Sep 24, 2019
How do you talk about something in therapy when all you want to do is avoid thinking about it? And why might it help to be able to tackle it?
Nick Gilbert talks to Dr Lucy Maddox about how he sought help for post traumatic stress disorder (PTSD) and his therapist, Dr Jen Wild, explains the theory behind the treatment, and dispels some myths about what it's like.
This show includes reference to suicide.
Show Notes and Transcript
Some more sources of information are listed below.
For more about BABCP check out: www.babcp.com
To find an accredited therapist: http://cbtregisteruk.com
NHS Website about treatments for PTSD are described here:
Support for veterans can be found here:
Overcoming Traumatic Stress by Claudia Herbert
Trauma is Really Strange by Steve Haines
Jen has a book coming out soon too - watch this space for details.
Lucy: Hi, and welcome to Let’s Talk About CBT with me, Dr Lucy Maddox. The podcast all about CBT, what it is, what it’s not and how it can useful.
In this episode we’ll find out about post-traumatic stress disorder, known as PTSD. I went to Oxford to record this episode and apologies in advance for the drilling, there were some building works going on outside where we were recording. We did try recording in the bathroom but it didn’t really work.
I met Nick Gilbert who was diagnosed with PTSD in 1990, six years after the event that triggered it. This is his story.
Nick: I’d reached a point where I was sat in my car and had no idea what I was going to do next. I was actually considering ways of ending my life.
So I’m sat in the car considering these things and I phoned my GP who was aware that I’d got issues – got some problems. He put me though to or put me in front of Talking Heads I think it’s called. And they phoned me and said would I be prepared to take part in a study. And, quite frankly, I was so desperate at the time, if they’ve have suggested witchcraft I’d have probably gone along with it.
Lucy: Nick started having CBT in 2012.
Nick: And then I met Dr Jennifer Wild and I don’t think it’s too much to say that that lady changed my life.
Jen: The people I work with are suffering from post-traumatic stress disorder and the treatment I’m giving is trauma-focused cognitive behavioural therapy.
Lucy: Jen Wild is a consultant clinical psychologist at the Oxford Centre for Anxiety Disorders and Trauma.
Jen: Post-traumatic stress disorder, or PTSD as it’s commonly known, is a severe stress reaction that can develop after natural disasters like a tsunami, a physical assault, sexual assault, car accidents, really unpleasant events where people flooded with unwanted memories and can’t get them out of their head. It’s very debilitating, it’s very terrifying, it takes up their concentration. They feel very hyperalert.
Lucy: What does hyperalert mean?
Jen: Hyperalert is feeling very on edge, very aware of your surroundings. And I think what happens with PTSD is people’s focus of attention shifts. So instead of being very absorbed in their environment or with their work or their family, for example, suddenly people are very focused on something bad could happen, “I could lose my life at any moment. Something might happen to my kids.”
So the shift of attention is from being absorbed in the environment to something terrible could happen. And when people are focused on danger they notice danger.
Lucy: It sounds just like it’s very scary all of the time.
Jen: It’s very scary, it’s very unsettling. There are four clusters of symptoms with PTSD.
So the first cluster called the reexperiencing symptoms, and that really means people are reexperiencing the trauma in the form of unwanted memories or nightmares or physical reactions in response to trauma reminders.
The second cluster of symptoms are the avoidance symptoms. So understandably when we’ve been through something horrendous, we want to push it out of our mind, avoid reminders, avoid people who remind us of the situation, avoid TV programmes that might remind us of the horrible trauma. So the second cluster of symptoms are the avoidance symptoms.
The third cluster of symptoms are what’s called, in our language, negative alterations in cognition and mood. That basically means people feel and think more negatively. So they might have thoughts like, “I’m permanently changed for the worse,” or “This trauma happened and it’s 100% my fault.” So they may be excessively blaming themselves.
And then the fourth cluster of symptoms are what we call the hyperarousal symptoms. So that’s the sleep problems, the concentration problems, that feeling of being on edge, hyperalert to danger. And that they’re usually caused, these hyperarousal symptoms, by the trauma memory, so the memory of the trauma keeps people feeling like danger is just around the corner.
