Introduction
Domestic abuse (DA) is defined as controlling, coercive, threatening and violent behaviour by a family member, partner or ex-partner. DA can include psychological, emotional, financial, physical or sexual abuse, as well as controlling behaviours such as isolating a victim or monitoring their movements (Pill et al., Reference Pill, Day and Mildred2017). DA survivors are more likely to experience depression, mis-use illicit drugs and alcohol, display emotional distress, experience suicidal thoughts and attempt suicide (Pill et al., Reference Pill, Day and Mildred2017). Post-traumatic stress disorder (PTSD) is the most common mental health problem in those who have experienced DA (Dokkedahl et al., Reference Dokkedahl, Kristensen and Elklit2022), with prevalence rates ranging from 31% to 84% among survivors (Pill et al., Reference Pill, Day and Mildred2017). PTSD is typically experienced after a single event trauma or short-term traumatic event. PTSD symptoms include involuntarily reliving the event, for example through nightmares and flashbacks, avoidance of reminders of the traumatic event, increased levels of arousal, and negative changes in cognitions and mood (American Psychiatric Association, 2022). Complex PTSD (cPTSD) occurs following prolonged, repeated and interpersonal traumas. cPTSD includes all the symptoms of PTSD plus more significant challenges with regulating emotions, persistent feelings of worthlessness and guilt, a distorted sense of self and challenges in interpersonal relationships (Cloitre et al., Reference Cloitre, Garvert, Brewin, Bryant and Maercker2013). cPTSD was found to be twice as prevalent in a sample of women who had experienced DA than PTSD (Fernández-Fillol et al., Reference Fernández-Fillol, Pitsiakou, Perez-Garcia, Teva and Hidalgo-Ruzzante2021) which is unsurprising given the usually repeated, ongoing and interpersonal nature of DA (World Health Organisation, 2022). DA often involves the removal of one’s power and control over choices about one’s life (McGirr and Sullivan, Reference McGirr and Sullivan2017). Additionally, DA survivors are likely to experience further stressors including poverty, parenting strain, lack of social support, and ongoing contact with their perpetrator, often due to childcare (Beck et al., Reference Beck, Clapp, Jacobs-Lentz, McNiff, Avery and Olsen2014; Pitt et al., Reference Pitt, Feder, Gregory, Hawcroft, Kessler, Malpass and Lewis2020). Cognitive distortions that develop because of DA can create a barrier to breaking the cycle of abuse (Beck et al., Reference Beck, Clapp, Jacobs-Lentz, McNiff, Avery and Olsen2014) and people who have experienced DA are at risk of further victimisation and trauma (Kuijpers et al., Reference Kuijpers, van der Knaap and Winkel2012).
Treatment guidelines
Trauma-focused psychological interventions, including trauma-focused cognitive behavioural therapy (TF-CBT) and eye movement desensitisation and reprocessing (EMDR), are the first-line recommended treatments for PTSD by the National Institute for Health and Care Excellence (2018). TF-CBT and EMDR have been found to be equally effective at treating PTSD (Mavranezouli et al., Reference Mavranezouli, Megnin-Viggars, Daly, Dias, Welton, Stockton and Pilling2020).
TF-CBT has been evidenced to be an effective and acceptable treatment for a variety of traumatic events through randomised controlled trials (Ehlers et al., Reference Ehlers, Clark, Hackmann, McManus, Fennell, Herbert and Mayou2003; Ehlers et al., Reference Ehlers, Clark, Hackmann, McManus and Fennell2005; Ehlers et al., Reference Ehlers, Hackmann, Grey, Wild, Liness, Albert and Clark2014). It has also been found to reduce symptoms of depression and anxiety in a DA specific sample (Dokkedahl et al., Reference Dokkedahl, Kristensen and Elklit2022). The TF-CBT protocol for PTSD developed based on Ehlers and Clark’s (Reference Ehlers and Clark2000) model of PTSD is referred to as cognitive therapy for PTSD, or CT-PTSD. The primary goal of CT-PTSD is to reduce the sense of ongoing threat through cognitive restructuring, exposure to trauma memories and triggers, reducing avoidance, and developing supportive coping strategies. CT-PTSD includes psycho-education and stabilisation skills as and when needed throughout the therapy in a person-centred way, but does not require a formal stabilisation phase.
Previously, interventions for cPTSD were suggested to follow three phases consisting of: stabilisation (to improve self-regulation and prepare for reprocessing), reprocessing of trauma memories (including TF-CBT or EMDR), and a final reintegration phase whereby individuals reclaim the life they wish to lead (Cloitre et al., Reference Cloitre, Courtois, Ford, Green, Alexander, Briere and Van der Hart2012; Herman, Reference Herman1992). Research from the last decade has challenged the need for a linear, stage-based approach with research showing that TF-CBT and EMDR can be effective without a separate initial stabilisation phase (de Jongh et al., Reference de Jongh, Resick, Zoellner, van Minnen, Lee and Monson2016; van Vliet et al., Reference van Vliet, Huntjens, van Dijk and de Jongh2018). Current best practice is therefore suggested to be an individualised approach, bearing in mind those with complex presentations may benefit from a formal stabilisation phase to TF-CBT, but being flexible to move faster or slower, and include or exclude memory reprocessing work, depending on the readiness of the client (Bisson et al., Reference Bisson, Berliner, Cloitre, Forbes, Jensen, Lewis, Monson, Olff, Pilling, Riggs, Roberts and Shapiro2019; International Society for Traumatic Stress Studies, 2019). Increasing session number or duration and considering the individual’s safety and stability is recommended for cPTSD (National Institute for Health and Care Excellence, 2018).
A flexible, modular approach is suggested for cPTSD as outlined in the Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR) (Karatzias et al., Reference Karatzias, Mc Glanaghy and Cloitre2023). The ESTAIR protocol consists of four modules: emotion regulation, relationship patterns, self-concept, and narrative therapy. Similarly, these modules are expected to be used in a flexible order based on individual treatment needs (Karatzias et al., Reference Karatzias, Mc Glanaghy and Cloitre2023). ESTAIR and its previous iterations have included a strong focus on skills development, assertiveness training and stabilisation with memory reprocessing through narrative memory work included if deemed beneficial and tolerable for the patient.
