difficulties, understand them via a model and then look at some treatment options
Client Assessment
Here its understandable if the client wants to tell you all about the accident but at this point, you don’t need to go into details, just yet.
Current symptoms
Cognitions: What’s changed pre and post accidents in your beliefs
Emotions: What’s changed pre and post accidents in your emotions: what can they tell us about how you see the world , now and then
Behavioural: What’s changed pre and post accidents in your behaviours, what are you doing more of or less of. What are the effects of these behaviour changes, in thoughts, emotions and other behaviours.
Memories=Dreams/Flashback/Ruminations: how are these affecting you
Substance: how is alcohol, food, and sleep
Meta-cognitions=Accident/Sequalae. With these beliefs, how does this affect your behaviour.
Triggers=Do you notice any triggers to remembering the trauma
History=are there any events that happened to you, that could support the beliefs that you generated from the accident
Client Psychoeducation
Need to psychoeducation about memories
Accident Memory
Is overwhelming, the amygdala encodes the memory but doesn’t process it. What this means is the memory can be retriggered but isn’t stored properly, so an association can remind you of it, but its not like a standard memory which is filed and relates to other similar memories, so for instance if you went for a walk today, your memory would go amongst all the other walks you had, some which were pleasant, some less so.
How does this seem to you, does it make sense with your experience?
Memory Content
The memory of the event is both the image of what happened, the physical and emotional feelings, as well as the beliefs that you have about yourself and the world. So when memories are triggered you can get parts of the memory, i.e. thoughts, or emotions, or all of it. Because the memory is triggered rather than recalled sometimes it might not seem like a memory
Memory effects
What are the effects of
1. Remembering a lovely holiday: emotions
2. Remembering a sad event: emotions
If you imagine replaying a memory then the brain experiences the event over again.
How do you think that might affect its beliefs.
If you then add in that you get memory affects but it might not seem like a memory, e.g. RTA trauma memories
What stops trauma memory processing?
Avoiding the memory as its painful
How do memories normally get processed?
By talking about the event in a number of ways, with a number of people. At night as you dream REM sleep processes memory by making connections between the event and all the other similar events.
What makes the memory so painful?
The powerful beliefs that get constructed from it
How can we now work with your memory?
By going through the memory repeatedly so the anxiety from it reduces. This means staying with the memory until the anxiety reduces to show that theres nothing from about the memory that we need to be frightened of.
Going through the memory in detail. Here we are looking for any hotspots, i.e. moments of significant distress, that might have been true at the time, but aren’t now. Doing this both weakens the power of the memory and processes it by making the connections to the rest of our memories.
Client formulation
Accident happens
Memory not processed
Memory re-triggered/Memory thought about=>Feels like it is still happening
On the basis that its still happening=>behaviour changes
Some post accident beliefs supported by early experiences
Behaviour change then supports beliefs coming out of the accident
Treatment
Stage 1: Preparation
Assessment, Formulation and psycheducation
Stage 2: increase the safe base, secure haven and soothing system
BA: Increase pleasure and meaning in life to support reliving
Soothing for pre and post reliving:
1. Compassion: how you would/you would like another to act to a loved one if something horrible happened to them
2. Special place
3. Light stream
4. Breathing meditation
Practice each one of these daily and increase pleasure and meaningful activity
Stage 3 Reliving
Making a script, write it, then read it into a phone
Write down pre anxiety, during and post.
If pre anxiety is high then use a soothing activity, until it reduces.
Play script
Mark down how high anxiety was when you finished
If post anxiety is high then use a soothing activity until it reduces
Mark down any “hotspots” on the form
Go at your own pace, make your goals challenging but realistic, so vary the amount of time you do it, and how long you do it for.
Continue reliving, until the memory is processed
Stage 4 Rebuilding
Given this has happened how do you want to be living in the face of it.
Values
BA
Appendix
Assessment questionnaire
So I understand you were in a RTA, whilst I can imagine it was a very difficult event, if I could start with looking at the current effects of the accident.
Firstly when was the date of the accident
What are the current problems and symptoms that relate to the accident
Specific PTSD
Accident memories
Do you get flashbacks of the accident , a movie like youre back there again?
Do you have unpleasant dreams of the accident?
Do you get unpleasant memories of the accident?
Accident prevention
Do you find yourself avoiding things you used to do
Do you find yourself checking for danger, excessively
Do you find yourself doing things to keep yourself safe excessively
Emotional management
Do you find yourself having unpleasant emotions about the accident
How do you manage them, substance, disassociation?
Maintenance
Do you ruminate about the accident?
Do you try to get rid of any thoughts\memories about he accident
Accident
What do you think of the fact that accident happened?
What do you think of the effects of the accident?
What was the worst part of the accident for you?
Cognitive
Do you notice any change to your beliefs pre and post accident about self\world\others?
Previous traumas
Does this trauma remind you of any previous ones?
Treatment
Is this more appropriate for EMDR or tfCBT?
