Ten misconceptions about trauma-focused CBT for PTSD with Dr Nick Grey
In this episode of Let's Talk about CBT – Research Matters, host Steph Curnow speaks with Dr. Nick Grey, a consultant clinical psychologist with extensive experience in anxiety disorders and PTSD. Together, they discuss the paper "Ten Misconceptions about Trauma-Focused CBT for PTSD," co-authored by Nick and published in the Cognitive Behaviour Therapist. The paper addresses common myths and challenges in trauma-focused CBT, offering insights for both therapists and researchers in the field. Key misconceptions discussed include: Misconception 1: "Trauma-focused treatments are not suitable for complex or multiple trauma." Misconception 2: "Stabilisation is always needed before memory work." Misconception 10: "Cognitive Therapy for PTSD is rigid and inflexible." If you enjoyed this episode, please rate, review, and subscribe wherever you get your podcasts. Follow us on Twitter at @BABCPpodcasts or on Instagram . Share your feedback or episode suggestions by emailing [email protected]. Useful links: The paper discussed is: Murray, H., Grey, N., Warnock-Parkes, E., Kerr, A., Wild, J., Clark, D. M., & Ehlers, A. (2022). Ten misconceptions about trauma-focused CBT for PTSD. The Cognitive Behaviour Therapist, 15, e33. doi:10.1017/S1754470X22000307 The full version of the article can be found freely available here: https://bit.ly/47KIwPL Transcript: Steph: Hello and welcome to Let's Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT. Today I am talking to Dr Nick Grey. Nick is a consultant clinical psychologist and has worked in the field of anxiety disorders and PTSD for many years. He is also one of the authors of the paper we are going to be talking about today which is titled "Ten misconceptions about trauma-focused CBT for PTSD" and is published in the Cognitive Behaviour Therapist. So Nick, welcome to the podcast. Nick: Thank you, Steph. It's nice to be here. Steph: It's great to have you. So before we get talking about the paper, I was wondering if you would just mind telling everyone a bit about who you are and the areas in which you work. Nick: Yeah, sure. So, I'm a clinical psychologist by professional background and a sort of a CBT therapist by sort of flavour of psychological therapy. And I work down in Sussex now, based in Brighton working across Sussex partnership and for many years I worked up in London at the Centre for Anxiety Disorders and Trauma and continue to work together with David Clark, Anke Ehlers and other members of the Wellcome Trust anxiety disorders team who are based in Oxford. And, and that's where a lot of the work that we're going to be talking about has originated in both London and Oxford and in particular the paper is pulled together by the Oxford team. What I should also say and just wanted to say up front is that the paper is lead authored by Hannah Murray, who sadly passed away after a long illness in December 2023 and her input, not just to this paper, but to us as a group has been unbelievably crucial and, both us as a team, but I know that the wider, sort of CBT community will really miss her. Miss her contribution. Steph: Absolutely. And thank you for mentioning Hannah. She was a great friend to the journals as well. She spent so much time contributing to both of our journals, mentoring people, reviewing for us. Yeah, we really miss her. So I really wanted to talk to you about this paper today, because not only is it one of our most widely read papers, which is brilliant, but the format of this paper was so popular, it's actually sparked a whole new series of papers for us. We're doing a whole new set of "10 Misconceptions" papers now that we're currently commissioning. I just wanted to ask how did this come about? What was the idea for this? Nick: The idea came around because we found ourselves, doing a lot of training, a lot of supervision over a number of years, particularly for the treatment that we provide Cognitive Therapy for PTSD, which is one of the types of trauma focused kind of CBT. And we found ourselves saying many of the same things again and again, really sensible questions that people would raise in training workshops, really sensible questions people would raise in supervision, and we thought it would be helpful for us and therefore for all the people that we are also sort of like supervising and training to have us almost perhaps a single resource. So like an FAQs, around some of the things in this line of work. Steph: Before we get into talking about the misconceptions themselves, you've worked in PTSD and trauma for a long time now. If you don't mind me asking, when you started out were there any myths or misconceptions that you held about working with clients with PTSD? Nick: Yes, all of the ones that are in the paper at some stage or other, I think this is a normal process that actually we hold all of these to one degree or other, until perhaps we've had the chance to test them out or we've had the chance to learn more. One of the key things for me, I think one of the key things that we're always trying to get across in the work that we do is there's a difference between having a history of traumatic events and having experienced traumatic events, and then the types of presenting problems that people may have, which will include, may include PTSD, but may not only be PTSD. And this really came through to me, the sort of where I started in, in sort of psychology and mental health in the NHS was a long time ago, working as a research assistant, actually at the Spinal Injury Centre at Stoke Mandeville Hospital and part of the project