This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with psychological trauma, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is not written for the people concerned: if you are in danger today, contact your country's emergency services or a victim support line.
1. The programme at a glance
Indication. Established post-traumatic stress disorder in adults, after one or several traumatic events, in a person who is safe today.
Reference model. Trauma-focused cognitive behavioural therapy: repeated work on the memory, systematic lifting of avoidance, and modification of the meanings that settled in afterwards — about oneself, about others, about the world.
Format. Twelve 90-minute sessions. The length is part of the protocol: an imaginal exposure does not fit into fifty minutes. One to two sessions a week. Two booster sessions, at one month and at three months.
Mechanism targeted. Allowing the memory to become a memory: something that belongs to the past, that can be told in full, and that no longer triggers the alarm. That requires going back to it, and it does not happen by talking about it from a distance.
| Session |
Focus |
Session output |
| 1 |
Assess and make safe |
Safety checked, baseline measures |
| 2 |
Understand and decide |
Model explained, method chosen |
| 3 |
The account, first time |
First full account recorded |
| 4 |
The hot spots |
The three hardest moments isolated |
| 5 |
Going out |
First in vivo exposure |
| 6 |
Continuing both |
Account deepened, three situations resumed |
| 7 |
Guilt |
Responsibility redistributed in writing |
| 8 |
Shame |
What is hidden, said once |
| 9 |
Trust and danger |
Safety rules revised |
| 10 |
Anger |
What is just, and what it costs |
| 11 |
Taking things back |
What the trauma took, taken back |
| 12 |
Review, relapse, maintenance |
Written plan, measures repeated |
What the person takes away. Seven printable worksheets, listed in section 40: my record, what I avoid, my account, what I tell myself, my situations, the corner for those close to me, my plan for what comes next.
What distinguishes this programme from the other manuals on this site. Three things. The section on present safety, which can suspend the whole programme. The refusal of a mandatory stabilisation phase, explained in section 39. And the three sessions devoted to guilt, shame and anger, which do not feature in the most widespread exposure protocols.
2. Before you begin
Who this programme is for
This text is written for psychologists, psychiatrists, psychotherapists and doctors trained in cognitive behavioural therapy, with experience of psychological trauma and access to supervision. It assumes that you can hear the detailed account of a rape, a fatal accident or a war scene, several times over, without changing the subject.
It is written neither for the people concerned nor for those close to them.
The four preliminary decisions
Is the person safe today? That is section 10, and it is the only question that can stop the programme. Ongoing domestic violence, the perpetrator among those close to them, an occupational exposure that continues, imminent legal proceedings: the approach changes.
Is there current suicide risk? It is common in this indication, it is asked about explicitly, and it is addressed first.
Is there substance use that prevents the work? Alcohol and sedatives are massively used to sleep and to avoid. Section 9.
And which trauma are we talking about? A single event in an adult, repeated occupational exposure, or violence suffered during childhood do not call for the same format. Section 34.
What this programme does not treat
It does not treat a situation of present danger. Section 10.
It does not treat severe substance use disorder on its own. When alcohol use is massive, it is treated first or in parallel, within an appropriate setting.
It does not treat acute stress in the days following the event. Most early reactions resolve on their own; section 12 says what immediate intervention does and does not do.
It does not treat ordinary grief. Traumatic grief has a section of its own — section 35 — and ordinary bereavement belongs to another manual.
What this programme is not
It is not a debriefing. Section 39 says why systematic debriefings were abandoned.
It is not a therapy that bypasses the memory. Every approach with data behind it requires returning to it, in one form or another. This manual describes one; section 13 says what the others are worth.
It is not preparation for an expert assessment or for legal proceedings. Those two functions are incompatible with care, and section 10 says how to keep them separate.
How to use it
Read the whole thing before the first session, in particular sections 6, 10, 30, 32 and 33: the model, safety, imaginal exposure, cognitive work, and dissociation. These are the five places where treatment tips one way or the other.
Each session is described on the same framework: the aim, the sequence of steps, what you say, the common errors, and the criterion for moving on.
