Cognitive therapy for PTSD

1. Introduction

Version followed: the Oxford/OxCADAT Cognitive Therapy for PTSD (CT-PTSD) of Anke Ehlers, David M. Clark and colleagues. It is based on the Ehlers & Clark (2000) cognitive model and described in the group's practice papers: Wild et al. (2020) on remote delivery, Murray et al. (2022) on ten misconceptions, the Thew et al. (2024) practice review and the group's session-components checklist. The standard weekly face-to-face course is described first. The 7-day intensive, video/telephone and therapist-guided internet (iCT-PTSD) formats are noted where they differ. The treatment manual itself and the full texts of Ehlers & Clark (2000) and Ehlers et al. (2005) are not drawn on. Claims that rest only on secondary summaries of those texts are tagged [uncertain].

CT-PTSD is an individual, trauma-focused cognitive therapy. Its developers recommend it as first-line, and they report that thousands of NHS therapists have been trained in it [source: Oxford project page; Thew et al. 2024]. How change happens: the model holds that PTSD persists when the trauma is processed in a way that creates a sense of serious current threat, either to physical safety or to self-worth. Three things keep that sense of threat going:

• Negative appraisals of the trauma and its aftermath, for example "I am to blame", "I'm permanently changed" or "the world is unsafe".
• A disjointed, poorly elaborated trauma memory. Its worst moments ("hotspots") come back as vivid, sensory intrusions with a here-and-now quality, set off by cues that resemble the trauma.
• Maintaining strategies such as suppression, rumination, avoidance, safety behaviours and hypervigilance. These bring short-term relief but stop the memory and its meanings from being updated.

Therapy pursues three goals: (1) modify the problematic appraisals; (2) elaborate the trauma memory, update its hotspots with corrective information, and discriminate triggers so they stop firing the memory; (3) drop the maintaining strategies while the client reclaims their life [source: Wild et al. 2020; Smith 2006 summarising Ehlers & Clark 2000; Psychology Tools formulation guide].

2. Framework

CT-PTSD is not a session-by-session protocol. The core elements are the same for every client, but their order and delivery are fitted to the formulation, which the authors call "flexibility within fidelity" [source: Murray et al. 2022]. There is no formal stabilisation phase. Memory work usually begins in session 2 [source: Murray et al. 2022; Thew et al. 2024].

Format and dose [source: Wild et al. 2020; Cloitre 2014 on Ehlers et al. 2014; Wild et al. 2016 abstract]

• Standard weekly: typically about 12 weekly sessions over about 3 months. Sessions that include memory work last 90 minutes. Up to three optional booster sessions follow at monthly intervals.
• 7-day intensive: about 18 therapy hours in total, delivered over 5–7 working days. There are usually two sessions per day, each 90 minutes to 2 hours. The follow-up and booster schedule for the intensive format is not given in the sources [uncertain].
• Video or telephone: the same components in the same typical order, with the adaptations listed in section 4. Brief between-session text messages are allowed with consent and within service policy.
• Internet (iCT-PTSD): online modules with remote therapist guidance. In the pilot, therapist contact averaged about 3 hours per client plus about 1 hour reviewing progress and messages. That is under a quarter of face-to-face therapist time. The modules cover memory updating, trigger discrimination, site visits, appraisal work, behavioural experiments and reclaiming life. The number of modules and the number of weeks were not confirmed [uncertain].
• Length of sessions without memory work: not stated in the sources. One published case series used about 60 minutes [uncertain; Smith 2006].

Components in their typical order. They overlap; this is not a rigid sequence [source: Murray et al. 2022; Wild et al. 2020; CT-PTSD components session sheet].

Changing the order for particular clients [source: Murray et al. 2022; Wild et al. 2020]

• High dissociation: introduce trigger discrimination and here-and-now anchors first. Usually start memory work with a written narrative rather than reliving.
• High shame or degradation, or guilt linked to a perpetrator: work on those appraisals first, for example with a survey. Then link the updates to the hotspots.
• Bereavement: talk about the person who died before reliving.
• Life instability or severe symptoms: go ahead if the client consents and feels able. Sleep often improves once memory work starts.
• Multiple traumas: draw a life timeline and choose the traumas that drive current re-experiencing.

Monitoring at every session [source: Wild et al. 2020]

• Symptoms: PCL-5 or IES-R every session.
• Process measures: the Posttraumatic Cognitions Inventory (or a weekly short form), the Responses to Intrusions Questionnaire, the Safety Behaviours Questionnaire and the Unwanted Memories Questionnaire. These are free from OxCADAT and are not reproduced here.
• Risk: PHQ-9, with attention to the self-harm item.
• During memory work: verbal ratings of distress and "nowness".

Criteria for ending: the sources do not give formal criteria. A reasonable rule: end when the main hotspots are updated with low nowness, triggers are discriminated, key maintaining behaviours have been dropped, measures are in the non-clinical range or have plateaued, and the blueprint is written [synthesis].