Guilt and shame are distinct but related emotional experiences that are often experienced by survivors of DA in addition to PTSD, or cPTSD (Kubany and Watson, Reference Kubany and Watson2002; Lee et al., Reference Lee, Scragg and Turner2001). Guilt is related to negative judgements about specific actions or behaviours in certain situations often involving feelings of responsibility and wrongdoing and is therefore closely linked to self-blame (Kubany et al., Reference Kubany, Hill, Owens, Iannce-Spencer, McCaig and Tremayne2004). For survivors of DA, appraisals such as ‘I could have prevented it’ often evoke negative affect. This, in turn, can lead to shame-related appraisals of the guilt experienced. Shame involves negative self-evaluation, impacting one’s entire identity and, within DA survivors, may involve appraisals such as ‘I’m so stupid’ or ‘I’m a bad mother’ (Kubany et al., Reference Kubany, Hill, Owens, Iannce-Spencer, McCaig and Tremayne2004). Furthermore, guilt and shame can be particularly complex within women survivors of DA, relating to worries about a ‘failed’ marriage, the impact of violence on children and decisions about staying or leaving an abusive relationship (Kubany et al., Reference Kubany, Hill, Owens, Iannce-Spencer, McCaig and Tremayne2004). Models of PTSD often focus on fear as the predominant emotion, but it is suggested that shame should be more prominently addressed when working with clients who have experienced interpersonal violence as this may act as a barrier to recovery (Lee et al., Reference Lee, Scragg and Turner2001; Plante et al., Reference Plante, Tufford and Shute2022). Shame is also likely to reinforce feelings of powerlessness experienced during the abuse (McGirr and Sullivan, Reference McGirr and Sullivan2017; Plante et al., Reference Plante, Tufford and Shute2022). Suggestions for addressing shame prior to exposure work include exploring and contextualising shame and shame triggers as to avoid pathologising the individual (Brown, Reference Brown2006). This could include developing an understanding of a client’s cultural norms, gender expectations, family scripts, and religious teachings (Brown, Reference Brown2006). It is also suggested that empathy from others is a strong avenue for increasing a sense of connection and power to reduce feelings of shame, but that this can also come from oneself in the development of self-empathy. Guidelines for working with cPTSD recommend that approaches such as compassion-focused therapy can be integrated into treatment to allow shame-related appraisals to be addressed (Cloitre et al., Reference Cloitre, Courtois, Ford, Green, Alexander, Briere and Van der Hart2012). Moreover, incorporating self-compassion into cognitive behavioural and exposure-based interventions to reduce self-criticism is thought to support recovery from trauma (Munroe et al., Reference Munroe, Al-Refae, Chan and Ferrari2022).
Ongoing threat
The applicability of TF-CBT has been queried for certain populations who are at risk of ongoing or further re-victimisation, such as those within DA relationships. This is because the underlying theory of PTSD and cPTSD is that symptoms arise from past traumas (Cohen et al., Reference Cohen, Mannarino and Iyengar2011; Ennis et al., Reference Ennis, Sijercic and Monson2021). People who have PTSD or cPTSD from DA, depending on the circumstances, are potentially at risk for further instances of violence or abuse from the partner given the wide definition of DA. Ongoing threat also presents issues in terms of the safety and stability in accessing exposure-based interventions (Cohen et al., Reference Cohen, Mannarino and Iyengar2011; Ennis et al., Reference Ennis, Sijercic and Monson2021; Foa et al., Reference Foa, Keane, Friedman and Cohen2010; Warshaw et al., Reference Warshaw, Sullivan and Rivera2013). Furthermore, there are concerns that TF-CBT may ‘desensitise’ individuals to cues they are in current danger (Cohen et al., Reference Cohen, Mannarino and Iyengar2011). It is therefore important to address the safety and re-victimisation risk when offering trauma-focused treatments (Bailey et al., Reference Bailey, Trevillion and Gilchrist2020; Ennis et al., Reference Ennis, Sijercic and Monson2021; Yim et al., Reference Yim, Lorenz and Salkovskis2023).
There is an emerging evidence base for TF-CBT with people experiencing ongoing threat of re-exposure to trauma (Ennis et al., Reference Ennis, Sijercic and Monson2021; Yim et al., Reference Yim, Lorenz and Salkovskis2023). A recent systematic review identified five studies where trauma-focused interventions were used with samples under threat of further DA (Ennis et al., Reference Ennis, Sijercic and Monson2021). Three studies were of a CBT-based programme called Helping to Overcome PTSD through Empowerment (HOPE; Johnson et al., Reference Johnson, Zlotnick and Perez2011; Johnson et al., Reference Johnson, Johnson, Perez, Palmieri and Zlotnick2016). HOPE led to significantly reduced PTSD symptoms compared with standard care with only 18.5% of participants still meeting criteria for PTSD compared with 52.5% in the control arm (Johnson et al., Reference Johnson, Johnson, Perez, Palmieri and Zlotnick2016). However, HOPE was conducted in a women’s shelter so it could be argued that the risk of re-victimisation was mitigated to some extent, which may have diluted the specificity for ongoing threat (Yim et al., Reference Yim, Lorenz and Salkovskis2023). Therefore, it is unclear whether this CBT-based intervention is equally as effective for those living in the community with limited protection from ongoing threat (Ennis et al., Reference Ennis, Sijercic and Monson2021).
Studies do not support the fear that treating PTSD leads to increased re-victimsation rates following treatment by reducing sensitivity to cues of danger, and reviews have highlighted that providing psychological interventions for trauma-related difficulties where there is a risk of further re-victimisation are likely beneficial (Cohen et al., Reference Cohen, Mannarino and Iyengar2011; Foa et al., Reference Foa, Keane, Friedman and Cohen2010; Yim et al., Reference Yim, Lorenz and Salkovskis2023). Studies explain that as trauma prevents individuals from exiting ongoing events, withholding PTSD interventions could increase the risk of re-victimisation (Ennis et al., Reference Ennis, Sijercic and Monson2021; Yim et al., Reference Yim, Lorenz and Salkovskis2023). However, adaptations are recommended such as prioritising safety planning, helping clients to identify the difference between real danger and trauma reminders, the provision of advocacy and attention to confidentiality (Murray et al., Reference Murray, Cohen and Mannarino2013; Yim et al., Reference Yim, Lorenz and Salkovskis2023). To the authors’ knowledge, this has not yet been applied to those at risk of ongoing DA in a community setting.
