WORKSHOP 1

How to bounce back when the going gets tough:  Treating comorbid PTSD and depression in adults
Reg Nixon, School of Psychology, Flinders University, Australia

Clinicians rarely have the luxury of treating PTSD in the absence of other comorbidity. Depression is one of the most common comorbid disorders to accompany PTSD. Features of depression such as entrenched maladaptive core beliefs and numbing can interfere with the known mechanisms through which PTSD is successfully treated with CBT (e.g., reducing rigid trauma-related beliefs, amelioration of strong negative affect associated with trauma memories etc).                                                                                                      

There are a myriad of different CBT methods that are effective for PTSD and depression (e.g., cognitive therapy, behavioural activation, imaginal or written exposure, in vivo exposure). This workshop will focus on when and how to most effectively use these skills in clients with PTSD and comorbid depression. Issues of treatment sequencing, clinical challenges associated with trauma-focused work and how to adapt evidence-based protocols for routine clinical practice will be addressed.

Learning objectives:

1. To increase understanding of how PTSD and depression can reciprocally influence therapy outcome.
2. To develop confidence in synthesising varying treatment methods to address both PTSD and depression.
3. To understand how to flexibly apply CBT methods in the treatment of comorbid PTSD and depression without diluting its effectiveness.

Implications for the science and practice of CBT:
Workshop participants should become more confident in conceptualising how to best treat comorbid PTSD and depression. Participants will also acquire practical resources and materials to better assist their clients.

Reg Nixon is a registered clinical psychologist and academic who has been involved in the research and treatment of child and adult PTSD for the past 14 years. He has worked with a range of client groups, including single-incident trauma as well as child and adult survivors of physical and sexual assault, domestic violence, and combat-related trauma.  His clinical work in PTSD has been in the context of research trials examining the efficacy of components of CBT as well as the use and dissemination of trauma-focused therapy into routine clinical practice. He is an accredited trainer in Cognitive Processing Therapy, and is accredited by the Psychology Board of Australia (the national registration board) as a clinical psychology supervisor.
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Martel, C.R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: A clinician’s guide. New York, NY: Guildford Press.
Nixon, R.D.V. & Nearmy, D.M. (2011). Treatment of Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder: A Pilot Study. Journal of Traumatic Stress, 24, 451–455.
Resick, P.A., Monson, C.M., & Rizvi, S.L. (2008). Posttraumatic Stress Disorder. In Barlow, D.H. (2008). Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual (4th ed.) (pgs. 65-122). New York: Guilford Press.

WORKSHOP 2

New advances in treating child and adolescent trauma
Patrick Smith, King’s College London & South London and Maudsley NHS Foundation Trust

Cognitive models of PTSD were developed initially to explain adults’ reactions to traumatic events.  More recently, models have been adapted for children and adolescents, tested in at risk (ie trauma-exposed) young people, and used to inform developmentally-appropriate Trauma-Focused CBT treatment protocols.

This workshop will describe how Ehlers and Clark’s (2000) cognitive model of PTSD and treatment protocol has been adapted for use with young people.  Recent evidence regarding children’s appraisals, the nature of trauma memories, and family functioning in the aftermath of trauma will be reviewed.  The workshop will cover:  how to carry out assessment and derive an idiosyncratic cognitive formulation; and how to implement key treatment components of TF-CBT with young people, including imaginal reliving, updating traumatic memories, working with triggers, and working with families.  The emphasis will be on individual, formulation-driven TF-CBT.  Protocols for working with very young preschool children will also be demonstrated.

Learning objectives:
Up to date knowledge of the applicability of cognitive models of PTSD to children and young people.
How to carry out assessment and formulation with young people and families.
How to plan and deliver individually tailored TF-CBT with children and families.

Implications for the science and practice of CBT:
Participants will be able to deliver effective, evidence-based treatment for young people with PTSD.

Patrick Smith is a lecturer in psychology at the Institute of Psychiatry King’s College London, and Honorary Consultant Clinical Psychologist at the South London and Maudsley NHS Foundation Trust.  He works in a long-established Child Traumatic Stress Clinic, and is co-founder of a specialist Mood Disorder Clinic for young people.  On completing his clinical training, he led a UNICEF-funded psychosocial programme for war-affected children in Bosnia.  His collaborative research since then has focused on understanding children’s psychological reactions to trauma, and on developing interventions for traumatised young people.  With colleagues, he has investigated cognitive models of PTSD in children; evaluated individual Trauma-Focused CBT for children and young people in a randomized controlled trial; and has helped to develop and evaluate group interventions for children exposed to war and disasters.