that I was working on, led and supervised by Paul Kennedy, a clinical psychologist, was around how do people cope following spinal cord injury. And my job involved speaking to lots and lots of people who had experienced a spinal cord injury and how they were coping and, how, what helped them, what was difficult and those kind of things. And one of the things that I was really struck by was just how varied their current presenting difficulties or lack of difficulties were, given many of the similarities in the experiences that they'd had which had resulted in life changing injuries for all of them, essentially. And a small proportion of those people who had a spinal cord injury also were having repeated unwanted memories, nightmares, waking in the night on the wards, reliving the experiences that had led to their injury. But it was only a kind of a proportion. And then there was differences in how they coped with, with those experiences as well. So one of the things that I really took from that is that firstly that not everybody who experiences a traumatic event is going to be negatively affected in the long term, that the types of impact and effects that people may have following a traumatic event may be very varied or be very personal to them and even for those people who are having like unwanted memories or nightmares, for many people those also reduce naturally over time. And then what we're working with, certainly thinking about cognitive therapy for PTSD, thinking about trauma focused therapies as a whole, we're working with people who have become stuck in that process of natural recovery. So, I think one of the first misconceptions for me in this area was that everybody who goes through a trauma is going to be affected and they're going to be negatively affected and they're going to have PTSD. And I think some of that, that sort of misconception that I certainly, I think, held before getting more experience, is still to some degree commonly held in health systems. I wouldn't say necessarily by CBT therapists or people working in mental health, but as a whole, if you've had a trauma, it's definitely going to affect you and you're definitely going to need a trauma focused therapy. And I think this is one of the things that certainly exercises me in the present day as well, when people talk about things like treating complex trauma. And this ties in a little bit with the first misconception in the paper about multiple traumatic events or prolonged traumatic events and the complexity of kind of memory presentations and for me complex trauma is a description of the history, is a description of what the person has experienced and it's not a description of the presenting difficulties that they may have if they do in fact have significant difficulties. So we're never, and I don't think it is just semantics, I think it's important about how we conceptualise reactions to traumatic events, how we conceptualise PTSD, and therefore, really importantly how we provide treatment, is that we need to make sure that actually when we talk about treating complex trauma, it makes no sense. We're not treating the history per se. Of course, the history is massively important in the formulation, in understanding what's going on, in the possibility of there being PTSD. But what we're talking about in this paper, what we're talking about with cognitive therapy for PTSD is helping people, that subset of people who have experienced traumatic events who do meet criteria for PTSD or complex PTSD. And crucially it's those people who have re-experiencing symptoms where they have unwanted memories or bad dreams, where when they have those experiences, it feels to some degree like those events are happening again in the present. Rather than being simply memories from the past, and it's definitely taken me time to, to really get my head around that, that it's just a small subsection of people that kind of we're working with, and, and actually that treating multiple traumas, actually what we're treating is the re-experiencing symptoms, perhaps, to people who may have had a whole range of traumatic events, but maybe they may only be re-experiencing one or two, and then there's a question about well, why those one or two- usually links but a long answer meandering answer, but just to say that, I think my main misconception very early on in my career was that everyone after trauma gets PTSD. Yeah. And if there's multiple traumas, we're treating complex trauma, we're treating multiple trauma. Whereas actually what we need to think about carefully is to listen to people about what are the difficulties that they have and how are those influenced by their histories, but also how do we help them now? What's got them stuck now? Steph: I think that's really, really helpful. Yeah. So shall we get into the paper itself? As we discussed before we started recording, if we went through all ten misconceptions, we might be here for quite some time and end up with a very long record. But there were a couple that we wanted to pick out and highlight that we thought might be really helpful for people to hear. So, do you want to kick off with the ones that you've picked and why? Nick: Yeah, so, so the ones, I started getting into it a little bit there and got a little bit more to say about it, which was about, the first one is around multiple traumatic experiences and how we work with those. The other ones I want to bring to the fore are also around the second misconception around stabilisation and that we always have to have lots of sort of stabilisation before being trauma focused. And then the very last sort of