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What Keeps Post-Traumatic Stress Disorder (PTSD) Going?

The "What Keeps It Going?" series is a set of one-page diagrams explaining how common mental health conditions are maintained. Friendly and concise, they provide an easy way for clients to understand at a glance why their disorders persist, and how they might be interrupted. What Keeps Post-Traumatic Stress Disorder (PTSD) Going? is designed to help clients with PTSD understand more about their condition.

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A PDF of the resource, theoretical background, suggested therapist questions and prompts.

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A PDF of the resource plus client-friendly instructions where appropriate.

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An editable Microsoft PowerPoint version of the resource.

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Languages this resource is available in

  • Chinese (Simplified)
  • English (GB)
  • English (US)
  • German
  • Hebrew
  • Italian
  • Polish
  • Russian
  • Spanish (International)

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Introduction & Theoretical Background

If you have been through a trauma, it is normal to feel shocked, scared, guilty, ashamed, angry, vulnerable, or numb. With time, most people recover from their experiences, or find a way to live with them, without needing professional help. In spite of this, for many people the effects of trauma last for much longer and may develop into post-traumatic stress disorder (PTSD). Symptoms of PTSD can be split into groups (APA, 2013):

  • Re-experiencing symptoms.
  • Arousal symptoms.
  • Avoidance symptoms.
  • Negative thoughts and mood.

Research studies have shown that Cognitive Behavioural Therapy (CBT) is one of the most effective treatments for panic disorder (Watkins et al, 2018). CBT therapists work a bit like firefighters: while the fire is burning they aren’t very interested in what caused it, but are more focused on what is keeping it going. This is because if they can work out what keeps the problem going, they can treat it by ‘removing the fuel’ and interrupting this maintaining cycle. 

Psychologists Anke Ehlers and David Clark identified the key components that are thought to explain why PTSD persists (Ehlers & Clark, 2000). The What Keeps Post-Traumatic Stress Disorder Going? information handout describes these factors, which maintain PTSD. It illustrates them in a vicious flower format in which each ‘petal’ represents a separate maintenance cycle. Helping clients to understand more about the cognitive model is an essential part of cognitive therapy for PTSD. Therapists can use this handout as a focus for discussion, or as a template from which to formulate an idiosyncratic model of a client’s experiences of PTSD.

Therapist Guidance

“One interesting way of thinking about PTSD is to look at why, for some people, it does not get better by itself. This handout shows the most common reasons why some people’s PTSD persists. I wonder if we could look at it together and think about whether it describes some of what is happening for you?”

References And Further Reading

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
  • Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319-345.
  • Watkins, L. E., Sprang, K. R., & Rothbaum, B. (2018).Treating PTSD: a review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258.