3. Guiding principles

[source: Murray et al. 2022; Thew et al. 2024; Wild et al. 2020; Psychology Tools; tagged where otherwise]

• Formulation-driven. Every technique choice comes from the client's own maintenance cycle. When in doubt, go back to the formulation [Thew et al. 2024].
• Flexibility within fidelity. Keep all the core elements but change their order and delivery for the person in front of you [Murray et al. 2022].
• Target current threat. Ask what makes the trauma feel dangerous now, to safety or to self-worth, and work on that [Wild et al. 2020].
• Get to the memory early. Do not delay for stabilisation. The editorial puts it as "get going with work on the trauma memory as soon as possible" [Thew et al. 2024].
• Update, don't just repeat. Reliving is used to find the hotspots and their meanings, then to insert updates. Repeating it many times without updating is not the method [Murray et al. 2022].
• The client sets the pace. Collaborate, give a clear rationale, explain confidentiality, prepare the client for temporary distress and plan what they will do after sessions [Murray et al. 2022].
• Work with all the emotions, not only fear. Expect shame, guilt, anger, humiliation, betrayal, disgust and sadness. Update every meaning at a hotspot until the emotion shifts [Murray et al. 2022].
• A "doing" therapy. Include experiential work in most sessions: updating, imagery, discrimination, surveys, experiments and site visits. In the editorial's words, "CBT is a doing therapy, not just a talking therapy" [Thew et al. 2024].
• Test beliefs; don't grade exposure. One or two well-designed behavioural experiments that test the key appraisal replace graded hierarchies [Murray et al. 2022].
• Reclaim life from session 1. Valued activity both builds hope and tests beliefs such as "I'm permanently changed" [Wild et al. 2020].
• Then vs now. Keep helping the client tell the past apart from the present, in memory, with triggers and at the site [Wild et al. 2020].
• Normalise; don't criticise. Treat avoidance and safety behaviours as understandable attempts to cope, then look at their costs [Psychology Tools; Wild et al. 2020].
• Be honest about real outcomes. Do not pretend the worst did not happen. Correct distorted self-blame, but help the client accept any responsibility that is genuinely theirs [Murray et al. 2022].
• Safety first. Assess and manage risk to self, from others and to others before memory work, and monitor it every session [Murray et al. 2022; Wild et al. 2020].
• Measure every session. Use symptom and process measures to guide the next step [Wild et al. 2020].
• Involve supporters. Partners and family can help spot triggers and can join reclaiming activities, experiments and site visits [Wild et al. 2020; Murray et al. 2022].
• Look after the therapist. Take breaks, separate work from home (especially when working remotely) and use supervision [Wild et al. 2020].

4. Intervention inventory

The inventory follows the group's components checklist: (A) setting up; (B) the three memory-updating steps; (C) trigger discrimination and site visits; (D) appraisal-specific methods; (E) dropping maintaining behaviours; (F) consolidation and delivery formats [source: CT-PTSD components session sheet; Wild et al. 2020; Murray et al. 2022]. All example therapist language is illustrative unless it appears in quotation marks with a citation.

A1. Assessment, risk and session measures

• Purpose: map the client's maintenance cycle, find the hotspots, and set up safety and measurement before memory work begins [source: Wild et al. 2020; Psychology Tools].
• Steps:
  1. Ask for a brief account of the trauma in the client's own words. Do not collect detail early, because it can raise distress or set off dissociation.
  2. Ask about involuntary responses during the event: freezing, dissociation, numbing.
  3. List the intrusions and nightmares and the moments they come from (the hotspots). Note their sensory qualities and how strongly they feel as if happening now.
  4. Ask what the trauma and the symptoms mean to the client now. Separate "then" appraisals ("I'm going to die") from "now" appraisals ("I'm broken"). Ask directly about shame and self-blame.
  5. List the coping strategies and their short-term and long-term effects.
  6. Assess suicide risk, risk from others and risk to others. Assess dissociation. Agree a written crisis plan.
  7. Give the session measures (see section 2) and review them at the start of each session.
• Example language (illustrative): "I don't need the details today, just a few sentences. Which moments come back most?" / "When that picture comes back, how much does it feel like it's happening now, from 0 to 100?"
• Watch for: a client who rushes into detail or starts to dissociate; slow them down. Look for hidden hotspots of shame or guilt, which clients often leave out at first.

A2. Psychoeducation and normalising

• Purpose: turn symptoms into understandable reactions and give a rationale for memory work [source: Smith 2006 summarising Ehlers & Clark 2000; Murray et al. 2022].
• Steps:
  1. Explain that intrusions, arousal and avoidance are common reactions to an extreme event.
  2. Explain that the memory has not been filed as past, so its worst moments come back with a here-and-now feeling.
  3. Explain that understandable coping (pushing memories away, avoiding, staying on guard) keeps the memory unprocessed.
  4. Explain that talking through the memory in a planned way lets it be updated and put in the past. A metaphor helps; the sources mention metaphors but the specific ones were not confirmed [uncertain].
• Example language (illustrative): "Your memory is behaving as if the danger is still going on. Each time we push it away, it stays unsorted. If we go through it together, at a pace you choose, we can update it with what you know now."
• Watch for: fear that talking will "re-traumatise". Answer it with the rationale and by giving the client control over the pace (see section 5).

A3. Individualised formulation

• Purpose: a shared map that guides every later choice [source: Wild et al. 2020; Thew et al. 2024; Psychology Tools].
• Steps:
  1. Using the client's own examples, draw the sense of current threat in the middle.
  2. Link it to three things: features of the trauma memory (nowness, disjointedness, triggers); the meanings; and the maintaining strategies.
  3. Draw the smaller cycles collaboratively, for example "trigger → intrusion → push it away → more intrusions".
  4. On video, share the screen while you draw. On the phone, send the diagram afterwards.
  5. Turn the formulation into goals and a plan.
• Example language: check understanding regularly, for example "Does this make sense?" [Wild et al. 2020]. Illustrative: "So the thought 'it was my fault' leads to the shame, and the shame is why you avoid talking about it?"
• Watch for: a formulation that is too complex to use. Keep one cycle per problem.

