Cognitive · 2000
Cognitive Therapy for PTSD
The problem is not the trauma in the past, but the way the system keeps generating a threat in the present.
Ehlers and Clark's Cognitive Therapy for PTSD is a cognitive model that explains the persistence of post-traumatic stress disorder in terms of an internally generated sense of current threat. This state arises from the interaction between idiosyncratic negative appraisals of the trauma and a trauma memory that is poorly elaborated and poorly contextualised, which makes it easy to reactivate as if it were happening now. The model focuses not on the event itself but on how it is processed. Intervention is directed at three main targets: elaboration of the trauma memory, updating of dysfunctional meanings, and removal of the maintaining strategies that block change. It is one of the most influential and empirically validated cognitive models in the treatment of trauma.
Theory of change
A person changes when the trauma stops feeling like a present threat and can be integrated as a past event within autobiographical memory.
Core ideas
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PTSD is maintained by a sense of current threat
The core of the model is that the problem does not lie in the past event but in the present experience of danger ("sense of current threat"). This sensation is generated internally and is the central target of therapeutic intervention. (Ehlers & Clark, 2000).
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Current threat emerges from the interaction between memory and meanings
The sense of threat does not come from a single factor, but from the interaction between a poorly elaborated trauma memory and negative appraisals of the trauma and its aftermath. Both components are needed to explain why the disorder persists. (Ehlers & Clark, 2000).
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Idiosyncratic negative appraisals are the cognitive core of the problem
Beliefs about the trauma, oneself and the world (for example, extreme danger, incapacity or guilt) are highly idiosyncratic and determine the intensity and persistence of the sense of threat. They are a central target of treatment. (Ehlers & Clark, 2000).
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The trauma memory is poorly elaborated and poorly contextualised
The trauma is encoded in a fragmented, sensory form with little integration into autobiographical memory, which makes automatic reactivation easy and lends it the quality of happening now. (Ehlers & Clark, 2000).
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Re-experiencing reflects the activation of unintegrated memory
Flashbacks and intrusions are not simply anxiety, but the activation of a memory that lacks temporal and autobiographical context, which explains their immediacy and their present-tense quality. (Ehlers & Clark, 2000).
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Maintaining strategies prevent recovery
Behaviours such as avoidance, suppression, hypervigilance and safety behaviours reduce distress in the short term, but prevent the memory from being elaborated and beliefs from being revised, sustaining the sense of threat. (Ehlers & Clark, 2000).
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The problem is not the intensity of the trauma but its processing
The model explains that people exposed to similar events may or may not develop PTSD depending on how they cognitively process the experience, not simply on the objective severity of the event. (Ehlers & Clark, 2000).
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Therapeutic change requires modifying both memory and meanings
Recovery involves both the elaboration and contextualisation of the trauma memory and the modification of negative appraisals, since both processes are responsible for maintaining the disorder. (Ehlers & Clark, 2000).
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Reducing the sense of threat is the central criterion of improvement
The aim of treatment is not merely to reduce symptoms but to remove the experience of current danger, which is achieved when the memory is integrated, meanings are updated and maintaining strategies disappear. (Ehlers & Clark, 2000).
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The trauma must be integrated as a past event in the autobiographical narrative
Recovery means that the traumatic event stops being experienced as present and becomes part of the person's history, with a more accurate and less threatening meaning. (Ehlers & Clark, 2000; Ehlers, 2013).
Influences
- Beck's cognitive therapy
- Clark's cognitive model of panic
Key references
- Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder.
- Ehlers, A., Clark, D. M. (2005). Cognitive therapy for PTSD: Development and evaluation.
- Ehlers, A. (2013). Cognitive Therapy for PTSD.