misconception, which was, that, you know, that this treatment, Cognitive Therapy for PTSD is rigid and inflexible and protocolised. So those were the three and I know there's something that probably we'll get into discussion about a couple of the others around talking about certain events and stuff. But, if we come back to the first one, which is the thing around multiple kind of traumatic events. Steph: Yeah, and I'll just say for the listener as well that the way that we phrased it in the paper is "trauma focused treatments are not suitable for complex or multiple trauma". Nick: Yes, thank you and I should have had right in front of me to just remind myself of exactly the wording. Again, the first point is that. because the person has had a history, which has unfortunately included multiple traumatic experiences, that in itself doesn't tell us anything about their presenting difficulties. We need to listen carefully to what their presenting difficulties actually are, whether those would meet criteria for PTSD or complex PTSD, or whether those would be better conceptualised as some kind of other kind of presenting problem. Then within the realm of multiple traumatic experiences, if there are a number of events being re-experienced, actually there's a question of, well, where do we start? Yeah, it's not a case of well we know it's not suitable for complex kind of traumatic histories. What we're looking for is what are the kind of the key moments, the key events, the key memories, nightmares re-experienced, kind of flashbacks. And that's our guide. That's where we I think would want to start typically. I think one of the questions or issues here is that sometimes people think what if there's lots and lots of traumatic events, I can't possibly talk about them all. And that's true. I think that's right. Nor would we want to try. And even when we're talking about a single event, we can't ever talk about every single detail of it in as much emotional detail as possible. We're always getting a story. We're always getting the person's recollection. We're always getting what their experience is of these flashbacks or nightmares. And so what we're looking for, I think, if people have had multiple traumatic experiences, is to think about, well, look, given the range of kind of memories or the range of difficulties, what might make the biggest difference to how they're living their life? What is it that they want to be different about their life? How is it that what's getting in the way of that? And if it's these memories that are getting in the way, which of the memories is causing the greatest difficulty? And what we can do is focus on that memory or those memories around that particular period of time. And what we're trying to do particularly in this treatment is not to try and grind through talking about every memory, but we're trying to identify what some of the key meanings are, the key meanings associated with an individual memory, but key meanings which then generalise across experiences. Typically, the same kinds of meanings that may be across a whole range of experiences. Meanings such as people can't be trusted, I'm weak, I'm to blame, things that kind of commonly come up in this work. And what we're trying to do is work on a particular event or memory and then think about how we can generalise the learning for people. And I don't think that, because people have had multiple traumatic experiences and maybe reliving multiple traumatic experiences, that should mean that they shouldn't receive the kind of treatments which are known to be most effective for those types of kind of presentations. What is the case and what I do want to recognise is that those people who have had multiple traumatic experiences are also likely to have additional difficulties. Yeah, this is captured within ICD-11 within the complex PTSD label, which in addition to the core symptoms of PTSD, which is the re-experiencing, the avoidance and hyper arousal. The three additional areas of difficulty that are needed, which are around difficulties in emotion regulation, including dissociation, interpersonal difficulties and also difficulties related to kind of sense of self-worth, seeing oneself as worthless. And of course, those additional difficulties, the emotion regulation, interpersonal difficulties and the self-worth are much more likely to be present if people have had multiple traumatic experiences. Yeah, they can be present after single events as well, but they're more likely present after multiple traumatic experiences, particularly if those experiences occurred in childhood at developmentally important stages of the person's life. And so, what we will need to do is to think about what additional interventions or how do we flex the interventions that we have within cognitive therapy for PTSD to address those meanings. Fortunately, and this will come to the misconception number 10 about how protocolised things are or how rigid or otherwise things are. One of the great things for me about this kind of treatment is that actually we do personalise it. We are driven by the formulation. We do try and make it individual so that actually we can draw on our range of CBT tools and ideas in order to address the particular difficulties and the particular meanings that people have. Steph: Great. Should we move on to the second misconception then, which is "stabilisation is always needed before memory work". Nick: Yeah. So, stabilisation, there's a question here. What do we even mean by the term? Yeah. So there's a, from the early nineties, there was a kind of fabulous book, "Trauma and Recovery" by