Table 3.

Essential practicalities for the in person and remote updating trauma memories procedure.

In Person & Remote Delivery		Purpose
Give rationale (e.g. to help put the trauma in the past; update the most distressing moments so they no longer feel like they’re happening now)		Increases understanding and engagement with the trauma-focused work.
Elicit and address concerns about reliving or narrative writing		Guides adaptations (e.g. conducting imaginal reliving for a part of the trauma in the first instance rather than the whole story) and informs behavioural experiments to test patient’s concerns, if necessary (e.g. testing predictions that the patient will not be able to stop crying, for example, if they talk through their trauma).
Agree where in the trauma story to start and stop. Generally, start before the main traumatic event and continue until the person felt safer, or the worst parts are over.		Provides clarity for the patient. Stopping reliving or narrative writing at a point where the patient felt safe ensures the patient is not left in moments of heightened distress and helps to demarcate the end of the traumatic event, wherever possible.
Allocate enough time to finish reliving or narrative writing.		This ensures you do not finish at the worst moment of the trauma associated with heightened distress, but rather have time to finish the trauma story at a point where the patient felt reasonably safe.
Be aware of avoidance		Spotting signs of avoidance (e.g. skipping over parts of the trauma) can help you to engage patients with their memory of the trauma in future reliving/narrative writing/updating and ensures that memory updating will be maximally effective for patients.
Identify worst moments (‘hot spots’)		Identifying the worst moments helps identify the worst meanings that are maintaining distress and symptoms.
Take ratings of distress and newness		These ratings show levels of distress and how much the memory seemed as though it was happening now rather than being in the past. When updating information is linked to worst moments, we would expect shifts in these ratings.
Identify updating information		This information will help to make the meanings less threatening and distressing. Information may emerge from knowledge about how the event unfolded (e.g. the outcome was better than expected) or from cognitive restructuring of meanings.
Include updates early		For outcomes that were better than expected (e.g. ‘I survived’; ‘I am still living with my family’) include such updating information in early reliving/narrative writing since this helps to reduce distress and increases hope and motivation.
Insert updates in narrative writing in a different colour		This helps to reinforce the updating information and helps to reduce distress.
Ask for feedback		Helps you to understand the patient’s experience and gives you information to make adaptations, if necessary.
Capture updates in a written flashcard or a photo		This helps patients to easily access updates. Flashcards and photos can be accessed on their phone.
Plan activity (e.g. a reclaiming life or self-care activity) the patient will do after the session		Rewards patients’ efforts, ensures they will move onto a cognitive or behavioural activity that is not trauma-focused, and may reduce opportunities for rumination.
Adaptations for Remote Delivery
Check the patient has privacy		This helps to create a safe place for the patient to engage with the trauma memory.
Elicit any concerns the patient has about remote work		Provides the opportunity to address specific concerns and may likely increase the sense of safety with remote therapy.
For video conferencing sessions, ask the patient to show you their reminders of the here and now		Allows you to refer to specific reminders to bring the patient’s attention back to the here and now if they begin to dissociate.
For video conferencing sessions, routinely give patients the choice of reliving or writing a trauma narrative together		Increases the patient’s sense of control. If writing a trauma narrative, share screen. Patient or therapist can type the narrative. Use your voice and reminders of the here and now if the patient over-engages with the memory.
For telephone sessions, conduct narrative writing		Narrative writing is recommended for phone calls because we think it is important for the therapist to be able to see emotional reactions during reliving which is not possible during a phone call. The narrative can be written in session or for homework and emailed to you in advance of the call. To increase emotional engagement, especially when updating hot spots, ask the patient to read the narrative out loud or read it out to them if they prefer.