Philip, a White 60-year-old British man, had a road traffic accident on the motorway 3 months before presenting for assessment. The driver of an adjacent car fell asleep and drove into Philip's car from the side. His daughter and grandson were sitting in the back seat. Philip's car spun twice. He tried to look around to see if his daughter and grandson were safe, but he was trapped and could not see them. He thought they were flying about in the car like everything else and that they had died. The car eventually landed on its four wheels. Philip described excruciating pain in his back. He thought that he had broken his back. He could not hear his daughter or grandson and believed they must be dead. However, they had survived. His daughter had a broken arm and his grandson was without injury.
When Philip presented for assessment he was having intrusive memories of the accident every day in which he saw the car spinning. He also had intrusive images of what could have happened and pictured his daughter and grandson dead in the backseat. Philip had flashbacks when he drove his car, which happened several times per week, and he felt hot and sweaty in these situations. He also often woke up with nightmares about the accident.
Philip pushed memories of the accident out of his mind, especially at bedtime. He avoided places that reminded him of the trauma, especially motorways and where it happened on the motorway. Whilst he could remember the trauma, he could not remember that the car had rolled twice until he was told by his daughter. Philip had many hyperarousal symptoms. He had difficulty sleeping, felt irritable, had trouble concentrating, and was overly alert.
Philip also developed depression after the accident. He was low in mood, tearful, unmotivated, and preferred to stay indoors rather than engage in his previous activities, such as meeting friends for a drink and going out with his wife once a week for a meal.
Philip met the criteria for PTSD and major depression as set out in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association,) and assessed with the Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams,). In addition, Philip had chronic back pain from the accident. The pain was a constant reminder of the accident and could trigger intrusive memories and rumination.
In terms of personal meanings of the trauma, objectively Philip knew the accident was not his fault but he felt as though it was. He believed this 60%. He concluded from the accident that he was incapable of keeping his daughter and grandson safe, especially because another (small) accident had happened when his grandson was in his care. He believed this 80%.
Philip's primary symptoms were upsetting, recurrent memories of seeing the car spinning. His memory was unclear about some details, for example, he had only learned from his daughter about the car spinning twice. When the intrusive memories popped up, he imagined his daughter and grandson being dead, and then tried to push thoughts of the accident out of his mind. Thought suppression made his images pop-up more frequently. Pushing them out of his mind at the worst moments also prevented him from updating these moments in memory with the information that in fact his daughter and grandson were alive.
In addition to the suppression of trauma memories, Philip used a range of other behaviours that maintained his PTSD. Philip still drove but he avoided going on motorways. When he was required to drive on the motorway, he checked the position and speed of other cars very closely and imagined accidents happening. This maintained his conviction that he had to be especially careful to prevent further accidents and, thus, his anxiety about driving. He ruminated about the accident being his fault and his inability to keep his family safe, which maintained these appraisals and caused him to feel sad. He also avoided seeing his grandson to limit the chances of further accidents and limited how often he saw his daughter because he felt guilty about what had happened. The withdrawal from his family prevented him from finding out that they were safe with him. It also contributed to his low mood and because he felt low, he stopped going out and doing the things he used to enjoy such as eating out once a week with his wife. This further maintained his low mood.
According to the case formulation, the main treatment goals according to the Ehlers and Clark model were:
To reduce Philip's sense that he was responsible for the accident.
To change his appraisal that he was incapable of keeping his daughter and grandson safe.
To reduce intrusive re-experiencing and nightmares by (1) identifying information that puts the threatening meanings of the moments represented in re-experiencing into perspective, and (2) updating these moments in memory with this information.
Suppression of intrusive memories.
Rumination about his perceived inability to keep his daughter and grandson safe.
Avoidance of his daughter and grandson.
Avoidance of motorways.
Excessive checking of other traffic when driving.
Activities that were important to Philip before the accident.
Daily activity, including physical activity, to help with depression and pain.
To reduce:To build up: 
Updating the memory for the worst moments of the trauma.
 Reclaiming your life assignments.
Behavioural experiments to reduce thought suppression, avoidance, and excessive checking.
Cognitive restructuring of appraisals of being responsible for the accident and incapable of keeping his family safe.
