UOA04-02: Creating an Effective Psychological Therapy for Post-Traumatic Stress Disorder (PTSD) and Showing that Another Commonly Given Treatment is Ineffective
Submitting InstitutionUniversity of Oxford
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
Research by Anke Ehlers' group at Oxford University has had major impacts
on the treatment and outcome of post-traumatic stress disorder (PTSD). The
group developed and validated a psychological model of the key factors
that lead to PTSD. A novel form of cognitive therapy (CT) that
specifically targets these psychological processes was then developed.
Randomised controlled trials showed that CT is highly acceptable and
highly effective in recent-onset and chronic PTSD, in adults and children.
It is one of the recommended first-line interventions in the NICE PTSD
guideline. It has been made widely available in the NHS through Improving
Access to Psychological Therapies (IAPT), and is being disseminated
in other countries. Separate research by Ehlers showed that a previously
leading treatment, debriefing, was ineffective, leading to it not
being recommended by NICE.
PTSD is a disabling condition that may develop after traumatic events
such as disaster, interpersonal violence, severe accidents or war zone
experiences. The 2007 Adult Psychiatric Morbidity Survey suggests that
2-3% of UK adults suffer from PTSD (1-1.5 million). PTSD interferes
severely with the individual's relationships with others and ability to
work. If untreated, it can lead to secondary mental and physical health
problems, and an increased risk of suicide.
Developing a cognitive model of PTSD
In the first phase of research in the late 1990s, Anke Ehlers and
colleagues at Oxford developed a model of PTSD (Ehlers & Clark, 2000)
that accounts for the development and persistence of the condition in
individuals who have experienced traumatic events by a combination of
three factors: 1) excessively negative appraisals, i.e. interpretations
that the trauma and/or its consequences indicate a current threat, 2) a
characteristic disturbance in autobiographical memory leading to unwanted
re-experiencing of distressing moments of the trauma, and 3) problematic
behaviours and cognitive strategies that prevent the appraisals and memory
disturbance from changing, such as excessive precautions and rumination
about the trauma. Experiments and prospective studies strongly supported
the model (e.g. Ehlers et al, 1998).
Developing an effective cognitive treatment for PTSD
In the second phase, the model was used to generate a specific cognitive
therapy (CT) for PTSD which sought to correct the three psychological
factors identified in the model. After pilot studies, Ehlers' group
conducted the first two randomised controlled trials (RCTs) (Ehlers et al,
2003, 2005) of the novel CT, and showed that it is effective in treating
chronic PTSD and as an early intervention to prevent the development of
chronic PTSD. Subsequent RCTs, by Ehlers' group, and others (e.g. Duffy et
al, BMJ 2007; 334:1147-50; Smith et al, J Am Acad Child Adol
Psychiatry 2007; 46:1051-1061), confirmed the effectiveness of the
treatment in adults and children, leading to recovery in over 70% of
cases. The treatment is very acceptable to patients, with lower dropout
rates than have been reported for other psychological trauma-focused
In addition to the evidence from RCTs, the value of CT for PTSD has been
shown in two naturalistic settings. First, Ehlers' group were asked to
train clinicians in Northern Ireland in the treatment in the first few
months after the 1998 Omagh bomb. They showed that it achieved results as
good as those in the Oxford RCTs when delivered to unselected individuals
who developed PTSD as a consequence of their experiences on the day of the
bombing. Second, and as a result of its success in Omagh, CT for PTSD was
an integral part of the NHS response to the 2005 London bombings. Again,
along with other trauma-focused psychological treatments, it achieved
effect sizes at least as good and as durable as in the RCTs (Brewin et al,
Finally, recent work shows that the treatment also has very large effects
in routine NHS clinical care, with 65% of PTSD patients achieving
clinically significant improvement (see Section 4).
`Debriefing' is not effective against PTSD
As well as developing the highly effective treatment for PTSD, Ehlers and
her colleagues at Oxford University also showed that an intervention that
was commonly used in the immediate aftermath of trauma events is not
effective. `Psychological debriefing' was often provided to both civilian
and military personnel after major events, but had rarely been tested
properly, i.e. in an RCT. Mayou et al (2000) randomised road
traffic accident victims shortly after the event to debriefing or no
intervention, and studied the long-term effects on PTSD symptoms. The
group who did not receive debriefing had a greater reduction in
symptoms than those who did, suggesting that debriefing was not only
ineffective but might even be harmful, by retarding natural recovery.
References to the research
Ehlers A, Clark DM (2000). A cognitive model of posttraumatic stress
disorder. Behaviour Research and Therapy, 38, 319-345. DOI:
Paper outlining the psychological model of PTSD and treatment approach
developed by the Oxford team. Scopus citations 4/9/13: 1174.
Ehlers A, Mayou RA, Bryant B (1998). Psychological predictors of chronic
PTSD after motor vehicle accidents. Journal of Abnormal Psychology,
107, 508-519. DOI: 10.1037//0021-843X.107.3.508. Prospective study
supporting key assumptions of the model. Citations: 513.