Presenting problem
Case introduction
This case study details the assessment, formulation, and intervention using TF-CBT with Sally (pseudonym) who consented to this case study being written for publication.
Sally, in her early 50s, was referred to her local community mental health team (CMHT) following reports to her GP that she was struggling with anxiety and low mood. She identified as a White, Christian, heterosexual, cis-gendered woman. Sally lived with the youngest two of her three children who were aged between mid-teens and early twenties, and worked full-time, but was signed off sick from work due to her mental health struggles. She had left the marital home approximately 3 years prior to the referral, after over 20 years of marriage. She had ongoing contact with her ex-partner due to their children and financial commitments. Sally reported that her ex-husband regularly attempted to resume their relationship. She also reported that there had been further incidents of abuse during their ongoing contact. Sally was socially isolated, having cut off from early life friends across the span of her marriage, partly as a result of coercive control from her ex-husband and the shame she felt about the DA.
Assessment and goals
In line with National Institute for Health and Care Excellence (NICE) guidance, the assessment included questions about re-experiencing, avoidance, hyperarousal, dissociation, negative alterations in cognition and mood, and functional impact (National Institute for Health and Care Excellence, 2018). In addition to clinical interview, Sally completed standardised measures which indicated that she met criteria for PTSD, generalised anxiety and depression (see outcome measures). Sally described her main difficulties as being ‘constantly on edge’, feeling guilty, and being self-critical. Sally disclosed emotional and physical abuse throughout her marriage and ongoing experiences of unwanted memories of the traumas, including nightmares. Sally had lost interest in previously enjoyed activities such as cooking and socialising, and was struggling with interpersonal dynamics within her family. Sally also reported financial stressors due to supporting her children and managing her rental property independently. Sally stated she was ‘only just functioning’, describing herself as ‘existing’ by going to work and going to bed, trying to get through each day. She reported a persistent sense of guilt and shame, difficulty managing the intensity of emotions, feeling out of control of some behaviours, and a loss of a sense of identity, struggling to recognise herself. Sally was taking prescribed anti-depressants when she was referred to the CMHT. Although she had not received therapy before, she had engaged with the Freedom project, a third-sector organisation aimed at increasing awareness of DA patterns and empowering survivors of DA to avoid abuse in the future. Given Sally’s description of problems with emotional regulation, beliefs about herself accompanied by feelings of shame and guilt and her difficulties in socialising, it was felt that Sally met criteria for cPTSD based on the ICD-11 (World Health Organization, 2022).
Sally’s main goal was to reduce the number of days in a week she felt on edge to fewer than seven. Sally’s second goal was to get back to ‘living’ rather than ‘just existing’. Sally was unsure what ‘living’ would entail given that her life and family set-up had changed significantly. Therefore, it was not possible to create specific goals around this.
Sally had begun to review CBT informed materials focused on building coping strategies with her care co-ordinator prior to her referral to the therapies team, which she had found a helpful foundation. Therefore, a TF-CBT model was considered an appropriate intervention as Sally was socialised to the CBT approach, the model is evidence-based with this population, and the therapist was suitably trained and supervised to deliver this intervention. The protocol adhered largely to the CT-PTSD protocol as reducing the sense of current threat was a key goal for Sally; however, there were variations to the protocol as outlined below.
Risk and safeguarding
Risk was assessed as part of the assessment sessions and included information obtained from a prior meeting with Sally’s care coordinator. Sally reported occasional thoughts that she ‘[could not] manage this anymore’. Sally denied any plans to harm herself or end her life, citing her parents as a protective factor.
Sally’s continued contact with the perpetrator made her vulnerable to further incidents of emotional and physical DA. However, it was reported by Sally that the severity of these incidents had been much lower since she left the marital home, and much less frequent. It was deemed, in line with the considerations above, that therapy could support Sally to further reduce this risk.
Sally’s children had witnessed DA in the past and the middle child had also experienced DA from his father directly. All children continued to have unsupervised contact with their father and the eldest child lived with him. Children’s social services were involved with the family and considering any risks posed to the youngest child; current risks to the children were deemed low.
Risk levels were assessed in an ongoing way within therapy sessions with Sally by checking in at the start of sessions about contact in the past week with her ex-husband and any incidents, in the therapist’s own supervision sessions and in team meetings, which included Sally’s care coordinator. Sally was encouraged to contact police in the event of any incident and was aware that reports of further incidents would be escalated via appropriate safeguarding routes.
Measures
The 24-item Post-Traumatic Diagnostic Scale for the Diagnostic and Statistical Manual of Mental Disorders (PDS-5; 5th edn; DSM-5) was used to measure PTSD symptom severity (Foa et al., Reference Foa, McLean, Zang, Zhong, Powers, Kauffman and Knowles2016). The PDS-5 norms are based on a majority White, half female community sample who mostly reported physical assault (Foa et al., Reference Foa, McLean, Zang, Zhong, Powers, Kauffman and Knowles2016) and therefore was seen as an appropriate measure to use and interpret with Sally. As the PDS-5 maps onto the diagnostic criteria in the DSM-5 it is a useful tool within the public sector for liaising with medical professionals, such as psychiatrists, about diagnosis (alongside the clinical interview conducted for assessment) and to monitor changes in clinical levels of PTSD. The PDS-5 also includes qualifying questions about distress and interference as well as symptom onset and duration. For this reason, the PDS-5 was chosen over the more commonly used Impact of Events Scale-Revised (IES-R) or the PTSD Checklist for DSM-5 (PCL-5).