A4. Thought-suppression demonstration

• Purpose: show from experience that pushing memories away makes them come back more [source: Wild et al. 2020].
• Steps:
  1. Ask the client to picture a vivid, neutral image. The paper's example is a "pink bunny rabbit sitting on the therapist's shoulder".
  2. Ask them to try hard not to think of it for a minute or two and to notice how often it comes back.
  3. Discuss what happened.
  4. Link the result to the trauma memories and agree to try letting intrusions come and go without fighting them.
• Example language (illustrative): "What happened when you tried not to think of it? What might that mean for the memories you've been pushing away?"
• Watch for: a client who reports no rebound. Ask how much effort it took, and check what happens with real intrusions in an intrusion diary.

A5. Reclaiming (rebuilding) your life assignments

• Purpose: bring back hope and mood, and test appraisals such as "I'm permanently changed" or "my life is ruined" [source: Wild et al. 2020; Murray et al. 2022].
• Steps:
  1. In session 1, review what the client has lost or stopped since the trauma in each domain: free time, work or study, home life, relationships and health.
  2. Pick one or two small, concrete activities for the coming week.
  3. Frame them as experiments: "What do you predict? What happened?"
  4. Review them at every session and plan the next step.
  5. Activities that are not possible yet (because of practical limits or remote delivery) are adapted, or written into the blueprint for later.
• Example language (illustrative): "What did you used to enjoy before this happened? What would be a small first step back towards it this week?"
• Watch for: activities done with safety behaviours, or done without any enjoyment because the client is ruminating. Return to these later in experiments.

A6. Here-and-now anchors and grounding objects

• Purpose: keep the client oriented to the present during memory work, especially if they tend to dissociate [source: Wild et al. 2020; Murray et al. 2022; components session sheet].
• Steps:
  1. Help the client spot the early signs of dissociation, such as feeling unreal, and its triggers.
  2. Choose present-day anchors and keep them at hand: a strong scent or taste (such as a lip balm), a recent photo, something to squeeze.
  3. During memory work, keep the client's eyes open, have them speak in the past tense, ask frequent questions, and use their name and your voice as anchors.
  4. Encourage small movements, such as walking on the spot or using a fidget toy or soft ball.
  5. Involve family members in noticing triggers.
• Example language (illustrative): "Smell the lip balm. What's around you right now? You're here with me, it's [date], and that's over."
• Watch for: the client going quiet, staring, or answering slowly. Step in early.

B1. Step 1 (part 1): imaginal reliving

• Purpose: reach the hotspots and the meanings attached to them; later, insert updates into the memory [source: Wild et al. 2020; Murray et al. 2022; Smith 2006 citing Grey et al. 2002].
• Steps:
  1. Give the rationale and agree a start point (before danger began) and an end point (when the client was safe).
  2. Leave enough session time to finish at a safer point and debrief.
  3. The client tells the event in the first person and present tense, with eyes open or closed, saying what happens, what they feel, think and sense. In a dissociative client, use the past tense and eyes open.
  4. Take distress and nowness ratings at intervals and at the worst moments.
  5. Note where distress peaks or the client skips or speeds up. These are candidate hotspots.
  6. Debrief by asking what the worst moments were and what went through their mind.
  7. Plan something pleasant or supportive for afterwards.
  8. Usually needed only 2–3 times; after that, sessions move to updating.
• Example language (illustrative): "Start just before it began. Tell it as if it's happening now. What are you seeing? What's going through your mind?" Debrief question: "what was the worst thing about that for you?" [Murray et al. 2022].
• Watch for: avoidance such as skipping, summarising or rushing; dissociation; over-engagement. Use the anchors (A6).

B2. Step 1 (part 2): written narrative

• Purpose: an alternative or addition to reliving that allows better pacing. Preferred for telephone sessions, prolonged or multiple traumas, and clients who dissociate [source: Wild et al. 2020; Murray et al. 2022; Smith 2006].
• Steps:
  1. The client writes the event step by step, with thoughts and feelings, in or between sessions. On video, use a shared screen.
  2. Read it together and mark the hotspots and their meanings.
  3. Later, add updates in a different colour (B5).
  4. Fill gaps in the memory using a timeline, police or medical records, ICU diaries, or an early site visit.
• Example language (illustrative): "Let's write it moment by moment. Where you get stuck or it feels worst, put a mark and we'll come back to it."
• Watch for: a narrative that leaves out the worst moments or has no emotion in it. Ask what happened in that gap.

B3. Step 1 (part 3): identifying hotspots and their meanings

• Purpose: find exactly which moments, and which meanings, drive the current threat [source: components session sheet; Wild et al. 2020; Murray et al. 2022].
• Steps:
  1. Collect hotspots from reliving, the narrative and the intrusions. Match each intrusion to its moment in the trauma.
  2. For each hotspot, ask what it meant then and what it means now. Keep asking until you reach the core meaning, using questions such as "what does that mean about you as a person?" [Murray et al. 2022].
  3. Name every emotion present: fear, shame, guilt, anger, disgust, sadness.
  4. Write down each hotspot, its emotion, its meaning and a belief rating.
• Example language (illustrative): "At the moment he pinned you down, what was going through your mind? And what does that say about you now?"
• Watch for: a meaning that seems too neutral for the level of distress. There is usually a deeper meaning, often shame, still to find.