Three warnings specific to this presenting problem.
The therapist's own avoidance is a major limiting factor. Many treatments get bogged down because the clinician never asks for the detail. If by session 6 you still do not know exactly what happened, the protocol has gone off the rails.
The patient will not ask to do this work. They will ask to get better without going back to it. That is legitimate, and the honest answer is that it does not work.
And supervision is not optional. Hearing these accounts has a cost, it is documented, and it is dealt with like everything else: by talking about it. Section 41.
3. Four presentations not to be confused
Four situations present themselves after a serious event, and they do not call for the same approach.
1. The normal reaction
What you observe. In the days and weeks that follow, images that come back, disturbed sleep, irritability, heightened vigilance, an urge to avoid what recalls the event. That is the rule, not the exception.
What points to it. The trajectory. The majority of these reactions decline spontaneously within a few weeks.
What that implies. Information, support, sleep, gradual resumption of activities, and a review at one month. No trauma-focused treatment, no debriefing.
2. Post-traumatic stress disorder
What you observe. Beyond one month, an established picture: re-experiencing, organised avoidance, lasting changes in mood and thinking, and hyperarousal.
What points to it. The persistence, the organisation of avoidance, and the impact on functioning.
What that implies. It is the programme described here.
3. Adjustment disorder
What you observe. Clear distress after a difficult event, but without the full picture: little or no intrusive re-experiencing, no organised avoidance of reminders.
What points to it. The event is not necessarily traumatic in the strict sense, and the picture is dominated by sadness, anxiety or difficulties in functioning.
What that implies. Problem-solving support, not trauma-focused treatment.
4. Depression after the event
What you observe. Mood, anhedonia, global guilt and slowing dominate. Re-experiencing is absent or in the background.
What points to it. The absence of avoidance of specific reminders, and the presence of permanent sadness rather than an alarm.
What that implies. Depression is treated first. Section 9.
The three other things to have ruled out
A head injury. Frequently associated with accidents and assaults, and it changes the interpretation of memory and concentration difficulties.
A psychotic disorder. Very intense re-experiencing can mimic one, and the reverse too. The question that helps: is the experience recognised as a memory?
And present danger. Hypervigilance in someone who is genuinely under threat is not a symptom. Section 10.
The three sorting questions
"Do images or sensations come back without your calling them up?" The central question: it isolates re-experiencing.
"What do you avoid because of this?" It isolates organised avoidance, which is the engine.
"For how long, and is it decreasing?" It separates the normal reaction from the established disorder.
4. The four symptom groups
Re-experiencing
What you observe. Intrusive memories that impose themselves, images, sounds, smells, bodily sensations. Nightmares. And sometimes states in which the person behaves as though the event were happening again.
What needs to be made clear. The difference between remembering and reliving. An ordinary memory is located in the past; re-experiencing is lived in the present, and it is that quality which makes it unbearable.
What triggers it. Internal reminders — a position, a pain, an emotional state — and external ones — a noise, a light, a smell, a date, a place. Many patients believe them random until they record them.
Avoidance
What you observe. Avoidance of thoughts and sensations connected with the event, and avoidance of external reminders: places, people, conversations, activities, objects, films, the news.
What you need to know. It is the engine of the disorder. It is also what explains why a patient gets better in the first days of a badly conducted treatment: they have been helped to avoid more efficiently.
The forms that get missed. Never talking about the event, not reading what is written about it, changing the subject, filling every hour, drinking to sleep, and telling the story while systematically skipping three minutes.
Negative changes in thinking and mood
What you observe. An inability to recall parts of the event. Persistent negative beliefs about oneself, about others, about the world. Distorted attribution of causes — "it is my fault", "I should have". A lasting negative emotional state. Loss of interest, a feeling of detachment, and difficulty feeling positive emotions.
What matters most in practice. Guilt, shame and anger. They are under-treated, they do not yield to exposure alone, and they account for a good share of non-response. Sessions 7, 8 and 10.
Hyperarousal
What you observe. Irritability and outbursts of anger, reckless or self-destructive behaviour, hypervigilance, startle responses, concentration difficulties, and disturbed sleep.