To complete the scale, respondents rate how much symptoms have bothered them on a Likert scale ranging from 0 to 4. A total severity score is then calculated (range 0–80), with higher scores indicating higher distress. A cut-off of 28 is recommended as identifying probable PTSD (Foa et al., Reference Foa, McLean, Zang, Zhong, Powers, Kauffman and Knowles2016) with 11, 21, and 36 representing moderate, moderate to severe, and severe PTSD (McCarthy, Reference McCarthy2008). The measure does not state what change in score would indicate reliable change. The PDS-5 has excellent test–retest reliability (r=.90) and internal consistency (α=.95). It also demonstrates good discriminant validity from anxiety and depression measures (Foa et al., Reference Foa, McLean, Zang, Zhong, Powers, Kauffman and Knowles2016).
The 9-item Patient Health Questionnaire (PHQ-9) was used as a screening tool for depression severity due to its brief, valid and reliable properties (Kroenke et al., Reference Kroenke, Spitzer and Williams2001). Scores range from 0 to 27, with 5, 10, 15, and 20 representing mild, moderate, moderately severe, and severe depression or, when used for screening purposes, a score of 10 or above indicates depression (Kroenke et al., Reference Kroenke, Spitzer and Williams2001; Levis et al., Reference Levis, Benedetti and Thombs2019). A score of ±6 points is taken to represent reliable change (National Collaborating Centre for Mental Health, 2023).
The Generalised Anxiety Disorder-7 (GAD-7) was also used to measure generalised anxiety given its valid and efficient screening properties (Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006). Scores on the GAD-7 range from 0 to 21, with scores of 5, 10, and 15 representing mild, moderate, and severe anxiety and a cut-off of 10 recommended when used as a screening tool (Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006). Reliable change is determined by ±4 points (National Collaborating Centre for Mental Health, 2023).
The PHQ-9 and GAD-7 cut-offs were derived from community out-patient samples. No further detail is provided regarding the sample demographics; therefore, it is not possible to determine whether this represents Sally’s characteristics or not. In addition to the standardised measures, two idiosyncratic measures were developed collaboratively with Sally in line with her presenting complaint and goals for therapy. These were (taken from the PDS-5) ‘during the last week, how often have you been overly alert or on guard’ on a scale of 0–4 (where 0 is not at all, and 4 is six or more times a week) and during the last week ‘I have been fully living’ on a scale of 0–10 (where 0 is completely agree, living life; and 10 is completely disagree, purely existing).
An A-B single case experimental design (SCED) was employed. The standardised measures (PDS-5, PHQ-9, GAD-7) were taken at the assessment phase, once by Sally’s care co-ordinator at the point of referral and then in the first two assessment sessions, and the end of the intervention phase. The PDS-5 was also taken approximately halfway through sessions to review progress and inform treatment planning. The idiosyncratic measures were taken session-by-session, at both assessment and intervention phases. The weekly idiosyncratic measures were used to guide session planning and prioritisation.
Formulation
Ehlers and Clark’s (Reference Ehlers and Clark2000) model was used to formulate Sally’s presenting difficulties (see Fig. 1). A maintenance cycle was developed with Sally, while also taking account of her early life experiences and beliefs before the traumas. Sally had grown up in a small, close, religious family with values of loyalty, trust and care for one another. Sally believed others were trustworthy and would look after her. She also described minimal experiences of conflict or disagreements, meaning she felt unable to manage confrontation and often suppressed her views or opinions to avoid disagreements. The therapist considered with Sally the subtle and explicit expectations and norms within her family and religion. Sally identified the importance placed on marriage and the nuclear family. Divorce or separation was not considered acceptable.
Figure 1. Diagrammatic formulation of Sally’s presenting problems based on Ehlers and Clark’s (2000) model.
The multiple traumas that occurred in Sally’s marriage violated her values, beliefs, and expectations of the world. During the traumas, she had thoughts she would be unable to cope with the events and that she may be to blame due to being not good enough for her husband. Following the traumas and her husband’s attempts to minimise the abuse, Sally often thought she was ‘going mad’, questioning her own judgement of situations. Sally experienced an ongoing sense of threat, including hyperarousal, feeling on edge, being unable to relax, and having an urge to escape. To reduce this, Sally suppressed and avoided trauma memories by distracting herself through keeping busy or sleeping in excess. Sally was hypervigilant to signs she had done something ‘wrong’ or was perceived as mad by others which led her to ruminating about interactions and withdrawing from previously enjoyed activities, such as socialising.
Sally commented that the formulation helped her to understand her presenting difficulties and normalised why the events had impacted her in the way they had.
In line with the formulation, goals, and evidence base, it was hypothesised that by increasing Sally’s understanding of trauma and access to coping skills through formulation, psychoeducation and stabilisation work, the frequency in which Sally felt on edge would reduce.
Furthermore, it was hypothesised that trauma reprocessing work to elaborate and update traumatic memories and restructure negative appraisals, would further reduce the sense of current threat and therefore the frequency of feeling on edge.
Finally, it was hypothesised that trauma reprocessing work, as well as intervening with strategies that maintained the sense of current threat, would enable Sally to identify and live the life she wanted to live, thereby reducing the extent to which she felt like she was ‘existing’ and increasing the degree to which she rated herself as ‘living’.
Course of therapy
Sally attended a total of 23 sessions over seven months. Five of these sessions were 90 minutes long to support memory reprocessing work, and the remaining 18 were 60 minutes long. The process of the therapy sessions is outlined below and summarised in Table 1. Sally continued to see her care coordinator approximately once a month during the therapy treatment, where more practical support was offered, including ongoing risk assessment, problem-solving and encouraging use of therapy skills.
Table 1. Overview of therapy session content
Preparation
Although, as discussed above, phase-based treatment approaches are not necessary or recommended, it was apparent during the assessment that Sally may benefit from a preparation phase of therapy. The formulation highlighted that Sally was struggling with heightened emotional dysregulation and shame-based self-attack was a strong maintenance factor for this. It was also hypothesised that shame could be an obstacle to the therapeutic relationship and to verbalising the trauma memories or associated hotspots. Sally also continued to experience life stressors related to her separation and children’s mental health and had minimal coping strategies for these ongoing events. Based on best practice to use an individualised approach, it was therefore agreed through discussion in supervision to begin intervention sessions with a preparation phase, akin to stabilisation phases outlined in the ESTAIR protocol, but tailored to Sally’s possible barriers to treatment. In addition to psychoeducational materials (such as trauma and the brain, window of tolerance, rationale for memory processing), sessions focused on: emotional regulation (including grounding strategies and self-care), and reducing shame and guilt (by developing self-compassion, reducing self-criticism, use of empathy within the therapeutic relationship). Specific attention was also paid to the ongoing risk of re-victimisation and this is discussed in detail later on. Preparation sessions took seven sessions and were revisited when indicated.