Judith, Herman where she suggested a sort of a phased model for treating people following kind of traumatic experiences and people with PTSD, which included sort of a stabilisation phase, a phase where people are helped to be made safe, a trauma processing phase, a sort of telling the story phase and a kind of a reconnection kind of phase. That framework, which actually my reading of things and what we say in the paper from Judith Herman's work was never meant to be too strict and linear, over time got a bit kind of like reified as you've got to have stabilisation, then you have trauma focus, then you have reconnection in that kind of way and I think that's a misreading of both her work and also a kind of an unhelpfully rigid ki way of approaching treatment. But there is something really important about this idea of stabilisation and ensuring safety. Yeah, what we do need to do is ensure that people are safe and safe in a couple of ways or the best we can do. If somebody is living at home, when they go home, they're living with a perpetrator and they're likely to be assaulted again. Yeah, they don't need a trauma focused therapy, they need help being made safe. And we as CBT therapists may be able to help that, but lots of other people, lots of other agencies are massively important in that. And we need to raise the appropriate concerns around that. So of course we need to help people get that physical safety. It may be from a perpetrator. Ideally, if it would be in my mind, more tricky to be offering this work to somebody who is street homeless, there wants to be a sort of some sense of safety in terms of almost like some roof over one's head, access to nutrition, food, drink, those kind of things, the basic needs being met. In addition, there's another element of stabilisation which is often wrapped up in the same thing, which is like psychological stabilisation. Yeah, and so that psychological stabilisation often refers to things like having better control over one's emotions. It might also include thinking about managing risk and of course, this is absolutely crucial for all of our work. So the things around almost basic needs and basic safety stabilisation. Of course, we're always thinking about that. We're also thinking about the psychological stabilisation around risk, risk to oneself. And that's got to be a crucial part of all our work in that way. Stabilisation work is just part of what we do as therapists. Yeah. It's not anything that's special to PTSD. The additional bit that sometimes come in when treating PTSD is that that kind of stabilisation means, Oh, we've got to treat everybody. So I offer or treat people with a whole range of tools. You've got to offer them a whole bunch of tools before we go anywhere near the memory, and that might be breathing retraining. It might be grounding strategies; it might be having a whole range of different tools to manage emotions. Now, none of those things are unhelpful. However, applying them in a kind of a rigid one size fits all way, the same thing has to be offered to everybody and commonly, for understandable kind of service sort of demand reasons, often in a kind of a group format, although there are some advantages to group formats around normalisation, overcoming sense of shame. I think often groups are offered, because it's seen as a kind of a, well, we'll pack as many people as we can into a stabilisation group. Then they've all got the basics and then some of them might graduate on to the trauma focused work. And there are many pathways like that, and I can understand that, but the evidence does not stack up. Yeah, the evidence does not stack up particularly around the idea of stabilisation groups where people have to go through a whole set of particular procedures and kind of treatments includes useful things like psychoeducation, like information about PTSD. Actually, making people go through a whole set of, kind of like set stabilisation procedures before getting trauma focused therapy isn't borne out by the research and isn't very personalised or individualised. What I think we're moving towards, and I think is much more in keeping with Judith Herman's actual original writing, which was where there was much more flexibility between moving between the phases rather than these being rigid linear things, is multi component interventions, where actually, of course, we need to be offering things that can help people with their emotions. Of course, we need to be helping people with their immediate safety, with managing their risk to themselves. But we don't need to offer the same things to everybody. There are different components that we can draw on for different people. And what we absolutely need to do is to personalise this rather than, everybody gets the sort of a stabilisation group. So what we're trying to get over in the paper is not to say, Oh, stabilisation is not helpful. We all do stabilisation. Again, depends on the meaning. We all do stabilisation with every single person we see for therapy. Yeah. Not just people with PTSD. And there may be some specific things that will help in stabilisation for people with PTSD, if they're very dissociative, thinking about grounding strategies. That makes sense. Yeah. But let's be individually tailored. This is one of the things that I'll find myself ranting about. So I apologise. Steph: No, not at all. And that's the one thing I was thinking as you were explaining that is, it goes right back to the very basics of therapy, doesn't it? Which is you treat the individual and I think that's a general misconception that CBT on the whole has in general, isn't