1. The Truculent Client Dr Michael J Scott michaeljscott1@virginmedia.com

2. ‘Fight’ or ‘Flight’

3. In the new DSM 5 Criteria for PTSD ‘Fight’ can be as important as ‘Flight’ Whilst avoidance continues to be part of the symptom profile, ‘Fight’ is given increased recognition. Cluster E in DSM 5 refers, amongst other symptoms, to: Irritable or aggressive behaviour and Reckless or self-destructive behaviour

4. The Incongruence of Client and Therapist Agendas in Trauma Focussed CBT (TFCBT)

5. The Powder Keg of Cognitive Avoidance and Increased Irritability

6. A Vignette Of The Truculent Client Therapist: I’ve noticed that you keep looking at the door Client: I just want to go Therapist: Why is that? Client: You’ve got it all there in the notes, and you are asking me about it, haven’t you even bothered to read the records!

7. Preventing Derailment • Anger leads to therapist non-compliance with evidence based treatment protocols. Barlow et al. 2013 • Derailment can be prevented by: Fidelity to a cognitive model of the disorder and Flexibility in the use of evidence based treatment protocols

8. A DSM 5 Based CBT Model of PTSD CBT for Common Trauma Responses . London: Sage Publications. Scott et al. 2012

9. Intrusions in PTSD clients are experienced as unwanted surprises Treatment should focus on the management of surprises by the distillation of coping self-statements in 4 stages: 1. Preparing for the stressor e.g flashback 2. Encountering the stressor 3. Coping with feeling overwhelmed by the stressor 4. Review of coping efforts

10. Anger can be viewed as ineffective coping with a state of terrified surprise Ineffective Coping A Preventative Function A Restorative Function Disproportionate anger when startled Avoidance of talking about the trauma ‘Control Freak’

11. Anger and avoidance can also be addressed usingcoping self-statements 1. Preparing for anger/ avoided situation 2. Encountering the anger / avoided situation 3. Coping with feeling overwhelmed 4. Reflection on coping

12. Psycho-education to prepare for stressors Useful metaphors • The ‘dodgy alarm’, ’bubble’, ‘lemonade bottle without the top on’ • Distress as inappropriately going back in the ‘Tardis’ to the memory of the trauma and constructing a model of current threat from elements retrieved in this time machine. Focussing on using a different ‘construction kit’.

13. The use of coping Self-Statementsconstitutes a Non-Trauma Focussed CBT intervention that is particularly apt for‘The Truculent Client’

14. Coping Skills and the Truculent Client A ‘coping skills’ approach: • Makes it easier to market ‘better ways of handling the flashbacks’ than TFCBT • Is an alternative for those who refuse TFCBT • May be a first step in facilitating TFCBT

15. The effectiveness of a Coping Skills approach to PTSD Increasing evidence that a coping skills approach to PTSD is effective The Cochrane Collaboration. Chichester: John Wiley & Son Ltd.Bisson et al. 2009 A comparison of Coping Skills/CBT with Support/CBT found: 1. Lower dropout rate in the Coping Skills/CBT group (17% cf 38%) 2. No difference in recovery between groups at end of treatment 3. At follow up a significantly higher proportion of clients had recovered from PTSD in the Skills/CBT group (72% cf 50%) Psychological Medicine. Epub ahead of print. Bryant et al. 2013

16. Presentation available at: michaeljscottptsd.com Thank You