B4. Step 2: identifying updating information

• Purpose: find information that contradicts the hotspot meaning [source: components session sheet; Wild et al. 2020].
• Steps:
  1. Look first for facts the client knows now but did not know then: "I didn't die", "my children are safe", "he was convicted".
  2. Discuss what happened during and after the trauma, including the full timeline of events.
  3. Use cognitive restructuring: information and psychoeducation (for example about freezing), guided discovery and reviewing the evidence for and against the meaning.
  4. Where talk is not enough, use the experiential methods in D1–D7: experiments, surveys, pie charts and imagery.
  5. Write the update in the client's own words.
• Example language (illustrative): "In that moment you were sure you would die. What do you know now that you didn't know then?"
• Watch for: an update the client says they "know" but do not feel. Strengthen it with experiential evidence before inserting it (see section 5).

B5. Step 3: incorporating updates into the memory

• Purpose: link the new meaning to the hotspot so the memory itself changes [source: Wild et al. 2020; Murray et al. 2022; components session sheet].
• Steps:
  1. Have the client bring up the hotspot through brief reliving or by reading the narrative up to that point.
  2. While they hold the hotspot in mind, ask them to say the update out loud, or say it to them.
  3. Add it to the narrative in a different colour, and read both versions aloud.
  4. Strengthen it with imagery (B6) and with movement or incompatible sensations (B7).
  5. Take nowness and distress ratings before and after.
  6. Put the update on a flashcard or a phone photo for use between sessions.
  7. Update hotspots one at a time, as early as possible. Early wins build hope.
• Example language: "I didn't allow this to happen, it wasn't my fault" [Murray et al. 2022]. Illustrative: "Go to the moment the car hit. Now remind yourself what you know now."
• Watch for: distress and nowness falling at that hotspot within the session and in the next week's intrusions. If they do not fall, the update has missed the core meaning; go back to B3.

B6. Imagery transformation and imagery rescripting

• Purpose: add emotionally convincing images that carry the update [source: Wild et al. 2020; Murray et al. 2022; Thew et al. 2024 for survivor guilt].
• Steps:
  1. Once the hotspot is active, invite an image that carries the new meaning. Examples: seeing the person who died at peace; seeing one's body now healed; for very early childhood trauma, the adult self comforting the child and taking them to safety.
  2. For childhood trauma, keep the messages simple and age-appropriate, such as "you are safe" or "it's not your fault".
  3. Survivor guilt has been treated with imagery rescripting in a proof-of-concept study. The exact procedure is not drawn on [uncertain].
  4. Check how the client feels as the image is held.
• Example language (illustrative): "Can you picture her now, peaceful and no longer in pain? Stay with that."
• Watch for: images that deny reality, such as rescripting a death so that it did not happen. Imagery should carry true meanings [source: Murray et al. 2022 on not pretending the worst did not happen].

B7. Movement and incompatible sensations

• Purpose: physically contradict the hotspot meaning, for example "I'm trapped" or "I'm badly injured" [source: Murray et al. 2022; Wild et al. 2020].
• Steps:
  1. When the hotspot is about being frozen, trapped or helpless, ask the client to stand up and move freely while saying the update.
  2. For injury meanings, have them touch a healed scar or body part.
  3. For loss meanings, have them look at recent photos.
  4. Re-rate nowness.
• Example language: "I can move now" [Murray et al. 2022]; "I see my children every day" [Murray et al. 2022].
• Watch for: fast drops in nowness, which show the update has landed.

B8. Time-tagging

• Purpose: label the memory as past, which helps especially with gappy memories, early childhood memories and clients who dissociate [source: Murray et al. 2022].
• Steps:
  1. At the hotspot, add a short reminder that the event is over.
  2. Repeat it in the narrative and on flashcards.
• Example language: "this is in the past, it is over, no one is touching me now" [Murray et al. 2022].
• Watch for: time-tagging used to push the memory away, which would make it a safety behaviour. It should be said while the memory is held in mind.

B9. Life timeline (multiple or prolonged trauma)

• Purpose: choose targets when there are many traumas, and link appraisals that run across them [source: Wild et al. 2020; Murray et al. 2022].
• Steps:
  1. Draw a line through the client's life, optionally into future goals.
  2. Mark the traumas on it, and mark which ones drive current intrusions.
  3. Find the meanings that run across traumas, such as "no one can be trusted".
  4. Update the most relevant hotspot first, then extend the update to related hotspots.
  5. Start with simple updates; not every detail needs to be recounted.
• Example language (illustrative): "Which of these memories pops into your head most? Which one feels most like it's happening now?"
• Watch for: trying to relive every trauma. Target the ones that drive the symptoms.