it? That it's very formulaic and it's not tailored to the individual when actually that's really just not the case. Nick: I think, well, I think that's true. But I also think, it gets us into the 10th misconception, but, I think probably there are some cultural differences in how CBT is implemented and certainly in how it's written about and therefore from my perspective some CBT therapists and researchers and clinicians haven't done themselves any favours because they write about it; it's like you do this, you do this, you do 10 minutes of this and 20 minutes of that and then 30 minutes of this, then 10 minutes that and then you do the set the homework in the last 10 minutes. And it's like, well, yes, but, but actually what's missing from that is, is actually the individual formulation. And there is a difference between, kind of like the formulation driven kind of CBT versus a kind of like a, a rigid, almost like, I couldn't see almost like how you do it, but formulation lacking kind of CBT. Certainly, that's how it's sometimes written about. And by formulation, if we're saying a formulation driven, it's not that kind of, we're trying to make something up, for each person completely differently each time. If we're working, let's say, with someone with PTSD, within cognitive therapy for PTSD, we have a roadmap. We have the Ehlers and Clark model. And the kind of this very simple thing I try and keep in my head, and I try and encourage my supervisees to keep in their heads, is look, key thing in this PTSD model is we're trying to reduce the sense of threat. We do that by giving a sense of safety through how we are with them through the therapeutic relationship, absolutely crucial. And also, we think about the things that keep that sense of threat stuck, which are about memories, meanings and then the behaviour. Yeah. And if we're working, if we know we've got information in each of those areas and we can work in each of those areas, then actually that is a model. So if you want to say that's rigid, okay, so be it. But what I'm saying is how we implement that model, how we implement those underlying principles will vary from person to person. And that's where the flexibility is. And that's where the creativity is. And that's where the challenges in this treatment and this kind of work. Steph: Okay, great. Thank you. I just wanted to touch on two more misconceptions before we wrap up really. And they, to me, they seem interlinked, but you might be able to tease apart the important differences in them, which are "talking about trauma memories is re traumatising" and "that some traumas shouldn't be relived". Nick: Yeah, these are related. And again, like many of the things that we've talked about, it depends what we're talking about. What do we mean by re traumatising? Yeah. The area of trauma and PTSD is people use terms in so many kind of different ways, and particularly in recent years where trauma almost as a model for human experience has become much more commonly spoken about in public, not just in health care systems, but just in society as a whole, and people use terms like "flashback" and "trauma" quite loosely and people use terms like complex trauma, like I was saying earlier, loosely and stabilisation and retraumatising. So partly my reaction to a lot of these is, well, okay, so what do you mean? Let me understand, let me understand what the concerns are here, what you mean about this. And clinicians are commonly using kind of retraumatisation in the way that deliberately thinking about past memories is going to make things worse. It's going to make the symptoms worse, and that worsening is going to be long lasting as well. Yeah, and that is definitely worth us considering. We need to understand that. We need to think about that. Not least from, the sort of in this field in history, the role of, let's say, individual emotionally focused debriefing and the big debates around that, which we won't get into right now, but we know that things that we can do might make things worse. We absolutely need to consider that. So it's a really sensible question to have. What the evidence tends to suggest is that most people actually don't have a significant symptom exacerbation, an increase in the symptoms when talking about the memories. And even if they do, that that symptom exacerbation is typically temporary and short lived. The large audit that we did in CADAT, it was like over sort of 300 people, there was reliable sort of deterioration. There was a sort of symptom exacerbation, I think in 14 people out of 300 and over 330. Yeah, so it does happen. We need to be mindful of it. We need to think, well, who are the people it might be more likely for, but it's very small numbers. And what we're looking to do, of course, with the memory focus work is to help people get better control over the symptoms over the unwanted memories. And that's what the evidence kind of suggests. However, what we need to think about is what does the person that we're working with, what their history? What's their experience of previous treatment? What's their experience of engaging with or not engaging with the traumatic memories? And what can we learn about that so that we can personalise things for them as well? And what we're not asking people to do, and I think this is one of the points I made much earlier is, is we're not asking them to tell us every single last detail of every single experience. That's not what's happening. It's not what could happen even. What we're trying to do is approach the memory, approach the emotion in order to identify key meanings. I mean, for me, one of the