Ehlers, A. & Clark, D.M. (2000). A cognitive model of post-traumatic stress disorder. Behaviour Research & Therapy, 38, 319-345.
Smith, P., Yule, W., Perrin, S, Tranah, T., Dalgleish, T., & Clark D.M. (2007).  Cognitive behavioural therapy for children and adolescents – a preliminary randomised controlled trial. Journal of the American Association for Child and Adolescent Psychiatry, 46, 1051-1061
Smith, P., Perrin, S., Yule, W., & Clark, D.M. (2010).  Cognitive therapy for post traumatic stress disorder.  Routledge Press, London

WORKSHOP 3

Memory-focused approaches in Cognitive Therapy for adults with PTSD
Nick Grey, Centre for Anxiety Disorders and Trauma, South London and Maudsley NHS Foundation Trust

Guidelines from around the world for the treatment of PTSD in adults recommend trauma-focused CBT as a first line treatment. In essence ‘trauma-focused’ means placing an emphasis on discussing the details of the traumatic memories. This can be emotionally demanding for both patient and therapist. Despite the treatment guidelines many therapists still do not use ‘trauma-focused’, i.e. memory-focused, approaches.

This workshop demonstrates the range of memory-focused approaches used in Cognitive Therapy for PTSD, the treatment based on Ehlers and Clark’s (2000) cognitive model for PTSD. These memory-focused techniques include reliving/exposure, written narratives, stimulus discrimination, and site visits. The obstacles that both patients and therapists present to using these highly effective techniques will be addressed. The timing of such techniques within an overall treatment programme will be discussed.

Learning objectives:
To be aware of the range of memory-focused techniques including reliving/exposure, written narratives, stimulus discrimination, and site visits.
How to choose which approach to adopt at which time.
How to integrate memory-focused approaches in a course of treatment.

Implications for the science and practice of CBT:
Participants should be more confident in trying to use memory focused techniques in treatment of adults with PTSD. Patients will receive the treatment approaches with the best evidence for their effectiveness.

Nick Grey is a Consultant Clinical Psychologist at, and Joint Clinical Director of, the Centre for Anxiety Disorders and Trauma (CADAT), South London & Maudsley NHS Foundation Trust, and Institute of Psychiatry, King’s College London. His clinical work is providing outpatient cognitive therapy to people with a variety of anxiety disorders and PTSD, both within randomized controlled trials and in a more general NHS service. CADAT forms part of three local IAPT services and also offers a national service (www.national.slam.nhs.uk/cadat). He is a BABCP accredited practitioner, supervisor and trainer.

Ehlers, A. & Clark, D.M. (2000). A cognitive model of post-traumatic stress disorder. Behaviour Research & Therapy, 38, 319-345.
Ehlers, A., Clark, D.M., Hackmann, A., McManus, F., & Fennell, M. (2005). Cognitive therapy for posttraumatic stress disorder: development and evaluation. Behaviour Research and Therapy, 43, 413-431.
Grey, N. (Ed.) (2009). A casebook of cognitive therapy for traumatic stress reactions. Hove: Routledge.

WORKSHOP 4

Treating PTSD in the perinatal period with trauma-focused CBT and imagery techniques.
Antje Horsch, University of Lausanne, Switzerland and Ann Hackmann, Oxford Cognitive Therapy Centre, UK

This workshop will draw on cognitive models to conceptualise PTSD in the perinatal period, i.e. during pregnancy and up to one year after childbirth, including perinatal loss (miscarriage, stillbirth, neonatal death). The focus of this skills-based workshop will be on developing specialist skills in assessment, formulation and trauma-focused cognitive-behavioural therapy (based on Ehlers and Clarks, 2000) for this population with a particular focus on imagery re-scripting techniques. Theories explaining the role of mental imagery in PTSD symptomatology will be presented and clinical applications of these in the treatment of women (and their partners) during the perinatal period will be discussed.

Learning objectives:

1. Participants will learn about cognitive models of PTSD and theoretical models explaining the role of mental imagery in the perinatal population.
2. Participants will develop specialist evidence-based skills in assessment, formulation and trauma-focused cognitive-behavioural therapy for PTSD in the perinatal period, with a particular focus on imagery re-scripting techniques.

Implications for the science and practice of CBT:
Participants should be able to apply evidence-based trauma-focused CBT techniques and imagery-rescripting techniques in their clinical work with women (and their partners) in the perinatal period.

Antje Horsch is a clinical psychologist who is now based at the University of Lausanne. Prior this, she worked in the Berkshire Traumatic Stress Service (Reading) where she ran a specialist clinic for women who had posttraumatic stress disorder (PTSD) following childbirth and perinatal loss, and at the Institute for Clinical Psychology Training (University of Oxford) where she conducted and supervised research in the area of PTSD and traumatic grief in the perinatal period and co-founded the Oxford Perinatal Psychology Research Group (OPAL).
Ann Hackmann is a clinical psychologist who is an associate of the Oxford Cognitive Therapy Centre, and the Oxford Mindfulness Centre at the University of Oxford. For many years she worked in a research group refining cognitive therapy protocols for anxiety disorders. She was a therapist in several trials of cognitive therapy for PTSD. Her special interest is in imagery, and with James Bennett-Levy and Emily Holmes she has published the Oxford Guide to Imagery in Cognitive therapy (2011). She also worked as the clinical supervisor on a trial of imagery rescripting in the treatment of depression.