What misleads. Irritability is often the only symptom reported by those close to the person, and it is rarely connected to the trauma by the patient themselves.
Dissociation
It is not a group in its own right but it changes how treatment is conducted: depersonalisation, derealisation, absences, slowing, the sense of being elsewhere. Section 33.
5. What maintains the disorder
Three mechanisms, and the treatment targets all three.
Avoidance
It prevents the memory from being processed and it prevents predictions from being disconfirmed. Every avoidance brings immediate relief and lasting reinforcement of the disorder. It is the central mechanism.
What it covers. External avoidance — places, people, conversations. Internal avoidance — not thinking about it, distracting oneself, keeping busy, drinking. And avoidance within the account itself, which is the hardest to spot: the person tells the story, tells a great deal of it, and always skips the same passage.
The badly filed memory
The traumatic memory differs from others: it is fragmented, highly sensory, without clear temporal anchoring, and it is triggered by elementary cues rather than by deliberate recall. Hence the sense that it is happening again.
What the treatment does with it. We do not try to erase it. It is told in full, several times, until it has a beginning, a middle and an end, and a date.
The meanings
What the event made the person believe. "I am soiled." "I did nothing." "You cannot trust anyone." "If I lower my guard, it will happen again." "I should have known."
What matters. These meanings are not errors to be corrected by logic. They are worked on by going back to what the person knew at that precise moment, to what they could decide, and to what they would ask of someone else in the same situation. Section 32.
The complete circle
A reminder triggers re-experiencing. The re-experiencing is lived as present danger. The danger justifies avoidance and hypervigilance. Avoidance prevents correction. The meanings harden. And the next reminder triggers more.
That is the diagram you draw in session 2.
Frequently asked questions
Should you wait until the patient is "stabilised"?
A brief preparation is useful: explaining, obtaining agreement, checking safety, planning the closing down. Several months of stabilisation has not demonstrated its necessity and it delays a treatment that works. See section 39.
The patient does not want to tell the story.
That is expected: it is the symptom. Explain why it is necessary, offer the written account as an alternative, start with a fragment, and let them choose the starting point. What is not negotiable is that it is returned to, one way or another.
What do you do if they dissociate during the account?
You anchor, eyes open, feet on the floor, you name the date and the place, and you take it up again in thirty-second sequences. Section 33.
And if they have no memory of the event?
You work with what they do remember, before and after, and with the sensory reminders. You never try to recover a missing memory: see section 39.
There are several traumas. Which one to start with?
The one producing the current intrusions, which is not always the most serious. Then three to five index events. Section 34.
The patient is involved in legal proceedings.
You can treat, and you prepare the key dates as planned exposures. You do not combine the roles of therapist and expert witness. Section 10.
Can telling the story make things worse?
An account conducted without preparation, without repetition, without an update and without closing down can make things worse. That is precisely why the procedure in section 30 is set out in detail.
Is EMDR equivalent?
It has efficacy data in this indication and it features in the guidelines. The debate concerns the mechanism, not the existence of an effect. Section 13.
How many sessions?
Twelve for a single event, often eight to sixteen. Twenty to thirty for repeated trauma.
The patient drinks to sleep.
Name it as an avoidance, treat the sleep, and coordinate with the doctor. Massive use is treated first.
They are better but their partner says life is unbearable.
Look at irritability: it is often the last symptom to move, and it is almost never reported by the patient. Session 10 and section 36.
The nightmares persist while everything else improves.
That is frequent and it has a treatment of its own, psychological and sometimes pharmacological. Section 14.
Should exposure sessions be recorded?
It is useful and it is not compulsory. Where there is a situation of violence or legal proceedings, the question of storage arises seriously. Section 40.
The patient says they have already had ten years of therapy with no result.
Ask what was done exactly. In the great majority of cases, the memory was never addressed in detail.
And if I can no longer bear these accounts?
That is a recognised and expected signal. Supervision, limiting the number of such cases seen in parallel, and referral if necessary. It is not a professional failing.