key principles of CBT is follow the emotion. Yeah. One of the reasons we follow the emotion is because that's where the key meanings are. PTSD actually kind of hands it to us on a plate for us as therapists because we know there's lots of emotion with the memories and these are the things that people are typically avoiding. So, we're going to want to go towards it in order to identify the key meanings. We're not, certainly even cognitive therapy for PTSD, we're not going over and over again the kind of traumatic experiences, we're trying to identify the key moments, and the key meanings associated with those so that we can work with them with people. The other thing here is that people with PTSD are experiencing, re-experiencing these awful memories. But it feels like they're happening in the here and now, in any case. So we're not typically asking them to do things, i.e. approach the memory, which is outside of their experience. What we're trying to get them to do is that when those memories come up, and of course we may try and deliberately approach it together with them, when those memories come up is to have almost like a different relationship with them, to try and use our understanding of the emotions and the meanings with those kinds of memories to try and help unstick things. So, if we simply just avoid the memories and avoid talking about the memories, we know that's actually one of the maintaining factors for PTSD. So, we're very unlikely to lead to the types of improvement that we're really trying to look for. So, it depends on what we mean by re traumatising. Absolutely. We want to be attentive to where how things could deteriorate. We do want to think about the personal circumstances of the individual that we're working with. But actually, we're only typically asking people to work with what's already coming up for them in any case. What ties in with that, then, is also this idea that, well, you're saying some traumas shouldn't be relived. And, again, I think what people are getting at, my understanding is, is that, is about that there'll be some things which will be too distressing for people. And most of these misconceptions are really well rooted in therapists desire to provide empathic, compassionate treatments and not to make things worse or not to put people to have unnecessary distress. Absolutely. I'm in complete agreement there. And that can have, of course, the unintended consequence that actually, for all problems that are characterised by avoidance, which PTSD, anxiety problems, maybe other problems as well, is that if those problems are characterised by avoidance, in all of those kinds of treatments, we need to move towards the thing that the person is avoiding. Yeah, because avoidance is one of the maintaining factors. So, a compassionate urge, the compassionate route here is not to avoid the memory. The compassionate route here is not to kind of like, allow, to encourage avoidance. The compassionate route is to encourage approach and engagement and hold the safety and to be there for the person and to explore the meanings and to try and change those meanings. So that compassionate urge to reduce distress, absolutely, but actually one of the things we know across avoidance related problems is that actually we're going to need to help people approach- and that will include almost like no matter what the memories are, no matter what the event is. Sexual trauma is the one that comes up most commonly here and actually the work around particularly Cognitive Processing Therapy and Prolonged Exposure which are two of the kind of evidence-based trauma focused CBT's, they began with working with women who'd been raped and PTSD in those circumstances. The thing that I think, again, and there's always a grain of truth in all the misconceptions, is, but what about those people who are really, really ashamed about what they're talking about? Absolutely. And that's such a good thing to be considering, and such an important thing to be considering. That doesn't mean we avoid it, but it does mean that we think about how do we work with shame? How do we work with the beliefs associated with shame? Like, I'm inadequate, I'm weak, I'm a bad person. Yeah. And what we might need to do, and I think we make reference to this in the paper, is that when there's a lot of shame, we may need to have a certain amount of work around normalising and discussion and cognitive work around that before we do some of the memory focus work so that we've got some work that we've done to draw on in terms of thinking about the person's immediate shameful reactions, not least when shame is activated in clinical sessions, is how are we as the therapist reacting and there's a lot of learning that can happen and a lot of kind of sort of change of beliefs by how we as a therapist are showing that actually we still think they're acceptable and we still want to work with them and we still think that they're a good, valued kind of person, despite things that they've disclosed. Which they may not have disclosed to anybody else. So, it's not that we avoid the things that are loaded with shame, but we do need to think about, ah, we need to spot shame, we need to normalise, we need to work with that and actually, we need to think about how in the relationship, that's a really kind of crucial opportunity for people to have new experiences of being heard and of, not being heard perhaps in their perception, not being dismissed or thought badly of. Steph: I wonder if part of the misconception around that as well, or how that misconception came to be, might be avoidance on the therapist part