Engaging With CBT

Tag: Moving On After Trauma

  • Refusing to be Defined by Your Trauma

    On Wednesday the BBC morning News featured a Southampton University student, Hamish, who, as a result of sepsis, lost his four limbs. Amazingly he’s back driving, walking and continuing his philosophy degree. Hamish is living proof that is not the trauma per se that is important but what it is taken to mean for today. Earlier in the week, on ITV, I watched an episode of ‘Long Lost Families’ which featured an unsupported Mum, who as a 15-16 year old gave her 6-month old son up for adoption. The experience had clearly been absolutely devastating for her, but the programme reunited them both. The good news for her was that it had been a good adoption. However, at aged 12 or 13 her son found out that he had been adopted. His world was turned upside down as he viewed his life to that point as having been a ‘fiction’. He became estranged from his adoptive parents and they were devastated, with no appreciation of what had brought about the sharp change in him. This served to underline that is the take on events that is pivotal for outcome, rather than the trauma itself. We are all engaged in mental time travel, going back and forth in our ‘Dr Who, Tardis” collecting items from the past and gauging their utility for today.

    But clinicians are often hi-jacked by the drama of the event and not the unfolding story, unnecessarily distressing themselves and their client, with a ‘re-living’ focus.  A recent paper by Zoellner et al (2025) suggest that clinicians have overestimated the importance of the trauma and have underestimated the significance of the re-framing processes that occur subsequently. In my self-help book Moving on After Trauma Routledge 2024 and Clinician Handbook Personalising Trauma Treatment: Re-framing and Re-imagining Routledge 2022, I have proposed that it is the centrality accorded to the trauma that is significant and this is where therapeutic efforts need to be targeted. This is a radical departure from the traditional trauma focused treatment. The beauty of a centrality approach is that it is applicable not only to extreme trauma but also to lessor stressors such as bullying at work or being a victim of a Data Breach.

    Dr Mike Scott

  • Reconceptualising Trauma Treatment

    • The dropout rate from trauma focused treatments (TFTs), in randomised controlled trials is 1 in 4
    • With a 50% recovery rate, but in routine practice only the tip-of-the iceberg recover
    • TFTs are not user-friendly for clinicians or clients, as the latter rarely want to re-live their trauma
    • But there is a new way forward – gradually daring the client to think and behave as they did pre-trauma. At the same time challenging the relevance of the intrusive memories to what they might do today. That is, changing the window through which they view themselves and their personal world.

    The Powerpoint presentation below highlights this different pathway:

    https://www.dropbox.com/scl/fi/zh3owqemrdh4vcac7j14o/Reconceptualising-Trauma-Treatment-2025.pdf?rlkey=0rwfvr5djghnag5tt8n5zu49m&st=qk09aany&dl=0

    Scott, M.J (2022) Personalising Trauma Treatment: Reframing and Reimagining London: Routledge and

    Scott,M.J (2024) Moving On After Trauma 2nd Edition London: Rutledge

    Dr Mike Scott

    • ‘Doing CBT’

      This is the title of the seminal 2nd Edition of this work, by David F Tolin, published last year by Guilford Press. He sees CBT at its’ core, as focussed on the reciprocal interactions of cognitions, behaviour, emotion and physiology. So that changing any one will impact on the others. This will be very familiar to all CBT therapists, for example if feeling low you could go for a walk (physiology) or alternatively change your thinking from ‘I have too much to do’, to ‘ I can get through it all, if I just pace myself with breaks, doing only one task at a time’. The strategies adopted synchronise with each other. Interestingly he describes his way of doing CBT, which he acknowledges might not be how another expert clinician might conduct CBT. This could be regarded as flexibility but it also may cause problems with regards to fidelity.

      For example he advocates, p xi, ‘that we de-emphasise the DSM In favor of a broad set of principles …which we can apply to all our clients, no matter who they are or what problem (s) they have’. But Judith Beck in CBT The Basics and Beyond (2020) states that the first thing she does is a diagnostic evaluation. Throughout her book she describes the treatment of 2 clients one with simply depression and the second with depression and a borderline personality disorder.

      Without categorisation both clients would likely have been treated in the same way.

      Tolin makes no mention of cognitive content specificity i.e that disorders are distinguished by their different cognitive content. Knowing the disorder(s) likely flags up a particular set of cognitions to be addressed, for example in PTSD those embodied in the Trauma Cognitions Inventory, Scott (2024) Moving On After Trauma 2nd edition. Without this the nascent CBT therapist might ‘zap’ every negative cognition in sight.

      Fidelity is more difficult to gauge with Tolin’s approach. He states that clients can be advised of a 50% recovery rate across the anxiety disorders on the basis of randomised controlled trials. Though on average treatment gains were maintained, it is unclear from the rcts what proportion of clients maintained recovery for say 6 months. This is the real-world data of interest to clients.

      Clinicians working in routine practice have to be accountable, but this cannot be easily demonstrated if a therapist is doing their own version of CBT. Treatment integrity is a major pressing and unaddressed issue in routine practice. Service providers have shown no inclination to address this, perhaps fearing that to do so might threaten their very existence. Neither Beck or Tolin, address the very different working context of routine practice, where I suspect flexibility has become infidelity.

      Dr Mike Scott