BABCP spring meeting: Nick Grey on memory-focused approaches in CBT for adults with PTSD - writing suggestions (4th post)
Last updated on 5th March 2015
I have written a series of blog posts on Nick Grey's expert workshop on CBT treatment of posttraumatic stress disorder. The day's focus was particularly on treatment approaches involving the trauma memory itself. Nick highlighted four interlinked memory-focused methods - exposure & reliving, written narrative, site visit, and discrimination of triggers. This post is the text of a client handout I subsequently put together discussing how best to go about the written narrative.
Introductory comments: Traumatic experience can be like a wound that has been bandaged up, but that still causes real difficulties in one's life. It is as though the wound has never been fully cleaned, has never had a chance to mend properly. Typically one did the best one knew at the time to move on from what happened, but in many ways one continues to be powerfully affected by these past experiences. The wound is now a bit like an abscess. It can still be badly stirred up, producing very real distress and interfering with fully living one's current life. This "cleaning out an old wound" metaphor is one way of understanding the importance of emotional processing for many old traumas. Another useful model is the "Factory metaphor" (see the associated handout). Restacking a badly packed cupboard or filling in an only partly completed jigsaw puzzle are other potentially helpful ways of seeing this type of processing work. The trauma may have been a single dreadful experience, or a series, or whole periods of one's life. In all these situations it may be important and very helpful to go back and re-process what happened, take the bandage off for a bit, clean the wound out better, and allow fuller healing. In cognitive therapy for posttraumatic stress disorder, this re-processing of trauma memories may well involve four components - retelling what happened, writing about it (the subject of this suggestions sheet), visiting/viewing where it happened, and discriminating between the original trauma warnings and current non-traumatic triggers. This handout gives more information about the writing part of this healing process.
From when to when & present or past tense?: If one is writing about a single dreadful traumatic experience, it's likely to be best to begin the description from just before things started to go wrong, and then to continue through to where one has emerged from the trauma and largely come out the other side. There isn't a cut-and-dried, right-or-wrong way of deciding exactly what period of time to include in one's writing but, for single traumas, it's typically from before things became unsafe to after one has emerged and the worst has passed. Similarly there isn't a definite right-or-wrong about writing in the present tense or in the past tense. Sometimes describing the trauma in the present tense - as if one is going through the experience as one writes - may help in making the description fuller and more vivid. This is likely to be helpful therapeutically. The main thing though is writing a full, detailed and emotional account of what happened, and it's OK to do this writing in the past tense if this is what feels best for you. If in doubt, first try writing in the present tense. For multiple traumas, it may be best to write a separate description for each of the most important events. For whole periods of one's life, sometimes it's useful to get an overview by filling in charts like the companion "Life review" sheets, or drawing out a time line on a piece of paper with marks to show when one's situation was particularly bad and maybe too, marks to show periods of time that were a bit easier. One can then write as for multiple traumas, with separate descriptions for a few of the very worst experiences. Every trauma episode that occurred over an extended period of one's life doesn't have to be written about. Typically working with the worst experiences will help too with not-quite-so-bad experiences, so one doesn't need to write about these as well.
By hand or using a computer?: Both writing by hand and using a computer can be fine. Sometimes writing in longhand allows people to be more expressive, more spontaneous and more able to get in touch with important emotions. If you do decide to write by hand, please leave plenty of space to go back and add more information later. To do this, some people only write on every third line, or leave very wide margins, or leave large spaces between paragraphs. If you're going to write by hand, work out beforehand how you'll make sure you can go back and add in more detail and understanding later on. Remember though - whether you're writing by hand or using a word processor - this is not about spelling, punctuation, or keeping things tidy. Far from it, this is about a healing process so as long as you can understand what you've written, please don't try to make it some kind of "literary work". Just go for it.
Writing using a computer can be good too, especially if you're familiar with using a word processor so the actual practicalities of typing don't get in the way of you really being able to engage with the writing as fully and honestly as you can. A potential big advantage of using a computer is that it's so easy to add further material later on. This additional information often comes from one's own memory. Once one has started writing and/or talking about what happened, more detail may well pop into one's mind both when one tries to remember further and also spontaneously - when thinking about other things or even in dreams. Some people may get more information too - more pieces of the jigsaw - from other sources and conversations. It's sometimes helpful to use different text colours or other distinguishing styles. For example one could use a different colour or font or put inside brackets or other method when one adds new information that one had initially forgotten or simply not known about. Some people may also use different text colours/styles/insertions when they add in new emotional responses and new understandings - particularly facts or perspectives that they didn't have access to at the time of the trauma.
What happened, what I felt, what it meant to me: When we write it can be helpful to see that there are at least three "lenses", three overlapping aspects that it's important to cover. One lens involves describing the external facts - what happened, who was there, what did it look like, what was said - all the details picked up through our senses. A second lens focuses on internal facts - what did we feel, what mix of emotions were there, in what order, what feelings were most intense? It's so important that we dig down deeply and honestly into our emotions. In many ways, re-contacting the feelings helps to "melt" our frozen responses and allows them to reform in updated and more healing ways. And this is the third lens - how did we understand what happened, what sense, what meaning, what explanations did we come up with? And crucially, now, with the greater understanding that we have, what meaning, what explanation can we now develop? Questionnaires like the "Posttraumatic cognitions inventory (PTCI)" and the "Postraumatic growth inventory" may be useful here.
Piecing together & letting light into the "worst moments": It's likely that successful treatment for posttraumatic reactions helps through at least two overlapping mechanisms. One is to organise & transform the memory so that it can be "packed away" and no longer keeps affecting us so badly. In a typical severe trauma there are likely to be several "hot spots" of particularly intense emotion. These hot spots are crucial therapeutic targets as they are often sections of memory that are most disorganized and that are key sources of self-damaging misunderstanding. Challenging & updating these "misunderstandings" or only "partial understandings" is a second major mechanism of effective & helpful treatment.
Concluding comments: Persisting distress after deeply upsetting experiences is very common. "Emotional processing" of these traumas - unpacking/clarifying/organizing the memories and challenging & updating the meanings we have given to them - can be tremendously helpful in easing sufferering and helping us reclaim & move on with our lives. Writing about what happened is often an important aspect of the cluster of methods used to make therapy for such problems as effective as possible. It can feel a daunting prospect to write in this way, but it can be immensely helpful & healing.
In a strange example of "life following art", I had a fairly terrifying experience on a mountain side just a couple of weeks after attending Nick Grey's workshop. For written accounts, see "Walking in Skye & Kintail: mountain rescue, helicopter winches, and avoiding death & PTSD" and "Walking in Skye & Kintail: lessons, self-compassion & posttraumatic growth".
And for a hot-off-the-press update on writing for PTSD, see the fascinating & encouraging paper by Sloan et al "Written exposure as an intervention for PTSD: A randomized clinical trial with motor vehicle accident survivors".