Throughout therapy, the therapist worked collaboratively with Sally to promote empowerment and redistribute the power within the therapeutic relationship as a way of offering Sally an alternative power dynamic to what she had experienced within her abusive relationship. This included offering choice, asking for Sally’s perspectives and emphasising that input from the therapist was just one perspective and was welcome to be challenged.
Trauma memory processing
The next part of the intervention focused on elaborating and updating the trauma memories and restructuring negative appraisals, in line with the CT-PTSD model. Using a trauma timeline, Sally identified the traumatic events throughout her marriage. There were several events on the map; the reprocessing phase of therapy focused on three memories of specific events of DA that were linked to the highest levels of distress.
Following the first imaginal reliving session, Sally reported an increase in distress and deterioration in mood resulting in suicidal ideation. Therefore, sessions focused on safety planning and recapping grounding strategies. Following this, Sally reported feeling less overwhelmed by the second reliving and felt better prepared to support herself following these sessions. During present-tense imaginal reliving of memory 1, two hotspots were identified with cognitions ‘it’s my fault’ and ‘I won’t get through this’, and shame and anxiety levels of 8/10 and 9/10, respectively. In memory 2, one hotspot was identified with the cognition ‘I’m a failure as a mum’, with shame levels of 10/10. In memory 3, one hotspot was identified with the belief ‘I am unsafe’, and anxiety rated at 7/10. Following imaginal reliving, strategies were used to update hotspots or restructure negative appraisals such as: linking psychoeducation to responses, use of responsibility pie charts to remove blame from Sally, developing a compassionate understanding and imagery rescripting (see Table 2 for hotspot updating for memory 1). Imaginal reliving was then repeated in the past tense, with updates. The adaptive cognitions that were included as updates included: ‘the responsibility is his’ (anxiety reduced from 8/10 to 3/10), ‘I survived’ (anxiety reduced from 9/10 to 0/10), ‘I have done my best as a mother’ (shame reduced from 10/10 to 4/10), and ‘I am safe in this moment’ (anxiety reduced from 7/10 to 1/10).
Table 2. Example hotspot updating chart for memory 1
For homework, Sally completed a thought and mood diary near the start of therapy, scheduled self-care activities, re-visited psycho-educational materials and practised grounding strategies. Following reliving sessions, Sally revisited the updated memory for homework. Sally listened to an audio recording of the updated meanings for memory 1, recorded in-session. For memory 2, Sally wrote out the updated narrative of the memory. The homework related to memory 3 updates included practising assertive responses and noting outcomes of this. Alongside the trauma reprocessing work, Sally also engaged with elements that could be considered under the ‘reclaiming life’ phase of therapy. She worked towards, and succeeded in, getting back to work, she shared with her colleagues about some of her historical and current struggles, she started to plan changes to her living conditions and what engaging with valued activities would look like. Further structured work on this part of therapy was handed over to her care coordinator due to time limitations related to the therapist’s placement with the service ending. Sally had been reluctant to draw on her Christian faith as part of her reclaiming life work as she maintained an element of shame around her divorce. Had there been more time the therapist would have considered the use of behavioural experiments, such as surveys or interviews with religious leaders (Wakelin and El-Leithy, Reference Wakelin and El-Leithy2025), in order to test Sally’s beliefs about accessing Church as someone who has separated from their husband. It is possible that this would have enhanced Sally’s faith as a protective and positive resource. Over the course of therapy, Sally continued to experience stressors including a further traumatic event with her ex-husband, ongoing deterioration of her daughter’s mental health, an unexpected change in care co-ordinator, and her parent’s health deterioration and death. In order to keep therapy on track, the therapist utilised agenda setting to ensure time was given to these events during the check-in and assess any change in risk while keeping Sally’s goals of therapy as a focus. As the service was targeted for complex presentations, session numbers were contracted on a case-by-case basis and could extend to long-term work. However, the therapist in this case was a trainee and sessions were necessarily limited by placement time. Sally was made aware of this at the start of therapy and this was regularly revisited.
Adaptations for working with ongoing risk of re-victimisation
Consideration was given to working with the ongoing risk of re-victimisation throughout Sally’s treatment.
A further rationale for the preparation phase was to address ongoing contact with the perpetrator of Sally’s DA. The therapist, drawing on interpersonal modules of the ESTAIR protocol and recommendations from the literature, discussed this contact with Sally such as whether or not contact was necessary, what cycles of abuse may be at play, how to communicate assertively in a safe way, what fears were linked to breaking contact with the perpetrator and what healthy boundaries might look like. Following the preparation phase, Sally and the therapist had an open discussion regarding safety planning for the next phase of therapy. As well as a possible increase in symptoms, the therapist discussed concerns within the literature regarding the possibility of desensitising individuals to ongoing harm. Sally suggested that, based on the psycho-education, re-processing would enable her to experience less distress by past traumatic events and, in turn, leave her better resourced to identify and respond to present threat. Sally also felt that exposure would provide a stark reminder of why she should not resume the relationship. Sally and the therapist therefore agreed to proceed with trauma reprocessing work, while continually checking in about symptoms and contact with her ex-husband.