too, thinking, not just, is this going to be really upsetting or distressing for my client, but actually, is this going to be really upsetting and distressing for me? How do I handle this? Nick: I think you're absolutely right, Steph. And, all of these things that we've flagged as misconceptions, they're all about therapist beliefs. They're all about therapist beliefs and they're all about what, what do we know? What have we learned? How do we, how do we change beliefs? And it's partly about giving some information. It's partly about thinking about the evidence. It's partly about then putting it to the test. It's testing it out. And one of the key things that is in this work as well is how does this impact us as therapists? So that kind of like the sort of the emotional things almost like follow the emotion find the meanings. This is true for us as therapists as well. If we're finding that we're feeling anxious in a session or we're feeling angry in a session, let's reflect and let's use our own supervision as well to think about actually what's happening there. And one of the things that's really crucial in this area, not just in supervision, but definitely in supervision is how we're looking after ourselves and more importantly, how we're looking after one another. Yeah, what are the systems that we set up within supervision, within services, within how we have informal contact, particularly now that we're working often remotely. How are we supporting one another with the challenges of this work? And look, I don't, I don't want to make a sort of big claim. Oh, it's only PTSD work that can affect us as therapists. All therapeutic work can affect us as therapists, maybe some additional elements within PTSD, which may be around a matching of life experience or the traumatic experiences that we as therapists may have had. It may be about sometimes the sort of the high levels of emotion that kind of difficult to deal with as well. So it may be that some of those things are brought more to the fore in PTSD work, but I think they're there in all of the work that we do. Steph: Yeah, I completely agree. I think this sort of leads me nicely into the next point I was going to make, which is one of the things that I really like about this paper is that right from the very beginning, it sets out its position, which is that it's not to blame or shame clinicians for having these misconceptions. Misconceptions exist for a reason. Normally, like you said, there's sometimes a grain of truth in some of what the misconceptions are and how they've come to be. So, and I guess what the hope for the paper was, was that you just want clinicians to read this, take this forward and apply it to their practice and really learn from it. Like you say, it's almost like an FAQs of things that you want people to know to be able to use. Nick: Absolutely, I think that's right. And I mean, any paper leaves a million questions hanging. Yeah, so there's loads of questions that we wouldn't ever expect a written paper to lead to belief change. Yeah, look, we're CBT therapists. We know that that in itself is not going to lead to belief change. One of the things that we know is much more likely to lead to belief change is experiential. Yeah, it's experiential activity. It's trying it out. It's actually trying some of these things and seeing what do we learn from experience as well as what my supervisor tells me or what these people have written in a paper somewhere. I wouldn't want anyone just to go. "Ah, yeah I've read that therefore, that's therefore I should be thinking that this is fine." It's look, it's test it out. Let's try out. Let's think about how we can actually try and learn. How do we learn? How do we change our beliefs as therapists? How do we help our kind of clients change their beliefs as well? And in some ways misconceptions was a kind of like a, I don't know, it's a bit of a negative way of pitching it really, you know but we couldn't think of a kind of a more sort of like positive spin on, here's 10 good things to think about cognitive therapy for CBT. Yes, you can use it for multiple trauma. Yes, you don't always need to do stabilisation. We could have pitched the whole paper in that way. But actually, what we were hearing in supervision, what we're hearing in training are the, the yes, buts, the kind of like the, the way in which we've framed it here. So this is why we've framed it in this way, rather than a kind of a more positive facing way. It's because this is how we're hearing the questions. This is how we're hearing the questions from therapists. Steph: Yeah, that's great. I was just going to ask if you had any reflections on the peer review process because this is quite a new paper and obviously it's very different to the way in which a very traditional research paper would have been presented when it went into review. Did you find reviewer comments helpful in that? Can you remember if you had any kind of things where you were like, oh, we should really change this, or if were you quite happy with it? Nick: I may be misremembering. Yeah. But look, reviewer comments are always helpful. Genuinely. Yeah and for those people listening who haven't reviewed, please do. And if you do review, thank you very much. It, it always improves papers and the more attention given to the review process by reviewers, usually the more improvement there is in the papers. I think. And I can't remember if we changed it, or it was due to kind of reviewer comment. It was originally called 10 Myths Around Cognitive Therapy for PTSD. Yeah, and I think the reviewer comment was like, Oh myths is a bit