Working Together: Dickie’s Recovery from PTSD

Meet Dickie, who sought therapy after a road traffic accident left him with post-traumatic stress disorder (PTSD) symptoms and chronic pain. He avoided driving out of fear, and when he did, he was extremely cautious – an issue made worse by his job in the car industry. This left him withdrawn, in pain and feeling hopeless. He was experiencing nightmares and flashbacks to the accident.

Dickie has kindly agreed to share his recovery story so that other people may have some insight into what is involved in PTSD treatment and, in so doing, demystify the evidence-based treatment for the pervasive experience of being scared of something that has already happened. 

Dickie’s Experience of Therapy in His Own Words

“First of all, it was scary because I was going into the unknown with a complete stranger. For the first four or five sessions, I felt that I wasn’t getting any benefit out of it, but that was because I hadn’t built a bond with my therapist. But over time, I relaxed, and my guard came down. 

After each session, it was difficult to take in all the information and what we'd done, but a couple of hours later, my mind would calm down and I started to see the importance of the work we'd done.

One of the turning points for me was a long drive to Devon, which was 223 miles each way. Caroline had a story about a lady she'd worked with who was scared of birds and how she overcame that. It gave me the motivation to do the drive. I felt like I was fighting through it, but I did it. 

The next thing that helped was the reliving; it helped me to see that the crash was in the past. But it was more the site visit that made the difference. I didn’t want to be there at all, but seeing everyday traffic and cars pulling out of the junction, on the road where the car crash happened, helped. I was shaking with fear and anxiety. I tried to avoid driving past the junction where the crash happened. I wanted to avoid it so much that I would have driven dangerously. I wanted to do a turn in a very busy main road, but Caroline was encouraging and supportive. 

I was very shaky after the site visit. I was anxious, but after a couple of hours, it all calmed down, and I realised what I had done and what an achievement that was. I felt like giving myself a pat on the back. It was a big sigh of relief and a weight lifted off my shoulders."

How Has Your Life Changed Since Therapy? 

“I'm a lot more cheerful and happier. I'm taking the kids out now, not pushing people away or closing myself up. Work colleagues have commented that I'm better and that I'd previously just gone in and out of work and was shut off from everybody.

I was going to get married anyway, but having the treatment allowed me to be more confident. Before the therapy, I'd been predicting the wedding day would be disastrous. I wasn’t looking forward to it. I didn’t want to make a speech, but I did. I drove to Scotland (and back) for our honeymoon, which was 364 miles each way, and I was a lot more comfortable, I was more relaxed and not on edge. It was a pleasant journey, and I knew that the relative risk of a crash happening again was low, at 0.003%. Driving was part of my job, and I wasn’t able to do it fully, which made me feel more depressed, and it affected my commission-based earnings. 

It really was the site visit that turned things around. It was the realisation that when it all calmed down, it wasn’t as bad as I thought it was going to be. It made it feel like I was getting closer to the light at the end of the tunnel. 

The kids are integrating with me more and doing activities, and they're talking to me more. The relationship with my new wife is getting better; she's saying that I'm happier, and it’s not all doom and gloom.”

What's Your Advice For Anyone Thinking About Getting Treatment For PTSD? 

“I would say no matter what you feel and think at the beginning, happiness is always at the end, giving you your life back, and the therapy is a big part of achieving that goal. Keep persevering, give it time.”

Notes and Reflections From Caroline

The Therapeutic Relationship

Dickie raised the importance of the therapeutic relationship. It has classically been asserted that the working alliance in psychotherapy is made up of three parts: 1. agreement on goals, 2. assignment of tasks and 3. the development of bonds (Bordin, 1979). The therapeutic alliance is deemed to be necessary, but not sufficient for therapeutic change, and has been found to be an important factor in the treatment of PTSD (Beierl, et. al, 2021).