Lucy: This was Nick’s experience of PTSD.
Nick: I sometimes burst into tears for no reason. And in my head I know I’m crying and I can’t understand why I’m crying and I don’t want to cry but I do. I feel angry and frustrated. I have no idea why. Little things upset me a lot. Stupid things.
You know that you shouldn’t react in the way that you do but you're almost a spectator. You don’t have any control over it. And you try very hard to break out of that but it sometimes is very difficult to do.
It goes after a while. And lots of other things, different reactions to things, triggers you see on TV and things.
And one of the weird things actually is not reacting. The incident that triggered my condition involved climbing down a cliff. For a long time I couldn’t even consider looking at a cliff. But now I see it on TV and it doesn’t bother me. And that bothers me.
Lucy: That bothers you that it doesn’t bother you?
Nick: Yeah. Because does that mean I don’t care anymore? Because there was a fatality. Should I feel that way?
For me, I don’t know about others, but for me there’s a, if you like, survivor guilt. And shame for surviving. And not understanding why I was the one that survived and other didn’t. So you almost feel offended on their behalf.
Lucy: Is it right that quite often feelings of shame might come along with it as well?
Jen: People can feel ashamed after their trauma when they start to question what they did during their trauma, if they have thoughts, “I should have acted quicker, I shouldn’t have been in that situation, I’m not happy with how I responded in that particular trauma.” Then that can lead to feelings of shame.
Of course people can also feel ashamed with trauma like sexual assaults where they felt very violated and very ashamed to talk about what happened. Maybe they were humiliated by their perpetrator and they may internalise the voice of their perpetrator and it may become very difficult to talk about what happened because they think their clinician or their therapist will judge them in the same way.
Lucy: So it sounds like something that’s understandably really difficult to seek treatment for actually. What is the treatment like?
Jen: The treatment is very effective. That’s the first point to make. And it has a scary title; it’s called trauma-focused cognitive behavioural therapy. The therapy is really looking to update the horrible trauma memory.
When we go through something horrendous we’re really focused on surviving and we don’t always pay attention to information at the time that is really helpful to link to the trauma memory.
So, for example, somebody might have had a horrendous car accident and thought they were going to die at the time. And then when they’re reminded of the trauma today they see a car, they get that feeling they’re about to die again. They may have unwanted memories coming to mind of the moment just before impact. And then in their mind the memories will stop at the worst moment, the moment before impact, for example.
And then what treatment would do is help to flesh out that memory in a little bit more detail. So we know if somebody’s sitting in our office that they have survived the trauma. So we want link that information, “I’ve survived,” to the memory of the car accident.
So by the end of treatment the trauma memory would be so much less threatening and it would be something around, “I’ve had a car accident, I thought I was going to die, I felt very afraid, I was injured, I now know I have recovered from some of the injuries, I’m safe and I have survived. It’s in the past.”
And you can see how that new information gives context to the trauma and makes the meaning much less threatening, which is what helps people to feel a lot better.
Lucy: And so does it involve sort of talking through the trauma quite a lot?
Jen: I think the common misconception is that the trauma-focused CBT really is about talking about the trauma a lot. But I’ve just looked at a case series where I counted the number of times I actually went into the trauma memory in a lot of detail with clients. And in a 12 session treatment I actually went into the trauma memory in a lot of detail in one session. So it is a misconception.
Of course we work with the trauma memory but we’re often working with trauma triggers. And that’s really breaking the link between the present and what’s going on now when the trigger appears to what happened in the past. And that’s not really talking through the trauma memory. It’s really about, “What’s going on now that’s different to the past that shows me that I’m safe?”
Lucy: So anyone listening to the podcast who’s thinking about having trauma-focused CBT could be quite reassured by that, that it’s not every session at all that you’re going through the trauma in detail.
Jen: It’s not every session that you’re going through the trauma in detail and I would say that one of the ways that CBT for PTSD is effective is you're helping to change the meaning of the trauma.