C1. Trigger (stimulus) discrimination: then vs now

• Purpose: break the automatic link between present cues and the trauma memory. Cues include sights, sounds, smells, body sensations, and colours or emotions with no obvious connection [source: Wild et al. 2020; components session sheet; Smith 2006 citing Clark & Ehlers 2005].
• Steps:
  1. Identify the triggers using an intrusion diary (when, where, what was just before) and by close questioning. Look for subtle ones too: bodily feelings, a colour, a mood.
  2. For one trigger, draw a Then vs Now table. List the ways it is similar to the trauma and the ways it differs: context, meaning, outcome, time.
  3. Bring on the trigger deliberately in session, for example by playing a recording, showing an image or doing a movement.
  4. As the memory starts, have the client shift attention to the differences. They can say them aloud, move around, or change the volume.
  5. Practise between sessions with real triggers.
  6. On video, gather image and audio triggers in advance and practise through a shared screen. On the phone, email the materials.
• Example: in Wild et al. (2020), a siren is listed as a similarity. The difference is that the ambulance now means help is coming. Illustrative language: "Notice the siren. Then it meant the crash. What's different now? Where are you, who's with you, what year is it?"
• Watch for: the client using discrimination to escape the memory rather than to notice the differences. Expect nowness ratings for a trigger to fall over a few practices. Teach discrimination before behavioural experiments so the client can use it if a memory is triggered during one [source: Murray et al. 2022].

C2. Site visit (in person or virtual)

• Purpose: show that the trauma is over, find new updating information, fill gaps in the memory, and test predictions such as "I'll lose control" [source: Wild et al. 2020; Thew et al. 2024; Murray, Merritt & Grey 2015 abstract].
• Steps:
  1. Recommended for most clients where feasible. The 2015 practice paper gives a framework for planning and timing, but only its abstract is drawn on [uncertain on details].
  2. Plan the visit: route, time, transport, the client's predictions and safety considerations. Agree whether the therapist comes along, joins by phone, or a supporter comes.
  3. On site, walk the route slowly. Name the then-vs-now differences. Look for new information, such as a detail that changes a meaning.
  4. Test the predictions and take photos or selfies as evidence of "now".
  5. Virtual alternative: use Google Street View (including historical images) or Google Earth together on a shared screen. For buildings with no inside view, use outside images or a virtual tour of a similar place.
  6. If gaps in the memory are blocking reliving, do the visit early to fill them [source: Murray et al. 2022].
  7. Afterwards, add what was learned to the narrative and the updates.
• Example language (illustrative): "What do you notice that's different from that night? What did you predict would happen here, and what's happening?"
• Watch for: rushing past parts of the site or avoiding them; ask the client to slow down. Watch for safety behaviours while there. Do not visit if the place is still genuinely dangerous [synthesis].

D1. Socratic questioning and guided discovery

• Purpose: the main verbal method for changing appraisals and finding updates [source: components session sheet; Wild et al. 2020; Smith 2006].
• Steps:
  1. Write the appraisal down and rate the belief.
  2. Ask for the evidence the client uses for it. Often this is a part of the memory that needs updating.
  3. Explore what else happened and what else they now know, including the timeline and psychoeducation such as how freezing works.
  4. Build an alternative in the client's own words and re-rate both beliefs.
• Example language (illustrative): "What tells you it was your fault? … How long did you have to decide? What did you know at that moment?"
• Watch for: debating with the client. Move to an experiential method (D2–D7) if belief does not shift.

D2. Behavioural experiments to test appraisals

• Purpose: test a feared prediction, or the effect of a safety behaviour, in real life [source: Murray et al. 2022; Thew et al. 2024; Wild et al. 2020].
• Steps:
  1. State a specific prediction from the appraisal and rate it, for example "if I go into a crowded place without checking, I'll be attacked".
  2. Design one or two strong tests. Do not build a graded hierarchy. An example from the source: going to a busy place with the therapist and closing one's eyes.
  3. Run the test with all safety behaviours dropped.
  4. Compare the outcome with the prediction and re-rate the belief.
  5. Experiments can also test disclosure predictions in shame, for example "people will be disgusted if I tell them".
• Example language (illustrative): "What exactly do you think will happen? How would we know? Let's find out."
• Watch for: hidden safety behaviours that let the client explain away the result, and experiments that are too gentle to test anything.

D3. Surveys

• Purpose: gather other people's views to counter shame and self-blame. Especially useful for shame-based meanings [source: Murray et al. 2022; Wild et al. 2020; Thew et al. 2024].
• Steps:
  1. With the client, write a short, neutral, anonymous description of the situation plus 2–4 questions, for example about blame or how the respondent would judge the person.
  2. The client predicts the answers.
  3. The therapist sends the survey to colleagues or contacts.
  4. Read the answers together and compare them with the predictions.
  5. Take the key result into the hotspot as an update.
• Example language: "other people do not think I am to blame" as an update [Murray et al. 2022]. Illustrative: "What percentage do you think will say you should have fought back?"
• Watch for: the client discounting the results ("they're just being kind"). Plan in advance how answers will be weighed.

D4. Responsibility pie chart

• Purpose: reduce guilt by sharing responsibility fairly among all the factors that contributed [source: Wild et al. 2020; components session sheet].
• Steps:
  1. List every contributing factor and person, with the client's own share left until last.
  2. Give each factor a slice of the pie.
  3. Give the client what remains.
  4. List the helpful things the client did during and after the event.
  5. Insert the new share into the hotspot as an update.
• Example language (illustrative): "Before we decide how much is yours, who and what else played a part?"
• Watch for: a share that genuinely belongs to the client. Help them accept it and make amends, rather than arguing it to zero [source: Murray et al. 2022].