Exposure Therapy

Dickie mentioned a story about birds; this was an intensive treatment I engaged in with a previous client. We spent two days together to treat the bird phobia she’d had for 50 years, and at the end of those days, I was more scared than she was!

Exposure therapy requires a person to face their fears about certain situations or in the presence of a feared object (e.g. a bird or driving a car) until the anxiety is no longer present. This is called habituation: the fear dissolves. Once Dickie decided to drive, I supported him so he could show himself that he could overcome his fears, just as he described. I was really proud that he did that for himself. He showed great courage, and it left him with a sense of safety and hope for his own recovery.

Reliving

Reliving is a process where we ask people who are re-experiencing a traumatic event to go through the memory in their mind's eye. Generally, people avoid thinking about the traumatic memory, because it's deeply unpleasant and makes them feel all sorts of horrible feelings, such as fear, anxiety, anger, guilt and shame. This stops them from processing the memory fully. 

The thing about a trauma memory is that it represents a life event – an unpleasant and unwanted life event – that comes out of the blue; there's no warning, no preparation, and then after that, we do our best to block it out, only for it to bounce back into our mind when we're reminded of it. For Dickie, that was every day when he went to work. He drove his car on his way to work (very cautiously), saw cars on the way to work and when talking with people who might want to buy a car from him. 

Most life event memories have a beginning, a middle and an end. Let’s take Dickie as an example. There was a lot of planning for his wedding; he thought about it before it happened, he was prepared, and he knew what to do. There was planning and then the wedding, and then the honeymoon, photographs, presents, and so on. All of these aspects put a ‘curve’ on a memory. The memory is recalled when it is congruent with an experience or conversation.

But there's no curve on an unprocessed traumatic memory; it's re-experienced, it bites you when something (sometimes unconsciously) reminds you of the trauma, and we retreat, withdraw and ruminate. Reliving helps us put a broader context to the memory back in place, where it belongs, which is in the past, exactly as Dickie told us. 

Site Visit

Since the pandemic, we've become much more creative in the way we do the therapeutic work in PTSD. Site visits used to be a rather grand affair where together we would go out to the place where the trauma occurred, and make a new memory in that place, and notice what's different now from how it was when the trauma occurred. Dickie’s site visit was done alone, with me supporting him on the journey via Teams. On the way there, he was talking to me on his phone, which was placed in the coffee cup holder in his car. Then he took ‘me’ out of the car via the video link. I was in my home office, and he was by the roadside. I was with him virtually. 

This meant I was able to see him and check on his mood state and encourage him to engage fully in the process, giving him a sense of safety. Once the anxiety he was experiencing had abated, and he'd habituated to the fear of being at the site, he realised that his car was facing the wrong way to avoid the junction where the car crash had occurred. As he said, he wanted to make a turn in the road to avoid this, but eventually he yielded when he realised (with a nudge from me) that it would be a dangerous move to do that; he went on and faced his fears and did it anyway. With me cradled in the coffee cup holder.

This turned into a bit of fun, and Dickie ribbed me for ‘making him do it’ which, of course, I had no power to do. But he did know that it was the right thing to do from a safety perspective, and for the fact that he would overcome his fear. 

Great job, Dickie! I'm so glad that you've reclaimed your life, and I'm very proud to have been a part of your journey.

Bibliotherapy

Beierl, E.T. (2021), The relationship between working alliance and symptom improvement in Cognitive Therapy for Posttraumatic Stress Disorder. https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2021.602648/full

Bordin, E.S. (1979), The Generalisability of the psychoanalytic concept of the working alliance. https://psycnet.apa.org/doiLanding?doi=10.1037%2Fh0085885

Ehlers, A. & Clark, D. (2000), A cognitive model of posttraumatic stress disorder. 

Murry. H, et al (2015), Clients' Experiences of returning to the Trauma Site during PTSD Treatment: An Exploratory Study. https://pubmed.ncbi.nlm.nih.gov/26190531/

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