The Truculent Client July 16th 2013

The Truculent Client
Dr Michael J Scott
[email protected]
‘Fight’ or ‘Flight’
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
Reckless or self-destructive behaviour
The Incongruence of Client and Therapist
Agendas in Trauma Focussed CBT (TFCBT)
Clients do not usually
want to talk of their
Therapist focussed on
discussion/exposure to
the trauma and its
The Powder Keg of Cognitive Avoidance
and Increased Irritability
A Vignette Of The Truculent Client
I’ve noticed that you keep looking at the door
I just want to go
Why is that?
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!
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
Flexibility in the use of evidence based treatment protocols
A DSM 5 Based CBT Model of PTSD
CBT for Common Trauma Responses . London: Sage Publications. Scott et al. 2012
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
Anger can be viewed as ineffective coping
with a state of terrified surprise
Ineffective Coping
A Preventative Function
‘Control Freak’
A Restorative Function
Disproportionate anger when startled
Avoidance of talking about the
Anger and avoidance can also be addressed
using coping self-statements
1. Preparing for anger/ avoided situation
2. Encountering the anger / avoided situation
3. Coping with feeling overwhelmed
4. Reflection on coping
Psycho-education to prepare for
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’.
The use of coping Self-Statements
constitutes a Non-Trauma Focussed CBT
intervention that is particularly apt for
‘The Truculent Client’
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
The effectiveness of a Coping Skills
approach to PTSD
Increasing evidence that a coping skills approach to PTSD is
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
Thank You
Presentation available at:

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