Ehlers A, Clark DM, Hackmann A, McManus F, Fennell MJ, Herbert C, Mayou
RA (2003). A randomized controlled trial of cognitive therapy, a self-help
booklet, and repeated assessment as early interventions for PTSD. Archives
of General Psychiatry, 60, 1024-1032. DOI:
10.1001/archpsyc.60.10.1024. The first randomised controlled trial of
CT for PTSD. Citations: 164.
Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M (2005). Cognitive
therapy for PTSD: development and evaluation. Behaviour Research and
Therapy, 43, 413-431. DOI: 10.1016/j.brat.2004.03.006. The
second randomised controlled trial. Citations: 145.
Brewin CR, Fuchkan N, Huntley Z, Robertson M, Thompson M, Scragg P,
d'Ardenne P, Ehlers A (2010). Outreach and screening following the 2005
London bombings: usage and outcomes.
Psychological Medicine, 40, 2049-2057. DOI:
10.1017/S0033291710000206. Shows that CT for PTSD, given as part of
the NHS Trauma Response Programme for those affected by the London 2005
bombings (together with other trauma-focused psychological treatments),
was as effective as it is in clinical trials. Citations: 8.
Mayou RA, Ehlers A, Hobbs M (2000). Psychological debriefing for road
traffic victims: three year follow-up of a randomized controlled trial. British
Journal of Psychiatry, 176, 589-593. DOI: 10.1192/bjp.176.6.589. Randomised
controlled trial finding poor long-term outcome after an early
intervention commonly in use and advocated at the time. Citations:
Major grants supporting the research
• Wellcome Principal Research Fellowship to Ehlers.
• Two consecutive Wellcome programme grants: `Cognitive processes in the
maintenance and treatment of anxiety disorders' (co-PI, David Clark) from
1993-8 and 1998-2003, total £1.5M.
• Wellcome Project Grant , `Psychological consequences of road traffic
accidents in children', 1993-2000 (£139K).
Key colleagues for the underpinning research included David Clark,
Richard Mayou and Ann Hackmann.
Details of the impact
The research described above has had, and continues to have, a major
impact on the treatment of PTSD in the NHS and overseas.
NICE clinical practice guidelines on the treatment of PTSD (see
Section 5, Sources 1-3)
The National Institute for Health and Care Excellence (NICE) has issued
guidelines for optimal treatment of PTSD. In the current version (NICE,
2005), Ehlers' CT for PTSD, together with other trauma-focused cognitive
behavioural therapy programmes, is one of the first-choice options. This
guidance was confirmed by a NICE evidence review in 2011, and is restated
in the 2012 NICE PTSD care pathway. Conversely, in light of the negative
findings from the Mayou et al (2000) trial (along with similar findings
from Bisson in Cardiff, and others) NICE does not recommend the
use of psychological debriefing immediately after a trauma. Instead,
watchful waiting is recommended for the first few weeks, followed by
Ehlers' CT, or another trauma focused psychological treatment, if natural
recovery does not occur. Thus, Ehlers' research has had two positive
impacts: providing a novel and effective treatment for PTSD, and avoiding
provision of an ineffective one.
CT for PTSD disseminated within the English NHS (see Section 5,
The Improving Access to Psychological Therapies (IAPT) programme,
which started in 2008, aims to greatly increase the availability of NICE
recommended psychological treatments for anxiety disorders and depression
by training up to 6,000 new psychological therapists by 2015 and employing
them in specialised treatments services. CT for PTSD is included in the
national training curriculum for IAPT (high intensity) therapists and has
been taught on 21 IAPT high intensity therapy courses. To date around
2,200 IAPT therapists have learned the treatment, and are delivering it in
over 130 local services. A further 900 IAPT therapists will be trained in
the treatment in next two years. In addition, CT for PTSD is taught on
other post-graduate diploma courses in psychological therapies (at least
1100 therapists trained in the treatment approach on these courses since
2008) and on clinical psychology courses.
CT for PTSD disseminated to victims of trauma in Northern Ireland (see
Section5, Source 7)
As noted in Section 2, Ehlers' CT proved effective for survivors of the
Omagh bombing. Presentation of the results to the Northern Ireland Office
by the Oxford/Omagh team led to funding to create the Centre for Trauma
and Transformation in Omagh. This provided victims of numerous civil
conflict events with CT for PTSD until 2011, when its activities were
mainstreamed with the creation of a specialist diploma in CT for PTSD run
from Queens University, Belfast. The diploma aims to spread CT for PTSD
skills to multiple clinical settings in Northern Ireland.