Of course we can’t change the facts of what happened. If something horrendous happened, it happened. But we can change how we interpret it and the meaning that we believe it says about ourself or other people or the world. We can update that. And that’s why I like to think of the therapy as an updating therapy.
Lucy: And is that kind of how it works? Is that the kind of main way that it changes how people feel, by changing the meaning of what has happened?
Jen: I think there are three ways in which the treatment works. I think one of the most important ways is changing the meaning of what happened so it’s less threatening to somebody.
The other way is we help clients to change some of their behaviours that might be increasing their anxiety. For example, if somebody is really worried about being attacked when they’re out and about, they might have one or two mobile phones with them. They might have them ready to call the police. And they might be really focused on danger. And, of course, that’s going to increase their sense of danger just by having their phones on a quick dial to the police.
So what we would want to do is to go out with people and get them to drop these specific strategies so that their brain discovers that they can walk out and about without having to take extra precautions. So that helps to change their behaviour, reduce anxiety.
And the other area is breaking the link between the present and the past by working with trauma triggers.
And there is actually another area and that is working with the thoughts. This is the meaning more or less that we touched on. And updating the memory. So we update the memory so it no longer stops at the worst moment.
Lucy: What sort of things should people expect if they were coming for CBT for PTSD?
Nick: I think the expectation is a very important thing. You're in so much pain – I don’t mean physical pain – that you’ll do anything. But some people expect it to be like taking a drug. And that all of a sudden you’ll feel better. Well that’s not the case. It takes time. And energy. And effort. And pain.
There were times I left Jen’s office and I felt like crying. I was so emotional – it’s so emotionally charged that I’m absolutely shattered afterwards. Absolutely shattered.
Lucy: Why do you think people put off talking about it?
Nick: Because once you’ve opened Pandora’s Box you can’t close it. Once you start the process you can’t not do it anymore. It’s something you’ve got to do. You’ve got to see it through to the end.
Lucy: And did you have to talk through what happened quite a lot? Were there other things you talked about as well or…?
Nick: You talk about lots of aspects of your life. And, yes, you talk about whatever the trigger incident was. And I say a trigger incident for a reason.
In actual fact for many years if I even mentioned it I would tear up. I talked to somebody about it the other day and it was just like any other conversation. Which again amazes me but also shames me because a part of me still feels that I should be suffering on behalf of Annie and because I’m not there’s an element of guilt there.
But you see that’s the PTSD. That’s not me. I’ve reasoned that. I know what it is. Therefore I can deal with it. I think a striking indication of maturity is when you realise that life isn’t fair.
Lucy: I asked Jennifer about what people should expect from CBT for PTSD.
Jen: The treatment’s a very active treatment. I would say I try and get out of the office as much as possible with clients because that’s where life happens. And we want people to kind of reclaim their life as well.
So in the first session I would be working with people to think about their longer-term goals and we would touch on their goals in every session and making sure that they're working towards them. And picking up activities that they may have dropped because of the trauma.
Lucy: So what sort of places do you go to?
Jen: Well, you might be surprised to hear that we would go back to where the trauma happened. And that is very important for a number of reasons. It helps people to discover that the site has moved on. There’s no one still there suffering. That the suffering is over, it’s in the past.
It also helps clients to feel that they can cope with it. Often people understandably are incredibly anxious about going back to the site of the trauma but once they’re there they can focus on what’s different and how it’s changed since the time of their trauma. And that really helps to give a sense of movement in terms of their life, but also with the fact that the memory’s in the past. It’s a quite clear distinction between what’s going on now and the memory being in the past.
Lucy: Jen also sometimes uses Google Maps with people so that they can look at the place where they trauma happened online instead of going there in person.
Jen: And if clients have developed anxiety or avoidance about different situations, about shopping, about walking down the road, for example, we would go out and about with them, walk down the road, go to a shop. And really test their beliefs about what they think will happen and then find out what actually happens and the outcome is always good. They usually realise that bad things don’t happen when we leave our house and that actually it’s safe to do so.
And they also typically experience a boost in mood. So it’s good motivation to keep doing those behaviours, like leaving the house, for example.