Horsch, A. (2009). Post-traumatic stress disorder following childbirth and pregnancy loss. In H. Beinart, P. Kennedy & S. Llweleyn (Eds.), Clinical Psychology in Practice. Oxford: Blackwell Publishing Ltd.
Ayers, S. (2004). Delivery as a traumatic event: Prevalence, risk factors, and treatment for postnatal posttraumatic stress disorder. Clinical Obstetrics and Gynecology, 47, 552-567.
Ayers, S., McKenzie-McHarg, K. & Eagle, A. (2007). Cognitive behaviour therapy for postnatal posttraumatic stress disorder: case studies. J of Psychosomatic Obsterics & Gynecology, 28, 177-184.
Hackmann, A., Bennett-Levy, J., and Holmes, E.A. (2011) Oxford Guide to Imagery     in Cognitive Therapy. Oxford University Press: Oxford.
Holmes, E. M. & Hackmann, A., (ed.) (2004). Imagery in Psychopathology and its Relationship to Memory. Special Issue of Memory.

WORKSHOP 5

Compassion-focused CBT for Adults with PTSD to Childhood Trauma
Deborah Lee, Berkshire Traumatic Stress Service & University College London

This workshop explore compassionate focused  therapeutic ways of working with  people who have experienced  childhood trauma that have left them feeling ashamed and very self- attacking. 

Although we can consider shame as in part, a threat based response, the fear is very much focused on how we perceive we live in the mind of others and the fear of how we live in our own minds.   Such fears do not necessarily respond well to exposure based clinical interventions and sometimes shame can intensify and exacerbate with exposure. This seems especially true for those of us who struggle to self sooth and access emotional memories of being soothed, cared for and feeling safe in the mind of others. These are essential experiences for psychological wellbeing that we learn in our key attachment relationships.

Compassion focused therapy focuses on the development of these emotional experiences of being soothed, cared for and feeling safe in the mind of others and it offers a theoretical, clinical and evidence based way to work with distressing shame and self attack. It is based on social mentality theory  (Gilbert, 2005)  and draws on neuroscience, attachment theory and evolution to explore nature of shame-based, negative self-evaluations.
The clinical conundrum is can we enhance our evidence based practice such as trauma focused CBT or EMDR with new clinical directions such as compassion focused Therapy which has been developed to work with those who suffer from profound feelings of shame and self attack. A combined approach could offer exciting new ways of working with shame based trauma experiences and shame based PTSD.

So this workshop will bring together two schools of thought to enhance our clinical practice with shame based trauma - trauma focused CBT and compassion focussed therapy

The workshop will present a phased based approach to treatment and  theory- practice links on how to develop a compassionate mind  in order access  feelings of self soothing and safeness. The chapter will explore ways to develop inner compassion via imagery and the generation of compassionate feelings for the self. These techniques will be illustrated in case material.  The workshop will then explore how to weave compassionate feelings, images and compassionate ways of thinking into more traditional ways of working with  childhood trauma such as developing a narrative, imaginal and in vivo exposure to traumatic events and, enhanced reliving.  Case material will be used to illustrate these integrated techniques and consideration will be given to challenges and  blocks that might arise in the course of therapy.

Learning objectives:
To be aware of the range of memory-focused techniques including reliving/exposure, written narratives, stimulus discrimination, and site visits.
How to choose which approach to adopt at which time.
How to integrate memory-focused approaches in a course of treatment.

Implications for the science and practice of CBT:
Participants should be more confident in trying to use memory focused techniques in treatment of adults with PTSD. Patients will receive the treatment approaches with the best evidence for their effectiveness.

Dr Deborah Lee is a Consultant Clinical Psychologist and Head of the Berkshire Traumatic Stress Service. She is honorary Senior Lecturer in Clinical Psychology at University College London.  Dr Lee has worked in the field of adult trauma, as a specialist for 20 years.  Her clinical interests lie in the working with adult survivors of PTSD, complex trauma and shame based memories relating to trauma experiences. Her research interests include shame and self- criticism in PTSD and the use of compassionate imagery to work with shame-based flashbacks aingf from child and adult trauma. She has recently developed a group based intervention using compassion approaches to treat PTSD.
She has provided teaching and training in the field of traumatic stress in the U.K., Europe and North America. She has published in academic and clinical journals and has written over 30 articles, book chapters and papers on her clinical work and research. She has recently finished a self help book on the compassionate mind guide to recovering from shame and trauma.

Gilbert, P (2009). The Compassionate Mind, Constable and Robinson, London
Lee, D.A (2009). Lee, D.A (2009). Compassion Focused Cognitive Therapy For Shame-based Trauma Memories and Flashbacks in PTSD. In Grey, N. (Eds.) A Casebook of Cognitive Therapy for Traumatic Stress Reactions. Chapter 15. London: Brunner-Routledge.
Lee, D,A., (2012) The Compassionate Mind Approach to Recovering from Trauma and Shame. New Harbinger Press.
Lee, D.A. (2005) The perfect Nurturer: Using imagery to develop compassion within the context of cognitive therapy. In Gilbert (Ed.) Compassion: Conceptualisations, Research and Use in Psychotherapy. London Brunner-Routledge.