MEQ: Choosing and planning trauma-focused therapy after assault

(i) Ehlers–Clark model applied (5). Persistent PTSD arises when trauma is processed so the person experiences serious current threat. Here: negative appraisals — self-blame (“I should have fought harder”), possibly shame and danger generalisation (night shifts/car parks = unsafe). Memory quality — intrusive images/nightmares suggest poorly elaborated, perceptually rich trauma memory re-experienced as if now. Maintaining strategies — avoidance of night work and car parks; alcohol to sleep/suppress affect; possible rumination/self-attack. These strategies prevent updating of the memory and disconfirmation of appraisals, so threat sense continues.[1][2]

(ii) Two first-line options and key techniques (5). Examples (any two trauma-focused first-line packages): Prolonged exposure — imaginal exposure to the assault narrative with processing + in vivo hierarchy of safe avoided cues (e.g. hospital car park with graded plan).[3] EMDR — eight-phase protocol with dual-attention bilateral stimulation while processing target memories (image, NC/PC, SUDs, body), installation and re-evaluation.[4] Alternatives equally creditworthy: CPT (impact statement, stuck-point work on self-blame) or CT-PTSD (memory updating, discrimination training, reclaiming life).[2][7][5][8]

(iii) Readiness, risk, explanation, consent (5). Assess suicide/self-harm, ongoing safety, substance pattern, dissociation, ability to attend, alliance. PCL-5 documents severity. Explain that trauma-focused therapy is structured, time-limited, and aims to change how the memory and meanings are held — not hypnosis or forced loss of control. Temporary increase in distress during/after sessions is common and planned for (grounding, session structure, crisis contacts). Collaborative choice among PE/CPT/EMDR by preference and local competence. Obtain informed consent; start when stable enough to process, not when asymptomatic. Alcohol misuse needs concurrent plan so sessions are not intoxicated and sleep strategy is replaced gradually.[3][4][5]

(iv) Alcohol, meds, non-response (5). Address alcohol as a maintaining safety strategy and sleep substitute — brief motivational work, harm reduction, medical review if dependence; do not wait forever for perfect abstinence if PTSD drives drinking, but do not run imaginal exposure while intoxicated. Pharmacotherapy: SSRI such as sertraline has RCT evidence and may be offered for severity, preference, access delay, or partial response — adjunct, not replacement for offering TF therapy; avoid default long-term benzodiazepine as core PTSD treatment.[6][5] If inadequate response after adequate dose and fidelity, review formulation/homework, then switch to another TF modality or specialist complex package rather than indefinite unstructured counselling.[5][8]