MEQ: Choosing and planning trauma-focused therapy after assault

(i) Ehlers–Clark model applied (5). Persistent PTSD arises when trauma is processed so the person experiences serious current threat. Here: negative appraisals — self-blame (“I should have fought harder”), possibly shame and danger generalisation (night shifts/car parks = unsafe). Memory quality — intrusive images/nightmares suggest poorly elaborated, perceptually rich trauma memory re-experienced as if now. Maintaining strategies — avoidance of night work and car parks; alcohol to sleep/suppress affect; possible rumination/self-attack. These strategies prevent updating of the memory and disconfirmation of appraisals, so threat sense continues.^[1][2]

(ii) Two first-line options and key techniques (5). Prolonged exposure is made up of two exposure techniques, imaginal exposure and in vivo exposure.^[12] EMDR is an eight-phase treatment (history taking, client preparation, assessment, desensitisation, installation, body scan, closure and re-evaluation); in desensitisation the client attends to the target image and eye movements simultaneously.^[10] CPT identifies and challenges dysfunctional cognitions resulting from the trauma, including assimilated and overaccommodated stuck points such as self-blame, with between-session practice assignments.^[13] Lewis 2020 gives a confident recommendation of CBT with a trauma focus and EMDR as first-line, with CPT, CT and PE the treatments of choice among the CBT-Ts.^[5]

(iii) Engagement, risk and explanation (5). People with PTSD may be apprehensive, anxious or ashamed, may avoid treatment or believe PTSD is untreatable; engagement strategies include following up missed appointments and flexible attendance. Where assessment identifies a significant risk of harm, establish a risk management and safety plan as part of initial treatment planning. Explain that trauma-focused CBT typically runs over 8 to 12 sessions; it includes psychoeducation about reactions to trauma, strategies for managing arousal and flashbacks, and safety planning, and it involves elaboration and processing of the trauma memories. EMDR includes self-calming techniques and techniques for managing flashbacks for use within and between sessions.^[9]

(iv) Alcohol, medication and residual symptoms (5). Do not exclude people with PTSD from treatment based solely on comorbid drug or alcohol misuse. Consider venlafaxine or an SSRI such as sertraline if she prefers drug treatment, and review it regularly. If she has residual symptoms after a trauma-focused intervention, consider CBT targeted at specific symptoms such as sleep disturbance or anger.^[9] In outpatients with PTSD, sertraline (25 mg/d for 1 week, then flexible 50 to 200 mg/d) beat placebo on 3 of 4 primary outcome measures.^[6] Benzodiazepines should be considered relatively contraindicated in PTSD.^[11]