Enhanced reliving’ in trauma-focused CBT for PTSD involves addressing the meaning associated with ‘hot spots’ of traumatic memory. This Hotspot Record is formatted to encourage reflection on “what I thought then” and “what I know now”.
Hotspot identification and updating is core component of the ‘enhanced reliving’ technique – cognitive restructuring within reliving for PTSD. In a typical course of therapy including enhanced reliving traumatic appriasals are identified during reliving, and updates are elaborated off-line (outside of reliving). Updated beliefs can then be inserted into the memory during another session of reliving by pausing to ask the critical question “and what do you know now?”. This Hotspot Record is formatted to facilitate this off-line process. It include spaces to record the event/hotspot, associated emotion, appraisal or belief in that moment, and the updated belief or current knowledge. Clinicians are strongly urged to read the paper by Grey, Young & Holmes (2002) which clearly details this process.
Enhanced reliving consists of a number of steps:
- Identification of (peri-) traumatic appraisals & emotions
- Identifying current knowledge (“what do you know now?”)
- Integrating current knowledge back into the memory
The Hotspot Record is designed to facilitate steps 1 & 2. Clients should be encouraged to:
- Describe the image which represents the worst moment of the trauma. They might re-experience this moment frequently in flashbacks, or you can ask “If the memory was like a movie, can you fast-forward to the worst point then pause it and describe the scene?”
- Rate the emotion(s) associated with that moment, and rate the intensity of each emotion.
- Identify the client’s appraisal of that worst moment by asking questions like “What does that image mean to you?”, “In that moment what did you think was going to happen?”, “In that moment, what did you think about yourself?”. The aim is to identify peri-traumatic cognitions – what sense did they make of that situation in that moment?
- Use appropriate cognitive restructuring techniques to generate ‘updates’. ‘Hot’ peri-traumatic cognitions are often biased, frozen in time, or have not been updated with subsequent information. Simple updates might include “I survived” or “I was injured but escaped”. More complex examples might include taking the stance of a compassionate adult towards a child, for example “It wasn’t my fault”, “I did nothing wrong, it is the abuser who should be ashamed of their actions”.
Techniques for integrating updates into trauma memories are described in Grey, Young & Holmes (2002).
- Ehlers, A., Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.
- Grey, N., Young, K., & Holmes, E. (2002). Cognitive restructuring within reliving: a treatment for peritraumatic emotional “hotspots” in posttraumatic stress disorder. Behavioural and Cognitive Psychotherapy, 30, 37-56.