pejorative. Yeah, these exist for a reason. It's not, it's not like quite like a, a unicorn. These are more grounded. And so that's why it's misconceptions. Yeah which again is our word. And maybe that's not a word that everybody likes either. But there were other things which helped us also helped us tease out the review process about which of these things apply to all trauma focused CBTs and which of these might be more particular or specific to cognitive therapy for PTSD. Look, cognitive therapy for PTSD is where our experience lies. But actually, it was highlighted that some of these are true across kind of trauma focused CBTs. And, and this isn't a normal, a sort of a research paper. That, that's for sure. And I think one of the benefits of the Cognitive Behaviour Therapist is that there are more kind of clinical guidance papers and practice papers, which is what BABCP members want, what CBT therapists want and, in some ways, it was interesting when I was re reading this paper, prior to this conversation, was that in Behavioural and Cognitive Psychotherapy, like the sister journal, there's a section now which is Empirically Guided Clinical Interventions, yeah? And, and that's a section which is a bit like this really, but it was a section which, which never used to exist. Yeah, and then actually I submitted a paper with colleagues back in around 2000 and in conversations with Paul Salkovskis, who was still the editor back then, extraordinary behaviour. But, actually he could see that it wasn't and it wasn't a research paper. It was a kind of a clinical paper, like a how we do things paper, but drawing on evidence and pulling things together. And it was off the back of that submission, plus other submissions, I don't want to make too big a claim, that actually he then developed the Empirically Guided Clinical Intervention section and that paper that I authored with Kerry Young and Emily Holmes on hotspots was the first one of those types of paper. And actually, probably that's, that's where over the years where my interests and, and efforts have gone in is, is around these kind of like guidance papers, practice papers. And so, while this is a kind of a slightly different paper in the way it's structured, 10 misconceptions and stuff. The principles underlying it there were, were the same as pretty much the first paper I ever submitted to BABCP journals, which was back in 2000. Which is look we want practice-oriented things which are grounded in evidence, which are drawing on models and thinking about how do we flexibly implement things? So, this for me this paper actually is probably a full loop to, it's not a loop, but it's it made me think back around. Actually. That's for me been really helpful when I've read those papers from other authors as well. Steph: Hmm. And this paper type is definitely the clinical guidance papers. They're definitely the paper type that are most read, and I think most widely shared. Because again, we want to disseminate knowledge, don't we? And we want to share information. It helps us be better clinicians. It helps us work for our clients better. Nick: Exactly. And look, the aim of all research and the more clear-cut empirical research papers, certainly for us as CBT therapists, for the journals, for the, of the BABCP, the aim of all of these including this paper, is that we're helping people. We're helping people get better treatment. We're helping become better therapists ourselves or supervisors or whatever. And the aim of all of this work is to try and actually make sure that our treatments are safe, they're effective, that they're well implemented and that people are given the best opportunity they can of making improvements. Steph: Oh, that's great. Thank you so much, Nick. Just before I let you go, is there anything else that you're working on that you want to talk about? Anything we can look out for? Nick: I think, I mean, as a group, the group of us who wrote this paper about misconceptions, where it came out of, I was saying it was about supervision, but that was actually partly around some top up training for NHS Talking Therapies, which is ongoing, and has been really, really rewarding and I think there's going to be probably more guidance that comes out of that, including for supervising trauma focused treatments and cognitive therapy for PTSD in particular. So hopefully there'll be a f supervision paper in due course. In terms of new research, the thing that I mentioned a little bit earlier in the conversation was, around, thinking about treating complex PTSD and we're looking at that together with a really great team from Berkshire, led by Deborah Lee, looking at the role of compassionate resilience as well and compassion focused elements being provided either earlier in treatment or not provided earlier in treatment to see what, what impact that might have on treatment outcome. Steph: Brilliant. Well, Nick, thank you so much. This has been such a great chat. Really thank you so much for coming on and talking to us. Nick: Well, thank you for inviting me. Steph:Thanks so much for listening. If you enjoyed this episode, then please rate, review and subscribe wherever you get your podcasts. And you can follow us on Twitter @BABCPpodcasts. If you have any feedback or suggestions for future episodes, then I'd love to hear from you. Email us at [email protected]. And why not check out our sister podcast. Let's talk about CBT- Practice Matters. This is hosted by the lovely Rachel Handley. And it's the perfect podcast for clinicians working in CBT. Thanks for tuning in, and I'll see you next time on Research Matters. Bye.