D5. Working with anger

• Purpose: loosen anger that keeps the memory active or turns into rumination [source: Wild et al. 2020; Smith 2006].
• Steps:
  1. Give information about why other people behaved as they did, where relevant.
  2. List the advantages and disadvantages of holding onto the anger.
  3. The client writes an unsent letter expressing the anger.
  4. Direct the energy into constructive action [Smith 2006].
• Example language (illustrative): "What does holding onto this anger do for you, and what does it cost you?"
• Watch for: anger that is justified. The aim is to reduce how much it costs the client, not to excuse what was done.

D6. Loss and traumatic bereavement

• Purpose: update the worst meanings when someone died [source: Wild et al. 2020; Murray et al. 2022].
• Steps:
  1. Talk about the person before reliving.
  2. Recall the person as a whole and what they brought to the client's life.
  3. Identify what has not been lost: memories, values, relationships.
  4. Target distorted meanings (for example "I'm alone forever") without pretending the death did not happen.
  5. Use imagery, such as the person at peace. Where relevant, consider that the person is no longer suffering.
• Example language (illustrative): "What did she bring to your life that you still carry with you?"
• Watch for: survivor guilt (D4, B6) and moral injury (see section 5).

D7. Body change and overgeneralised danger

• Purpose: address appraisals about permanent damage, and about the world being dangerous [source: Wild et al. 2020].
• Steps:
  1. Body change: look for ways to rebuild life around the change. Use video feedback to compare the appearance the client fears with how they actually look.
  2. Overgeneralised danger: use Socratic questions and objective risk estimates (published statistics). Use the Safety Behaviours Questionnaire to list precautions, then run experiments dropping them (E1).
• Example language (illustrative): "How likely is it really, according to the figures? How likely did it feel?"
• Watch for: real, ongoing risk. Problem-solve that rather than reappraising it.

D8. Other restructuring tools: continua, prejudice model, positive data log

• Purpose: named in the CT-PTSD components checklist as further options for appraisal change [source: components session sheet]. Their CT-PTSD-specific procedures were not described in the sources [uncertain].
• Steps (standard CBT use) [synthesis]:
  • Continuum: place the client and others on a scale for the belief, for example from "completely weak" to "completely strong", using defined criteria.
  • Prejudice model: show how a belief filters out contradicting evidence, the way a prejudice does.
  • Positive data log: record daily evidence for the new belief.
• Watch for: using these as worksheets alone. Link each result back to the hotspot.

E1. Dropping safety behaviours, hypervigilance and avoidance

• Purpose: remove the strategies that block updating [source: Wild et al. 2020; Murray et al. 2022; components session sheet].
• Steps:
  1. List the strategies, for example with the Safety Behaviours Questionnaire.
  2. Elicit their advantages and disadvantages.
  3. Run a contrast experiment: do more of the behaviour for a few minutes, then drop it, and compare anxiety and the sense of threat. In Wild et al. (2020), brief danger-checking raised anxiety and dropping it lowered anxiety. An attention-focus experiment can be used for hypervigilance.
  4. Generalise to trauma-relevant situations and check that the behaviour has really been dropped.
• Example language (illustrative): "For two minutes, scan the room as hard as you can for danger, then for two minutes just notice the conversation. What happened to your anxiety each time?"
• Watch for: safety behaviours being swapped for new ones.

E2. Rumination

• Purpose: stop unproductive "why" and "what if" thinking that keeps the trauma active [source: Wild et al. 2020].
• Steps:
  1. Explore what rumination does and whether it ever produces answers.
  2. Use the broken-down-car metaphor to contrast "Why is this happening to me?" with "How can I resolve this problem?"
  3. The client learns to notice and label rumination.
  4. They switch to a planned activity, or to concrete problem-solving.
• Example language (illustrative): "If your car broke down, would asking 'why me?' get you home? What question would?"
• Watch for: rumination presented as "processing". Check whether it leaves the client better or worse off.

E3. Other maintaining behaviours

• Purpose: the checklist lists these as targets: alcohol, cannabis, smoking or eating used to cope; unhelpful sleep habits; social withdrawal; excessive risk-taking [source: components session sheet].
• Steps: use the same pros-and-cons review and behavioural experiments as in E1. Specific procedures for each were not described in the sources [uncertain].
• Watch for: substance use heavy enough to stop new learning during sessions (see section 5).

F1. Blueprint

• Purpose: a relapse-prevention summary written by the client [source: Wild et al. 2020; components session sheet; Murray et al. 2022].
• Steps:
  1. Set it as homework near the end of therapy.
  2. It covers: how the problems developed; what kept them going; what helped; the most unhelpful thoughts and their alternatives; next steps for reclaiming life; anniversaries; and how to handle setbacks.
  3. Review it in session and revise it. Include goals deferred from A5.
• Example language: "How will I deal with any setbacks in the future?" is one of the blueprint questions [Wild et al. 2020].
• Watch for: a blueprint that only lists techniques. It should also name the key updates.

F2. Booster sessions

• Purpose: consolidate gains and handle setbacks [source: Wild et al. 2020].
• Steps: up to three sessions at monthly intervals. Review the blueprint, measures, remaining triggers and reclaiming goals.

F3. Involving significant others

• Purpose: support generalisation [source: Wild et al. 2020; Murray et al. 2022].
• Steps: with consent, invite a partner, friend or family member to help spot triggers and early signs of dissociation, and to join reclaiming activities, experiments and site visits.