According to the initial formulation, the following treatment procedures described in Appendix A appeared especially relevant for Philip: 
On the Post-traumatic Stress Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry,) Philip scored 29 in the moderate-to-severe range of PTSD symptom severity. On the Impact of Events Scale-Revised (IES-R; Weiss & Marmar,), Philip scored 71 in the severe range. On the 9-item Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams,), Philip scored 15 in the severe range for depression. On a 7-item measure of generalised anxiety (GAD-7; Spitzer, Kroenke, Williams, & Lowe,), Philip scored 16 in the severe range. Philip completed these questionnaires at assessment and prior to every weekly treatment session. Two weeks prior to session 1, Philip was assessed by an independent assessor who administered the Clinician-Administered PTSD Scale (CAPS; Blake et al.,). The total CAPS severity score was 76.
The therapist met briefly with Philip after the independent CAPS assessment to give him the first two core modules (It All Makes Sense and Reclaiming Your Life) and asked him to complete them before the first session.
The It All Makes Sense module focuses on normalising the symptoms of PTSD and obtaining information that will help the case formulation and develop treatment goals. It includes patient testimonies of their experience of CT-PTSD. It asks clients to describe their flashbacks as well as feelings and physical responses to reminders of their trauma. It encourages them to note any triggers of their trauma memories and the key emotions linked to their trauma, such as fear and shame, and the thoughts linked to these emotions. It then helps patients to identify their safety-seeking behaviours (Salkovskis,). The module explains why PTSD is linked to physiological arousal and guides the patient to elicit the ways in which they cope with their trauma memories, such as through distraction, alcohol, rumination, or suppression. The module includes an example of another client's treatment goals and space for the client to write out their goals for treatment.
The Reclaiming Your Life module educates the patient as to how PTSD can cause patients to stop doing activities they used to do. It then encourages patients to identify what they would like to do again in different areas of their life, such as in their free time and in their home and social life. The module then encourages them to complete a weekly plan in which they identify activities they would like to do and aim to try at least one of these before they meet with their therapist. The module includes a troubleshooting section, which normalises and problem solves potential obstacles to completing the planned activities, such as "I don't have any energy for doing anything" and "It will be too traumatic:I won't be able to cope."
In addition, the therapist gave Philip the Chronic Pain and PTSD module that describes the effects of chronic pain on feelings and behaviours and guides the patient to identify the effects of chronic pain in their life, as well as the effects of PTSD on chronic pain, such as continually reminding the patient of their trauma. The module also explains why it is important to not give up physical activity in response to chronic pain.
Philip arrived at the session having completed all three modules. The therapist reviewed these prior to commencing the 90-min session. Philip had spent 55 min over 2 days completing the It All Makes Sense module. He had spent 200 min over 2 days completing the Reclaiming Your Life module, and this included the time he spent on an activity he had conducted as part of his weekly plan to reclaim his life. He had spent 85 min over 3 days completing Chronic Pain and PTSD.
The therapist's aims for the session were to operationalise Philip's treatment goals in a concrete way, provide a treatment rationale, and to conduct an imaginal reliving of the accident (Foa & Rothbaum,) to identify Philip's emotional hot spots; that is, the worst moments of the trauma, their linked emotions, and personal meanings.
The client's operationalised goals were to: First, to feel happy, which would mean that he could go out more, go shopping with his wife, and feel comfortable driving on the motorway. His second goal was to reduce his nightmares so he could sleep through the night and no longer wake up in a cold sweat. His third goal was to think about his accident without getting upset.
The therapist was able to weave the client's goals into the rationale for revisiting and updating his memory of the accident, since it was hypothesised that his sleep would improve and he would come to terms with his trauma following the process of updating his trauma memory. When presenting the rationale, the therapist drew on information the client provided in the module It All Makes Sense, specifically that he pushed the trauma out of his mind. The client was guided to discover that going over his trauma memory in detail would help him to emotionally process it, and transform it into a regular autobiographical memory without unexpected intrusions. The session contained 30 min of imaginal reliving. Philip rated his distress at 90% and the "nowness" (impression that it is happening now rather than being a memory from the past) as 80%. This was followed by asking the client to identify his worst moments, and what went through his mind in these moments during the trauma. Philip identified two hot spots: The car spinning after the impact and then the car landing on its wheels from what appeared like a great height. Both hot spots meant at the time to him that his daughter and grandson may die or had died. This filled him with fear, sadness, and feelings of guilt. The second also meant to him that he may have broken his back.