During the intervention phase, attention was consistently paid to possible increases in risk for further re-victimisation. Imagery rescripting was used for the reprocessing stage of memory 2 (Wild and Clark, Reference Wild and Clark2011), with Sally creating an imaginal, alternative ending to the memory. At first, she chose an alternative ending where the perpetrator was kind to her and soothed her. Although Sally did not report this making her more sympathetic to her ex-husband, stating she was able to distinguish between an imaginal soothing image and reality, it was decided in supervision that such a positive association with her ex-husband could feasibly increase desire for connection with him and therefore increase the risk of further harm. For this reason, Sally was invited to create an alternative ending, which resulted in an outcome where she was in power, and he was small, apologetic and ashamed. However, despite exploration of the imaginal nature of the imagery and the rationale for a more empowered ending, practising this new ending did not lead to any further shifts in Sally’s ratings. Sally appeared to find it difficult to engage in this imagery and supervision was used to consider this. It was hypothesised that, due to Sally’s avoidance of conflict with others and mixed feelings related to her ex-husband, imagery rescripting which involved her ex-husband as inferior or upset was unlikely to meet Sally’s unmet needs in these memories. This led to further work on exploring Sally’s remaining feelings related to her ex-husband with Sally identifying thoughts about possible reconciliation of the relationship. When exploring advantages and disadvantages of this, Sally was able to use her understanding of DA patterns to ways in which her ex-husband may be convincing or manipulating her to consider this which she felt was more likely due to her tendency to be more passive in relationships. She acknowledged the likely outcomes of this decision as resulting in further DA, disruption to her children and reduced self-esteem and confidence. Given her ultimate decision of remaining separated and Sally’s identified difficulties with conflict, assertiveness skills were included. This then informed her updating in imaginal reliving.
As advised by the literature (Ennis et al., Reference Ennis, Sijercic and Monson2021; Yim et al., Reference Yim, Lorenz and Salkovskis2023), at the start of sessions, the therapist checked in with Sally regarding any contact with her ex-husband in the past week. There was an ongoing focus on self-care and grounding, including safe places to do this, for example in Sally’s flat and not around her ex-husband. Distinguishing between real current threat and a sense of current threat due to past traumas was also incorporated. This entailed exploring whether risk factors were present, such as the presence of her ex-partner, proximity to him, and conversations that included ‘risky’ topics. Sally identified some patterns and warning signs that suggested an incidence of DA may be imminent and considered how she could get herself to safety in such scenarios. Safety planning was consistently included in sessions. This included pre-empting risk and ways to reduce this (e.g. reduce in-person contact and pre-plan necessary contact to be with other people, use of professionals such as solicitors for communication), role-playing ways to end a conversation and set boundaries.
Sally was visiting the site of her traumas frequently as this is where she often met her ex-husband which posed a challenge to usual trigger discrimination work as there was a risk of further victimisation during these visits. Contrary to usual trigger discrimination work, where Sally would be supported to reduce her anxiety through this exposure and cognitive restructuring, it was important that Sally understood these were real risk situations and that it was adaptive for her to be anxious and alert to imminent threat. Therefore, current versus past threat discrimination was used to reduce arousal levels only insofar as to prevent flashbacks but while maintaining cognitions such as ‘I am unsafe around X’ alongside newer cognitions such as ‘I deserve respect’.
Outcome
Standardised measures
As illustrated in Fig. 2, Sally’s baseline PDS-5 score showed stability in her scoring within the severe range. At the end of the intervention phase, Sally scored 26, below the clinical cut-off and therefore indicating clinically significant change. This was maintained at follow-up.
Figure 2. Sally’s scores on the PDS-5. The red line indicates clinical cut-off for PTSD; the blue dotted line indicates gap between the assessment and intervention phases of the therapeutic intervention.
Figure 3a and 3b show that at the assessment phase, Sally consistently scored highly in both the PHQ-9 and GAD-7, indicating clinically significant depression and generalised anxiety. At the end of the intervention phase, although still above the clinical threshold for both, Sally’s scores indicated moderately severe depression and moderate generalised anxiety compared with severe for both at the assessment phase. Compared with Sally’s baseline scores, at the end of the intervention she showed reliable change on both the PHQ-9 and GAD-7. However, at follow-up, only the GAD-7 showed reliable change compared with Sally’s baseline scores. Sally attributed the increase in her PHQ-9 score to her experience of grief in relation to her mother’s death.
Figure 3. (a) Sally’s scores on the PHQ-9. The red line indicates clinical cut-off for depression; the blue dotted line indicates gap between the assessment and intervention phases of the therapeutic intervention. (b) Sally’s GAD-7 scores. The red line indicates clinical cut-off for generalised anxiety; the blue dotted line indicates gap between the assessment and intervention phases of the therapeutic intervention.
Idiosyncratic measures
As established in the assessment phase, Sally was feeling on edge and unable to relax six or more times a week. Following the intervention phase, this halved to two to three times a week (see Fig. 4a). After the preparation work in the intervention phase, Sally noticed that while she still experienced anxiety daily, it occurred less frequently, and she was able to implement coping strategies. During the intervention phase, Sally’s anxiety fluctuated; however, Sally observed that this was likely related to beginning to do things outside of her comfort zone such as leaving the house more and meeting up with friends. Following this, Sally’s ratings remained at a consistently reduced level of two to three, or four to five, days a week throughout reprocessing sessions in the intervention phase. In session 22, Sally’s score increased to her baseline levels of six or more times a week. However, this coincided with her mother, ex-husband, and daughter being hospitalised within 10 days of each other.
Figure 4. (a) Sally’s on edge ratings. The blue dotted line indicates gap between the assessment and intervention phases of the therapeutic intervention; a rating of 4 denotes ‘I have felt on edge’ six or more times and 0 denotes not at all, when considering the last week. (b) Sally’s living/existing ratings. The blue dotted line indicates gap between the assessment and intervention phases of the therapeutic intervention; a rating of 10 denotes ‘I have only been existing’, and a score of 0 denotes ‘I have been fully living’ when considering the last week.
Sally’s rating of the degree to which she is living versus existing showed stability throughout the assessment and first half of the intervention phases – rating herself as existing only (Fig. 4b). At session 17, Sally’s rating of this shifted for the first time. This coincides with the completion of the second trauma memory reprocessing. Sally reported noticing moments of enjoying herself and being more connected to the present. She stated that this was a significant change in how she had felt for the past few years.
As well as measures, Sally provided qualitative feedback on changes she had noticed over the course of therapy. She no longer felt the possibility of resuming a relationship with her ex-husband and described being more assertive in their ongoing contact. Sally also reported that she had started to make decisions based on her own needs rather than others. Furthermore, she was being kinder to herself and spoke encouragingly rather than critically to herself. Sally also noted that the frequency of re-experiencing symptoms had reduced and when she did have memories of the traumas, she did not feel as distressed by them. At the final session, Sally noted that despite ongoing stressors with regards to family members’ health and finances, she was coping and described feeling ‘strong’. Sally compared this with the start of therapy where she would have felt overwhelmed and suicidal. Sally had also reduced her anti-depressant medication dose for the first time since being commenced on it before therapy, and shared a goal to reduce it further over time until she could stop taking it completely.