F4. Remote delivery adaptations (video or telephone)

• Purpose: deliver all components remotely [source: Wild et al. 2020; Murray et al. 2022].
• Steps:
  1. Check that the client is alone. The therapist works privately, uses headphones and pans the camera to show they are alone.
  2. Make up for missing nonverbal cues with a warm voice and frequent checks. On the phone, consider sending a photo of yourself.
  3. Assess dissociation and self-harm risk before remote trauma work and agree a crisis plan. Check in whenever the client goes quiet.
  4. Prefer a written narrative on the phone.
  5. Share screens for formulation, narratives and triggers.
  6. Run experiments at home or by phone. Do site visits virtually, or with the client on site and the therapist on the phone.
  7. Send the blueprint by email.
  8. Text messages for reminders and encouragement are optional, with consent and within service policy.

F5. Internet-delivered CT-PTSD (iCT-PTSD)

• Purpose: keep the core procedures while cutting therapist time [source: Wild et al. 2016 abstract].
• Steps: the client works through online modules covering memory updating, trigger discrimination, a site visit, appraisal work for danger, guilt, shame and anger, behavioural experiments and reclaiming life. The therapist guides remotely through messages and calls. The module structure, number of calls and duration were not confirmed in the sources [uncertain].

F6. Imagery rehearsal for persistent nightmares (adjunct)

• Purpose: used in one published CT-PTSD case after cognitive restructuring [source: Smith 2006, citing Forbes et al. 2001 and Krakow et al. 2001]. Wild et al. (2020) give no dedicated nightmare protocol and note that updating often improves sleep.
• Status: treat this as an adjunct, not a core CT-PTSD component [uncertain]. Try updating the matching hotspots first.

5. Handling problems

Each item is tagged with where the guidance comes from: [source: …] means it comes from the CT-PTSD group's own papers; [synthesis] means it is my own guidance, consistent with the model but not stated in the sources.

• Fear that talking will re-traumatise, or reluctance to start memory work. Give the rationale about the unprocessed memory and the role of avoidance, using a metaphor. Stress that the client controls the pace and that confidentiality applies. Prepare them for temporary distress and plan supportive activities for after sessions. Frame reliving as showing that the memory and the distress can be tolerated and controlled [source: Murray et al. 2022]. If the client still declines, start with a written narrative or with a single hotspot [source: Wild et al. 2020; Murray et al. 2022].
• Overwhelm or over-engagement during memory work. Switch to past tense with eyes open. Use the here-and-now anchors and your voice, ask more questions, and move to a written narrative. Stop at a safer point that was agreed in advance [source: Wild et al. 2020; Murray et al. 2022]. Then update the hotspot that was overwhelming rather than repeating it [synthesis, based on Murray et al. 2022].
• Dissociation. Dissociation before treatment has not been found to predict a worse outcome, so it is not a reason to avoid memory work. Do these first: teach early-warning signs; practise trigger discrimination; use grounding objects with strong sensory input; use movement; take frequent ratings; involve family [source: Murray et al. 2022; Wild et al. 2020].
• Fragmented memory, or gaps. Build a timeline. Use records, ICU diaries or an early site visit to fill the gaps [source: Murray et al. 2022]. Delirium or hallucinations during ICU care are a recognised CT-PTSD application, but the specific procedure is not drawn on [uncertain; Thew et al. 2024].
• Under-engagement: summarising, skipping, numb telling. Slow down at the skipped moments and ask about sensory detail and thoughts there. Treat skipped moments as likely hotspots [source: Wild et al. 2020 on watching for avoidance; synthesis on technique].
• Stuck: "I know it wasn't my fault, but it doesn't feel that way." Check whether the hotspot holds another, unaddressed meaning, such as shame beneath fear, and ask "what does that mean about you as a person?" [Murray et al. 2022]. Make the evidence experiential (survey, experiment, movement, imagery) and put it into the hotspot instead of only discussing it [source: Murray et al. 2022]. If intrusions continue, look for unidentified triggers and for ongoing rumination or suppression [synthesis].
• Multiple or prolonged trauma. Expect it to take longer, not to fail. Link the appraisals that run across traumas, update the most relevant hotspot first, then generalise the update [source: Murray et al. 2022]. ICD-11 complex PTSD differs from "complexity" in general. The editorial advises flexing the order but staying close to the formulation [source: Thew et al. 2024].
• The worst really happened (a death, a permanent injury). Do not reassure falsely. Target the distorted meanings, such as "alone forever" or "life is over", and use loss work (D6) [source: Murray et al. 2022; Wild et al. 2020].
• Moral injury, or genuine responsibility. Separate distorted self-blame from the share that is real (use the pie chart). Help the client accept genuine responsibility, and consider making amends [source: Murray et al. 2022; Thew et al. 2024]. Specific moral-injury procedures are in a separate paper that is not drawn on [uncertain].
• Shame blocks disclosure. Work on the shame appraisals before reliving, using psychoeducation (for example about freezing) and a survey. Then link the updates to the hotspots [source: Murray et al. 2022]. Normalise the client's delay in disclosing and check regularly whether they feel judged [synthesis].
• Ongoing threat or instability. First assess and manage risk to self, from others and to others [source: Murray et al. 2022]. If the danger is real and current (for example ongoing abuse), give priority to safety planning and practical action; CT-PTSD targets overestimated current threat [synthesis]. Life instability on its own is not a reason to delay if the client consents [source: Murray et al. 2022].
• Suicide or self-harm risk. Monitor every session (PHQ-9 self-harm item), keep a joint crisis plan up to date, and do a full assessment before remote memory work [source: Wild et al. 2020]. Where needed, follow service risk protocols, including lethal-means safety planning (safe storage or removal) [synthesis].
• Not doing homework or reclaiming tasks. Find out which appraisal is behind it, for example "there's no point, I'm permanently changed" or "if I go out I'll be attacked". Then make the task the experiment that tests that appraisal. Make tasks smaller and more specific, and use text reminders with consent [source: Wild et al. 2020 for the texts; synthesis for the rest].
• Hidden safety behaviours undermining experiments. Ask exactly what the client did during the task. Check that the behaviours were really dropped, for example during calls [source: Wild et al. 2020]. Re-run the experiment without them [synthesis].
• Rumination or anger keeping the memory active. Use E2 and D5 [source: Wild et al. 2020].
• Substance use or comorbid depression or panic. Bring the maintaining appraisals and behaviours into the same formulation and treat them together [source: Murray et al. 2022]. If heavy use stops new learning, agree to reduce use around sessions, or arrange substance-use treatment first [synthesis].
• Rupture: anger at the therapist, feeling pushed, feeling judged. Ask for feedback on pace and content regularly [source: Wild et al. 2020]. If a rupture happens, name it, take your share of responsibility, give control back over pace and order, and check whether it echoes a trauma meaning such as betrayal or "no one can be trusted". If so, work with it as an appraisal [synthesis].
• Remote problems: no privacy, a quiet client, technology failures. Check privacy at the start of each session, check in whenever the client goes quiet, and agree a backup plan (such as phone) if video drops during memory work [source: Wild et al. 2020; synthesis on the backup plan].
• Therapist avoidance: delaying reliving, skipping site visits or experiments. The authors report these "doing" techniques are among the least used. Use supervision and the free OxCADAT training videos [source: Thew et al. 2024; Oxford project page]. Also monitor your own wellbeing [source: Wild et al. 2020].
• Legal proceedings or compensation claims under way. Not covered in the sources. Discuss with the client how written narratives will be stored and who could access them, and seek advice from your service [synthesis; uncertain].
• Setbacks after ending. Use the blueprint plan for setbacks and anniversaries, plus booster sessions [source: Wild et al. 2020].