To conclude the session, the therapist drew out a weekly plan of Reclaiming Your Life homework with Philip and asked him to note his level of satisfaction out of 100% for each activity. This aimed to target inactivity, which maintained his low mood and contributed to his pain. The client was also given a module, Working on Your Memories, which addresses the consequences of suppressing unwanted memories, how to cope with them, clients are asked to write out a narrative of the trauma in the first person present tense, and write out questions to help identify hot spots. The module also includes a patient's example of their written narrative and hot spots.
Philip had spent 65 min completing Working on Your Memories over 3 days. He had also completed his weekly Reclaiming Your Life plan and had rated most activities as being 70% satisfying. The therapist's plan for this session was to review the client's homework, reinforce what he had learned from being active, and elicit new information to update the meanings of his hot spots. Philip had learned that when he was active his mood improved, and this encouraged him to plan more activities. The therapist then focused on one belief linked to both hot spots: that his daughter and grandson had been harmed or died in the accident. The therapist encouraged Philip to think about what he knew now in relation to his daughter and grandson being alive. Philip was asked to think about the times he had seen them since the accident. He recalled that he had seen them a few times and that on one occasion this had been a happy experience. They had surprised him on Father's Day. Philip could visualise their smiling faces, recall their conversations, and could vividly picture his grandson playing with his mini-football. To update the hot spots in memory, Philip was then asked to close his eyes and recall the moment of impact of his accident, recalling what went through his mind and what he knew now. He ran the worst moment on to include the information that this daughter and grandson were safe and he pictured them at his recent Father's Day celebration.
Again, in conclusion to this session, the therapist and Philip agreed on a weekly plan of Reclaiming Your Life activities for him to complete and to note his level of satisfaction for each activity. As Philip had been avoiding seeing his daughter and grandson because he believed they would be unsafe with him, one of his reclaiming his life activities was set up as a behavioural experiment. This experiment had two purposes: to test his belief that they would be harmed in his presence and to encourage him to re-engage in significant activities he had given up since the trauma, which was to see his family more often.
The client was also given the Updating Your Memories module to further focus on information to update his worst moments. This module includes a rationale for looking at hot spots in detail to update them and examples of how other patients have done this. A space is provided for the patient to describe the situation linked to their hot spot, the thoughts that went through their mind, and their meaning at the time (then), what they know now, and how they can remind themselves of what they know now.
Philip had spent 70 min completing the Updating Your Memories module. Table 1 shows his hot spots and how he had updated them in the module. 
Philip had also completed his weekly Reclaiming Your Life plan and had rated most activities as being 80% satisfying. The therapist planned to review the client's homework; address his rumination about what could have happened and about his inability to keep his daughter and grandson safe, which were maintaining Philip's anxiety; and to address his appraisal that he was responsible for the accident.
Philip was continuing to learn from his homework that being active helped to lift his mood. In comparison to his level of activity before therapy, he was also able to see that being inactive kept him feeling low. Philip had completed his behavioural experiment to test his belief that his daughter and grandson were unsafe with him. He had asked them to come over for lunch on the weekend. Nothing had happened to them in his presence and he re-rated his belief that they would be harmed with him from 80 to 20%. In the session, the therapist guided Philip to discover that ruminating about his inability to keep his daughter and grandson safe triggered intrusive memories of his accident and made him feel anxious. He discovered that when he was ruminating, he was not taking in new information that they were in fact well and that there were many times he had been with them and no danger had occurred. Philip now planned to visualise his daughter and grandson at his Father's Day celebration when he noticed he was ruminating, and to focus on the information that they were well and had survived the accident. Philip was then asked to generate reasons for why the accident had happened. He recalled that the main one was that the driver who had hit their car had fallen asleep. This information did not fit with his belief that he was responsible for the accident, which dropped from 60 to 40% with this information. In addition, the session started to address Philip's checking behaviours when driving. Philip understood that constantly checking the position, speed, and so on of other cars may contribute to his concerns about the dangers of driving and he was willing to do a behavioural experiment that involved (1) driving on the motorway while checking, and (2) driving while dropping the checking behaviour to observe the effect on his levels of anxiety/relaxation and his sense that an accident was going to happen. To conclude the session, the therapist again drew out a weekly plan of Reclaiming Your Life activities with Philip to complete in the following week. The behavioural experiment to drive with and without checking behaviour was also noted on this plan.