Follow-up
Following completion of the preparation and reprocessing elements of therapy, Sally was unable to attend sessions due to her mother’s health deterioration. Sally attended four review sessions approximately two months following the completion of reprocessing. In this time, Sally’s mother had died. Initially, Sally reported envisioning a future moving away on her own. However, Sally then found it hard to imagine this as a realistic plan given ongoing difficulties with her children. Sally reported that while she no longer felt ‘traumatised’, she was managing worry and low mood daily and was able to normalise this in the context of her mother’s death and feeling at a crossroads with decisions about her future. A final set of measures were taken which supported her reports. Sally’s PDS-5 score showed a maintenance of being below the cut-off for PTSD and her GAD-7 stayed the same; however, her PHQ-9 illustrated daily low mood (Figs 2, 3a, 3b, 4a and 4b).
Sally identified feeling emotionally vulnerable due to grieving and reported that she had been spending more time at the marital home, around her ex-husband, as he had offered a source of practical support. Sally identified that this was confusing for herself and her family and meant she was exposing herself to a potential risk of further harm. Sally was able to identify that this represented a cycle of abuse in which she could be drawn back into resuming the relationship with no change in her husband’s behaviour. This was formulated with Sally in the context of her emotional vulnerability and desire to attain previously held ideals about family life that had been reactivated due to her mother’s death. Sally was re-attending a DA psychoeducation group run by the Freedom project and stated that this was supporting her to continue to identify the patterns of her behaviours. Sally identified that having a clearer sense of her values and the life she wished to lead would support her to reinstate boundaries and assert herself to prioritise her safety, as it had in earlier therapy sessions. A handover meeting was therefore arranged with Sally’s care co-ordinator to support with this. It was suggested that this phase of the work focused on the use of values to explore the life Sally wished to reclaim.
Discussion
This case study illustrates that delivering TF-CBT in the context of ongoing DA threat is plausible and effective. As demonstrated from the measures and qualitative feedback, Sally met her goal of reducing the frequency in which she felt on edge during the week. Following intervention work targeting preparation and reprocessing of traumatic memories, this reduced to half the days of the week, in support of the first hypothesis. Furthermore, Sally’s rating of the degree to which she was living compared with existing also demonstrated an improvement following reprocessing work. Sally’s scores on the standardised measures supported this shift, showing that her PTSD symptomology severity reduced to below the clinical cut-off and this was maintained at follow-up as well as her scores on the anxiety measure showing reliable change. Sally’s depression measure also showed reliable change at the end of the intervention but this was not maintained at follow-up. However, she attributed this to an understandable reaction to her mother’s death. This case study therefore supports previous findings that TF-CBT can lead to improvements on PTSD, depression, anxiety and quality of life measures (Ehlers et al., Reference Ehlers, Hackmann, Grey, Wild, Liness, Albert and Clark2014; Dokkedahl et al., Reference Dokkedahl, Kristensen and Elklit2022).
A strength of this case study is the SCED design which establishes a baseline of scores on the measures. Therefore, we can be more confident that the change observed in Sally’s scores are due to TF-CBT. Moreover, given that Sally continued to experience significant stressors in her life, the reduction on the measures is even more notable. However, pre and post data were only compared in terms of scoring and the strength of future case studies could be improved by utilising statistical analysis.
This case study supports conclusions from systematic reviews that delivering TF-CBT in ongoing threat is possible and beneficial (Ennis et al., Reference Ennis, Sijercic and Monson2021; Yim et al., Reference Yim, Lorenz and Salkovskis2023). Although this was not formally measured, there was no evidence to suggest that the use of exposure to previous trauma memories desensitised Sally to danger cues; in fact, Sally reported the opposite, that therapy enabled her to implement boundaries and prevent further victimisation. Notably, Sally was able to communicate with some of her colleagues about her situation after starting therapy, receiving positive responses from her managers, decreasing her social isolation and increasing her support system; this was a virtuous cycle, further reducing her shame and supporting gains in therapy. Moreover, Sally’s qualitative feedback regarding improvements in her assertiveness and clarity regarding her relationship with her ex-husband, the perpetrator of DA, highlights the importance of offering this intervention to empower individuals to break cycles of abuse and re-victimisation (Yim et al., Reference Yim, Lorenz and Salkovskis2023).
A limitation of interpreting this case study is that the CT-PTSD protocol was modified, often with consideration of the ESTAIR protocol. This included individualising a preparation phase, including assertiveness skills, addressing shame with compassion focused approaches, discrimination of past versus current threat, monitoring ongoing risk more closely, and the absence of a site visit. There were also modifications in line with the limitations of a community NHS setting, such as a stronger focus on the ‘reclaiming life’ phase being picked up by the care coordinator. These modifications reduce the ability of this paper to conclude on the suitability of a ‘pure’ CT-PTSD protocol in cases of cPTSD with the threat of ongoing risk; however, they reflect the need for a flexible and person-centred approach in the context of ongoing threat and a cPTSD presentation.
As has been noted elsewhere, the ‘phases’ of trauma therapy, whilst helpfully distinguished, often overlap and occur concurrently. This meant that stabilisation, trauma reprocessing and reclaiming life work were not necessarily discreet from each other; this is aligned with the CT-PTSD model, where the phases of trauma work are integrated, although as noted above this case did not strictly adhere to a CT-PTSD protocol. The extended preparation phase was reported by Sally to increase her confidence in her ability to complete the trauma treatment safely, to trust the therapist (building a therapeutic alliance), and to feel less shame. On reflection, it would have been useful to include some additional TF-CBT techniques, such as a survey to explore how others responded to her shame-based cognitions, behavioural experiments to increase social contact, and further work on trigger discrimination (e.g. exposure to loud noises or finger pointing). A limitation to the work was that, due to ongoing stressors within Sally’s system, the intervention focused less on reclaiming your life assignments and in-between session tasks than the therapist hoped. As Sally continued to experience and manage significant stressors during therapy, as is the nature of ongoing threat, in-between tasks tended to focus on continuing to put into place grounding and safety strategies to manage the impact of the work and ongoing difficulties. Had time allowed, a stronger focus within therapy on building social contacts, and generally on the ‘reclaiming life’ phase of therapy, to reduce reliance on her ex-husband would have no doubt been beneficial. Additionally, if Sally had not accessed support through a DA-specific organisation, the therapist’s and care coordinator’s roles would need to include more advocacy, such as supporting Sally to learn more about her legal rights and access more DA-specific support and information.
