Table 1.

CT-PTSD treatment strategies with ICU-PTSD applications

CT-PTSD treatment technique	ICU-PTSD application
Psychoeducation and normalisation	Include information about ICU-PTSD and delirium (if experienced), include information about physical reexperiencing and affect without recollection, and that memory gaps are common due to illness and medication
Individualised case formulation	Include the impact of the ICU environment, and pre-existing experiences (if relevant)
Reclaiming your life	Reframe as ‘rebuilding your life’ for people with significant losses or physical changes, include in each session. Pace according to pain and/or disability
Memory-focused techniques
Updating the trauma memory	Use timelines to provide an overview of ICU stay and/or a written narrative, even though trauma memories are likely to be very disorganised or may contain hallucinations Gaps are acknowledged (‘the next thing I remember is…’) To access meanings of particular hotspots, reliving of these moments is helpful Updates may include better than expected outcome (‘I did not die’), reasons for interventions, intention of staff to help, reasons for being alone, distorted sense of time due to illness, sleep disturbance and lack of day light (see Table 2 for examples) Include updates to make sense of delusions/hallucinations Consult medical notes and/or experts to generate possible updates
Trigger discrimination	Detective work identifying audio/visual/olfactory stimuli or bodily sensations that were present in ICU but are also ubiquitous in the post-ICU environment and act as triggers for trauma re-experiencing Then vs Now discrimination may involve behaving during memory elicitation in ways that were not possible during traumatic moments in ICU (i.e. standing up, moving around)
Site visits	Arrange to visit the ICU by contacting the ward where possible Prioritise visits if trauma memories include delusions or hallucinations Use virtual site visits and video tours of ICUs to prepare for site visits or if you cannot return in person
Working on meanings of the trauma and its aftermath	Common themes include: Beliefs about losing one’s mind – use psychoeducation, research, surveys and behavioural experiments Belief about permanent physical change – acknowledge and mourn losses, increase focus on what has not changed; photo and video feedback and surveys to address distortions about severity of changes in appearance/function Belief about permanent psychological change – identify and challenge loss of confidence in one’s own abilities (‘I can no longer be trusted to look after my family’) Health anxiety and beliefs about vulnerability to illness – use guided discovery and medical advice to calculate accurate risk probabilities; drop scanning of body sensations/signs of illness; behavioural experiments Survivor guilt – address beliefs about perceived responsibility and inequity, consider alternative meanings, use surveys Beliefs about mistreatment and mistrust of healthcare professionals – listen and empathise, address misappraisals, facilitate communication with hospital, reviews costs and benefits of holding on to anger, reduce rumination Address generalised appraisals re: trust by reviewing evidence, surveys and research
Address maintaining behaviours/cognitive strategies	Increase awareness of strategies, e.g. internal scanning, over-protectiveness, rumination, substance use and their role in maintaining PTSD Use behavioural experiments to test effects of strategies, including experiments in reducing and dropping strategies and experiments to modify appraisals that motivate the behaviours