The module Guilt and Self-Blame was given to the client. This module helps clients to understand why they feel guilty, what thoughts and thinking errors guilt is linked to, and how to let go of guilt. The client is encouraged to consider all possible causes of their trauma and to rate the contribution of these factors to the occurrence of their trauma in a responsibility pie chart. The module has examples of how other patients have completed specific questions.
The client had conducted his behavioural experiment and rated that he felt 80% relaxed when driving without checking compared to 80% anxious when he drove and checked. He agreed to build on this experience and do more driving without checking until the following session. He had also completed his Reclaiming Your Life tasks. He had spent 90 minutes over 4 days working on the Guilt and Self-Blame module. Philip's self-blame about the accident had dropped from 60 to 40% in the previous session and following this module, it dropped to 0%.
The main plan for this session was to continue updating Philip's hot spots by simultaneously bringing the hot spots and the information gathered in therapy to mind that were relevant to their meanings. First, this was that Philip's daughter and grandson had not died as he had feared. A moment when he had seen them just after the accident sitting on a bench talking and smiling reinforced the updated meaning that they were alive, as did the image of them smiling at his Father's Day celebration. Second, the accident was not Philip's fault as it was the other car that had hit theirs. Third, Philip did not break his back and could walk again after the accident. One problem that made it difficult for Philip to update his hot spots was that he had not been able to see his daughter and grandson during these moments. To facilitate access to his knowledge about what had actually happened while focusing on the trauma, the therapist had the client imagine the trauma from a third-person perspective, watching what was happening to him and his family. The client rated this as 75% distressing with a nowness rating of 80%, but this came down to 0% distressing and 10% for nowness when he also visualised his daughter and grandson in imagery first sitting on the bench smiling and then smiling at his Father's Day celebration.
Homework included driving without checking, teaching his other daughter how to drive, and pleasurable activities. The client was asked to read through the Guilt and Self-Blame module again to consolidate learning about being responsible for the accident.
The client felt much improved and his intrusive memories and nightmares had ceased. He had spent 30 min reviewing the Guilt and Self-Blame module, had continued to drive without checking, and reported he had felt 85% relaxed. This session addressed his belief that he was incapable of looking after his grandson because the car accident was the second time there had been an accident of some sort while Jake had been in his care. Another time, he had held Jake and had fallen. Philip realised that he had been with his grandson many times without any accidents happening and that he thus overestimated the likelihood of accidents. He further realised that the car accident had not been his fault and thus was not good evidence for his ability to look after his family. Furthermore, in both cases Jake had not been seriously hurt.
Homework was again to conduct daily activities, which included seeing his daughter and grandson and rate his satisfaction, to continue with his driving, and to complete the module Blueprint.
The Blueprint module reviews what the client has learned in treatment to help with the prevention of any setbacks or relapse. It asks the client to answer key questions about how their problem started, what kept it going, what they learned in therapy, what their unhelpful and now updated thoughts were, how they could build on what they have learned, and how they could address setbacks if they occurred.
This session focused on reviewing and adding to the client's blueprint and troubleshooting any problems that could arise in the 1-month follow-up period. Philip had spent 60 min completing his Blueprint module. For homework, the client was asked to continue driving, doing activities regularly, and to review his blueprint once per month.
Philip attended a brief follow-up session 1 month after treatment ended. This session contained a probe reliving the accident. Philip's distress and nowness levels were 0%.
Philip's treatment spanned 6 weeks. In his sixth and final session, he scored in the non-clinical range on all symptom measures, PDS: 2, IES-R: 8, PHQ-9: 1, GAD-7: 1. He no longer met criteria for PTSD on the CAPS as assessed by an independent assessor, with a CAPS total score of 4. He no longer met criteria for major depression as assessed by the SCID. At the 1-month follow-up session, he scored 0 on the PDS, IES-R, PHQ-9, and GAD-7. Philip was contacted again 2 months after treatment ended. He maintained his gains and scored in the non-clinical range on all measures, PDS: 4, IES-R: 5, PHQ-9: 4, and GAD-7: 0.