Working with Complexity in PTSD: A Cognitive Therapy Approach

349 Pages·2022·7.866 MB·English

by  Hannah Murray, Sharif El-Leithy

Working with Complexity in PTSD
This accessible, evidence-based book provides readers with a practical framework to understand,
formulate, and treat PTSD using the cognitive model while creatively adapting for complexity.
Cognitive therapy for PTSD is a highly effective treatment, but aspects of clinical complexity can
complicate treatment and limit its effectiveness. Trauma memories themselves can be complex,
the associated meanings can resist change and people may struggle to engage with them without
feeling overwhelmed. Problems that commonly arise alongside PTSD add to clinical complexity,
such as comorbid psychological or physical disorders, social problems, and ongoing risks.
Bringing together the science and art of therapy, this book demonstrates how to approach these
issues by holding firm to the principles of CBT, whilst flexing and creatively adapting techniques
for each unique circumstance. Rich case studies, top tips, and frequently asked questions are
used throughout to demonstrate the approach.
Written by clinicians for clinicians, the book synthesizes the latest research into a practical
treatment manual to help readers overcome obstacles in PTSD treatment and ‘supercharge’ their
therapy skills.
Dr Hannah Murray is a Research Clinical Psychologist based at the Oxford Centre for Anxiety
Disorders and Trauma, University of Oxford. She works clinically and in research to develop, test
and disseminate treatments for Post-Traumatic Stress Disorder, particularly Cognitive Therapy for
PTSD.
Dr Sharif El-Leithy is a Consultant Clinical Psychologist specialising in psychological reactions
to life-threatening traumas. He has over 20 years of experience in using cognitive-behavioural
therapy to treat PTSD arising from complex traumatic experiences, including victims of war,
torture, and domestic and childhood abuse.

Working with
Complexity in PTSD
A Cognitive Therapy Approach
Hannah Murray and Sharif El-Leithy
Cover image: © Maryam Salehi
First published 2022
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2023 Hannah Murray and Sharif El-Leithy
The right of Hannah Murray and Sharif El-Leithy to be identified as authors of
this work has been asserted in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from the
publishers.
Trademark notice: Product or corporate names may be trademarks or registered
trademarks, and are used only for identification and explanation without intent
to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record has been requested for this book
ISBN: 9781032264424 (hbk)
ISBN: 9781032264080 (pbk)
ISBN: 9781003288329 (ebk)
DOI: 10.4324/9781003288329
Typeset in Joanna
by codeMantra
For Hannah’s medical team, without whom this book would not have been written

Contents
Foreword ix
Preface xi
Acknowledgments xii
PART 1 Foundations 1
1 Understanding PTSD and complexity 3
2 Cognitive Therapy for PTSD 13
3 Assessment and formulation 25
PART 2 Complexity in memory work 37
4 Over-activation of trauma memories 39
5 Under-activation of trauma memories 51
6 Dissociation 61
7 Multiple trauma memories 72
8 Gaps in trauma memories 86
9 Recovered memories 99
10 Constructed memories 109
11 Psychosis-related PTSD 120
PART 3 Complexity in cognitive work 129
12 Strongly held or long-standing beliefs 131
1 3 Self-attacking beliefs and emotions 144
1 4 The head–heart gap 156
1 5 Loss 167
16 Moral injury 179
PART 4 Complexity in coping strategies 193
17 Drugs and alcohol 195
1 8 Reckless behaviour 205
1 9 Avoidance 215
PART 5 Comorbidity 225
2 0 Psychological comorbidity 227
2 1 Physical comorbidity 240
viii | Contents
22 Social comorbidity 253
2 3 Risk 264
PART 6 Complexities for the therapist 275
24 The therapeutic relationship 277
2 5 Diversity 288
2 6 Looking after yourself 300
References 311
Index 331
Foreword
It is an honour to write this foreword, and to have had an early opportunity to read this book.
As a clinician, researcher, and trainer in this field I have learned greatly from the questions I have
been asked by supervisees, workshop participants, and most of all clients with PTSD with whom
I have worked. These questions have typically revolved around issues of complexity of one sort
or another. Both for myself and for others there is now a core text to which we can all turn to
help address such questions.
The treatment that Hannah and Sharif describe is Cognitive Therapy for PTSD (CT-PTSD),
originated by Anke Ehlers and David Clark, and developed further by them and others in their
team since the late 1990s. There is excellent evidence for the effectiveness of this treatment
both in randomised controlled trials and routine clinical practice, and it forms part of the
many guidelines for the treatment of PTSD around the world. However, as clinicians, we are
often working ‘beyond the guidelines’, with varying issues of complexity, some of which are
not well covered by the existing evidence base. What to do in such situations? There are a
number of risks we face. We risk simply throwing out the evidence base, claiming it doesn’t
apply for the people we work with. We risk pushing on in a rigid fashion, slavishly following
a set recipe, in the face of no change or even deterioration. And we risk drifting away from
the core principles underlying the model and treatment, into a conceptually incoherent
eclecticism.
Hannah and Sharif guide us between these risks, providing example after example of ‘flexibility
within fidelity’. Many implicit myths about the use of CT-PTSD, in particular contexts, or with
particular people, are gently but firmly busted throughout this text. They provide an extremely
helpful framework for considering many types of complexity, and offer conceptual clarity to
issues around the definition of complexity, which is not simply synonymous with ‘Complex
PTSD’. At heart remain the core maintaining processes of PTSD, the nature of the trauma memory,
the meanings people have taken from their experiences, and the behaviours they use to cope.
This provides the framework for many chapters that address ‘memory complexity’, ‘cognitive
complexity’, and ‘complexity in coping’. Further chapters address other contextual complexities
inherent in this work. This framework will also help guide the gathering of further evidence in
these areas.
Jo Nesbo, the Norwegian thriller writer, suggests that ‘The art of dealing with ghosts is to dare
to look at them long and hard until you know that is what they are. Ghosts. Lifeless, powerless
ghosts.’ This applies to the people with whom we work in facing their personal memories, but
also applies to us as clinicians in recognising the ghosts of complexity, which, if we face, we can
also tackle.
It has been my privilege to work with Hannah and Sharif in various capacities over time. They
have many years of experience as practitioners, supervisors, and trainers of CT-PTSD. They have
the crucial combination of clarity of thought allied to clinical skill that allows both a deeper