International recognition and dissemination of CT for PTSD (see
Section 5, Sources 8-10)
The outstanding results obtained with Ehlers' CT for PTSD have led
clinicians and health service commissioners from many countries to request
training. Since 2008, Ehlers and her team have provided workshops on the
treatments in Australia, Denmark, Finland, France, Germany, Japan, Norway,
Poland, Sweden and USA. A therapist manual has been published in German
(Hogrefe; over 4000 sales since 2008). The manual is also available in
Japanese. The treatment is currently being delivered in a large primary
care intervention study in Stockholm. Ehlers received the German
Psychology Prize 2013 (jointly awarded by 4 academic and professional
psychology and psychotherapy organisations) in recognition of the impact
of her PTSD research and treatment.
Clinical service design
The IAPT programme is the world's largest programme for disseminating
evidence based psychological treatments. A key feature in the success of
the programme has been the creation of an outcome monitoring system that
is able to collect outcome data on almost everyone (>90%) who has any
treatment. This system is based on the session-by-session outcome
monitoring system that the Oxford based PTSD team pioneered in their
initial work in Northern Ireland.
Sources to corroborate the impact
NICE clinical practice guidelines on the treatment of PTSD
- NICE (2005). Post-traumatic stress disorder (PTSD): The management of
PTSD in adults and children in primary and secondary care (Clinical
Guideline 26). London, UK: National Institute for Clinical Excellence. http://www.nice.org.uk/nicemedia/pdf/CG026fullguideline.pdf
[Accessed 4/10/13]. Includes: 'All PTSD sufferers should be offered
a course of trauma-focused psychological treatment (trauma-focused
cognitive behavioural therapy* or eye movement desensitisation and
reprocessing). [category A evidence]. Also: `...debriefing
should not be routine practice...' [category A
evidence]. * includes Ehlers' CT for PTSD.
- The NICE Evidence review 2011 confirmed that the above guidelines
remain in force: http://guidance.nice.org.uk/CG26/ReviewDecision/pdf/English
- The NICE care pathway for PTSD (2012): http://pathways.nice.org.uk/pathways/post-traumatic-stress-disorder
CT for PTSD disseminated within the English NHS
- Department of Health (2008). IAPT Implementation Plan: Curriculum for
High Intensity Workers. Available at www.iapt.nhs.uk/silo/files/implementation-plan-curriculum-for-high8208intensity-therapies-workers.pdf
[Accessed 4/10/13]. Page 13 states that students need to be
trained in at least 1 of 3 the treatment programmes for PTSD described
in the 2007 competency framework [see next item], which includes
Ehlers' CT. Page 17 describes 16 competencies that students need to
develop in order to treat PTSD, six of which are specifically derived
from Ehlers' CT programme.
- Roth AD, Pilling S (2007). The competencies required to deliver
effective cognitive and behavioural therapy for depression and anxiety
disorders. Department of Health. Available at http://www.ucl.ac.uk/clinical-psychology/CORE/CBT_Competences/CBT_Competence_List.pdf
[Accessed 4/10/13]. Pages 51-57 detail the competencies required for
Ehlers' CT for PTSD.
- Ehlers A, Grey N, Wild J, Stott R, Liness S, Deale A, Handley R,
Albert I, Cullen D, Hackmann A, Manley J, McManus F, Brady F, Salkovskis
P, Clark DM (2013). Implementation of cognitive therapy for PTSD into
routine clinical care: Effectiveness and moderators of outcome in a
consecutive sample. Behaviour Research and Therapy. DOI:
10.1016/j.brat.2013.08.006 Describes effectiveness of CT for PTSD in
a consecutive NHS sample, after a wide range of traumas and concluded
"CT-PTSD was well tolerated and led to very large improvement in PTSD
symptoms, depression and anxiety".
CT for PTSD disseminated to victims of trauma in Northern Ireland
- Establishment of Northern Ireland Centre for Trauma and
`Established in 2002...over a 12 year period using trauma focused
cognitive therapy...the Centre...extended its provision to the wider
regional population [over 700 referrals].' NB: Link not currently
active; webpage archived and available on request.
International recognition and dissemination of CT for PTSD
Letters available on file from:
- Dr Michael Duffy (Queens University, Belfast) confirming the crucial
contribution of the work of Ehlers' team to the creation of the Centre
for Trauma and Transformation in Omagh, and the continuing work in
training Northern Ireland clinicians in CT for PTSD. Includes: `the
major impact of Professor Anke Ehlers' research on the training of
mental health clinicians....and the consequential provision of
evidence-based psychological treatments.... In 2013...the new Victims
and Survivors' Service...has specifically requested more extensive
training in the Ehlers Clark PTSD model for therapists across the
- Lord Richard Layard (London School of Economics and Political
Sciences) confirming the importance of the data collection model
developed for the Omagh study for the Improving Access to Psychological
Treatments programme: "the session-by-session monitoring developed on
the Omagh cohort has been critical to the success of IAPT and the
international acclaim it has achieved".
- Professor Lars-Goran Öst (Stockholm University, Sweden) confirming the
dissemination of CT for PTSD in Sweden.