Lucy: That sounds really important. It sounds like there’s potential to make huge change for people’s lives there.
Jen: The efficacy of trauma-focused CBT for PTSD is incredible. The majority of patients will recover with treatment. We normally offer up to 12 sessions, but many patients don’t need 12 sessions. So they may have a fewer than that.
Lucy: So it’s got a really strong evidence base.
Jen: It has the strongest evidence base of any treatments for PTSD. I highly recommend it but I think any of the clients that we treated would highly recommend it as well.
It helps people to reclaim their life and to lead a life that matches their dreams rather than their fears.
Lucy: Nick reclaimed his life in ways he would never have imagined.
Nick: I’m a funeral director now.
Lucy: Are you?
Nick: And I enjoy it immensely. And the reason I do that is because I’m able to help families through a very difficult period. I can understand how they’re feeling. And I say to them quite often, when they say, “I’m going to miss them,” I say, “Well, for as long as you talk about them they’re never not going to be there. They’re still alive in your memories. So talk about them. Don’t avoid talking about them.” Because people do because it might upset grandma. But as long as you talk about somebody they’re going to be there.
So I find that extremely helpful for me. And I think for them because I get good responses. People say that I’m good at what I do, etc. But I think I wouldn’t be anywhere near as good as I am, dare I say, if I hadn’t experienced what I had in the first place.
I know I’m a very different person to the person I was before the incident. And I know again that I’m a different person to the person I was before I went into CBT.
Lucy: It’s really striking the image of you in the car that you talked about at the start and now how you're doing a totally different career and you're feeling really good at that and enjoying it and getting really good feedback from people. Could you say just sort of how you feel like you're life has changed from one point to the other?
Nick: At that time I’m pretty certain, it was probably the lowest point in my life post the accident. You can’t see any further. But you move on. And then one day you suddenly realise, “Actually life isn’t too bad, is it?”
And then you feel guilty because you think, “If I think this will it all go horribly wrong again?” But the reality is you end up in a better place.
Lucy: What do you like about working with PTSD?
Jen: I love working with people who have developed PTSD. I know that it’s a problem that people can recover from. It’s very common. I know that most people I work with are going to recover with this treatment because it is an effective treatment.
But I also am very passionate about the idea of people reclaiming their life, and possibly going one step further. So it’s an opportunity when we go through some horrendous trauma to take a step back and re-evaluate our life, look at our symptoms, get some help and make a choice to lead not just an ordinary life but an extraordinary life. And that’s what I love most about this treatment.
Lucy: I asked both Nick and Jen if they had final advice for people thinking of doing the therapy.
Jen: The decision to have treatment is an important one and understandably people put it off. I think it can be more difficult when we’re feeling really ashamed about our trauma or the symptoms that we’re having to reach out for help.
And I would just like to invite people who have had trauma and are feeling ashamed to take that step and reach out because the treatment is so helpful and there’s so much relief from reducing that sense of shame and that can happen within one or two sessions. So I would really encourage people to reach out.
Nick: Well, first of all, if you're suffering with PTSD then I do feel for you. There’s almost a brotherhood of it.
Be careful of who you talk to about it. But if somebody is offering you this treatment, then do it, because once you’ve done it, if it works for you you’ll be in a far, far better place. And, to be honest, if it doesn’t you're no worse off than you are now.
But if you do it you’ve got to be committed to it. It’s like being on a diet. But you will feel the benefit.
Lucy: What kept you committed to it? How did you stick with it? Because it sounds hard.
Nick: I knew I had to do something because I honestly didn’t feel that I would be able to cope much longer and I would probably have taken my life. It was a turning point.
Lucy: That’s great. Thanks so much.
Nick: You’re very welcome.
Lucy: Thanks to both of my experts, Nick and Jen. If you’d like more information on CBT for post-traumatic stress disorder have a look at the show notes.
For more on CBT in general and for our register of accredited therapists, check out BABCP.com. And have a listen to our other podcast episodes for more on different types of CBT and other problems it can help with, including obsessive compulsive disorder and psychosis.
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