It is noteworthy that whilst Sally reported progress in therapy related to ongoing threat, namely an ability to recognise and resist DA cycles, this appeared to cease following the death of her mother. This was understood within the context of emotional vulnerability rather than TF-CBT having de-sensitised Sally to risk of further harm (as feared within the literature); the measures showed that Sally’s PTSD symptoms remained below the cut-off. It was unknown at this stage whether Sally would permanently and fully separate from her relationship with her ex-husband, which could leave her at risk of being drawn into further abuse cycles. However, it was noted that she had been liberated from daily distressing experiences of re-living and feeling on edge. Furthermore, she reported being more aware and wary of her ex-husband and this is evidence on the contrary to her being desensitised to danger cues.
Sally responded well to the here-and-now initial focus of the intervention. She found having strategies and grounding skills useful. Moreover, Sally appeared to find the normalising nature of the formulation and psychoeducation helpful, often seeking reassurance from the therapist that other people experienced these symptoms and had recovered. This could be linked to an opportunity to challenge appraisals Sally had developed following the traumas such as ‘I’m going mad’. The therapeutic relationship could also be considered a helpful component of the intervention with a focus on compassion at the start of therapy. Focusing on empowering Sally through supporting her informed choice around the sessions’ pace, content and direction as well as expressing empathy consistently not only supported the development of a supportive and trusting therapeutic relationship, but also allowed Sally to develop a sense of empowerment and begin to practise self-compassion. This supports suggestions from the literature regarding working with shame and PTSD in DA survivor populations and is arguably important (Au et al., 2016; Brown, Reference Brown2006; Cloitre et al., Reference Cloitre, Courtois, Ford, Green, Alexander, Briere and Van der Hart2012; Lee et al., Reference Lee, Scragg and Turner2001; McGirr and Sullivan, Reference McGirr and Sullivan2017; Murray et al., Reference Murray, Grey, Warnock-Parkes, Kerr, Wild, Clark and Ehlers2022).
The therapist regularly met with Sally’s care co-ordinator to share grounding and safety strategies that they could support Sally to practise in between sessions. A specific meeting was arranged when Sally’s care co-ordinator changed in order to share the formulation to support their understanding of Sally and progress in psychological therapy. As mentioned, the therapist also met with the care co-ordinator at the end of therapy in order to hand over ongoing goals related to reclaiming life elements of treatment with the hope to continue Sally’s progress in her ongoing community mental health support. It was hypothesised that this would lead to further reductions in Sally’s idiosyncratic measure of the extent to which she is living compared with existing, with further shifts towards the ‘living life’ end. Additionally, by intervening with strategies and consolidating cognitive shifts from the restructuring and reprocessing phase of therapy, Sally’s scores on the idiosyncratic ‘on edge’ measure, PDS-5, PHQ-9 and GAD-7 were also expected to show further reductions in severity.
An additional limitation was the use of a measure for PTSD rather than cPTSD, meaning the full spectrum of Sally’s post-trauma symptoms was not formally measured. Whilst the clinical interview indicated a cPTSD presentation, it would have been useful to be able to track this in a systematic way and re-assess what impact the intervention had on Sally’s wider issues. The International Trauma Questionnaire could have been informative, as could have the use of further measures to assess cognitions, such as the Post-Traumatic Cognitions Inventory, and coping strategies, such as the Coping Strategies Inventory.
Further research, including clinical case studies, could usefully unpick nuances in TF-CBT interventions where ongoing threat is present. In light of this paper, this might include exploring whether imagery rescripting needs to include survivors being empowered or if harmonious resolutions can lead to minimising the risk of further threat, or if TF-CBT work for DA when someone is still living with the perpetrator is effective. It would be interesting to understand the variations in therapy indicated depending on the type of ongoing threat, for example DA versus war. Exploring long-term outcomes, for instance rates of re-victimisation for those who have received TF-CBT versus those who have received other interventions, would also be informative.
The research in this field indicates that those experiencing PTSD in the context of ongoing threat can benefit from TF-CBT interventions.
Key practice points
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(1) TF-CBT can be delivered in the context of ongoing threat.
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(2) TF-CBT protocols can be adapted based on individual needs and preferences – extending, shortening and integrating phases as deemed appropriate.
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(3) When offering CT-PTSD in the context of ongoing threat, additional factors to consider include safety planning, differentiating between real and imagined danger, advocacy, and asking about ongoing contact or threat.
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(4) Explicit consideration of the therapeutic relationship and specifically the inherent power imbalance is imperative when working with domestic abuse survivors.
Data availability statement
No new data were created or analysed in this study, therefore the data availability statement is not applicable.
Acknowledgements
We would like to thank Sally (pseudonym) for her commitment to attending and applying therapy. We are grateful for her consent to the submission and publication of her assessment, formulation and intervention.
Author contributions
Alice Austin: Conceptualization (lead), Project administration (lead), Writing - original draft (lead), Writing - review & editing (supporting); Megan Cowles: Conceptualization (supporting), Project administration (supporting), Supervision (lead), Writing - original draft (supporting), Writing - review & editing (lead)
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
There are no completing interests.
Ethical standards
No specific ethical approval was required for this work as it reports on a routine piece of clinical work. Researchers have abided by the Ethical Principles of Psychologists and Code of Conduct as outlined by the British Psychological Society and British Association for Behavioural and Cognitive Psychotherapies. Informed consent from Sally (pseudonym) was obtained for the writing and publication of this case study, and identifiers have been removed to ensure confidentiality is maintained.
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