Sources

Sources:

• Preventing and treating post-traumatic stress disorder — University of Oxford, Department of Experimental Psychology
• Murray, Grey, Warnock-Parkes, Kerr, Wild, Clark & Ehlers (2022). Ten misconceptions about trauma-focused CBT for PTSD. The Cognitive Behaviour Therapist, 15, e33
• Thew, Warnock-Parkes, El-Leithy et al. (2024). Enhancing your delivery of cognitive therapy for PTSD: a celebration of the work of Hannah Murray. The Cognitive Behaviour Therapist, 17, e39. This is the practice review linked as PMC7617247. PubMed Central was not used.
• Wild, Warnock-Parkes, Murray, Kerr, Thew, Grey, Clark & Ehlers (2020). Treating posttraumatic stress disorder remotely with cognitive therapy for PTSD. European Journal of Psychotraumatology, 11, 1785818 (Oxford Research Archive copy)
• Components of CT-PTSD session sheet (hosted by NKVTS; authorship not stated on the page)
• Wild et al. (2016). Internet-delivered cognitive therapy for PTSD: a development pilot series. European Journal of Psychotraumatology (abstract page)
• Cloitre (2014). Editorial on Ehlers et al. (2014), 7-day intensive and weekly cognitive therapy for PTSD. American Journal of Psychiatry
• Murray, Merritt & Grey (2015). Returning to the scene of the trauma in PTSD treatment – why, how and when? The Cognitive Behaviour Therapist, 8, e28 (abstract only)
• Smith, T.-A. (2006). Frozen in time to reclaiming one's life: the Ehlers and Clark cognitive therapy model with a hijacking survivor. Rhodes University (secondary)
• Psychology Tools. A therapist's guide to PTSD formulation (secondary)
• Treating PTSD remotely with CT-PTSD — repository record (metadata only)

Further reading (not drawn on): the PMC and Europe PMC copies of PMC7617247; oxcadatresources.com/ptsd; the Taylor & Francis page for Wild et al. (2020).

Books and papers cited (not drawn on):

• Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–345.
• Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., & Fennell, M. (2005). Cognitive therapy for post-traumatic stress disorder: development and evaluation. Behaviour Research and Therapy, 43, 413–431.
• Ehlers, A., Hackmann, A., Grey, N., Wild, J., Liness, S., Albert, I., Deale, A., Stott, R., & Clark, D. M. (2014). A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. American Journal of Psychiatry, 171, 294–304.
• Grey, N., Young, K., & Holmes, E. (2002). Cognitive restructuring within reliving: a treatment for peritraumatic emotional "hotspots" in PTSD. Behavioural and Cognitive Psychotherapy, 30, 37–56.
• Ehlers, A., & Wild, J. Cognitive therapy for PTSD: updating memories and meanings of trauma. In U. Schnyder & M. Cloitre (Eds.), Evidence Based Treatments for Trauma-Related Psychological Disorders. Springer (2015; 2nd ed. 2022).
• Treatment materials, measures and therapist training videos: OxCADAT Resources (oxcadatresources.com, free registration).