Brief CBT for acute stress disorder

1. Introduction

Version followed: the Westmead/UNSW protocol of Richard Bryant and colleagues as published in the trial reports. The main template is the prolonged exposure plus anxiety management arm of Bryant, Sackville, Dang, Moulds & Guthrie (1999): five weekly, individual 90-minute sessions starting within about 2 weeks of the trauma. Named variants are noted where they differ: the 1998 CBT package (education, progressive muscle relaxation, imaginal exposure, cognitive restructuring, graded in vivo exposure), the 2003 mild traumatic brain injury trial (same package), the 2005 CBT plus hypnosis trial (six sessions), the 2008 trial comparing exposure with cognitive restructuring (five 90-minute sessions), and the six-session manual that ISTSS holds for its members. The full treatment chapters of Bryant & Harvey (2000), Acute Stress Disorder: A Handbook of Theory, Assessment, and Treatment (ch. 7, Treating acute stress disorder; ch. 8, Treatment obstacles), and the ISTSS manual are not drawn on. Session details below therefore come from the trial method sections. [source: Bryant et al. 1999; Bryant et al. 2003; ISTSS manual page; AUT library record of the Bryant & Harvey (2000) table of contents]

Brief CBT for acute stress disorder (ASD) is a short, early, trauma-focused CBT course. It is given only to adults who meet ASD criteria (or have clinically important acute PTSD symptoms) in the first month after a trauma. It is not offered to everyone who has been exposed. Its aim is to prevent chronic PTSD. The core idea of change: people with ASD are at high risk of chronic PTSD because they avoid the trauma memory and reminders and hold threat-laden beliefs about the event and their reactions. Supported, prolonged imaginal reliving of the memory, followed by testing those beliefs against the evidence and graded return to avoided situations, lets fear reduce and the memory be processed before avoidance becomes fixed. Bryant's group concluded that exposure "may be the most critical component" (1999). In the 2008 trial, exposure outperformed cognitive restructuring delivered alone. [source: Bryant et al. 1999 abstract; Psychiatric News 2008 report of Bryant et al. 2008; CEBC profile]

2. Framework

Format. Individual, face to face, weekly. Five sessions of about 90 minutes, delivered by clinical psychologists working from a manual, with weekly supervision of adherence and case notes. Some later versions use six sessions (the 2005 hypnosis trial and the ISTSS manual). [source: Bryant et al. 1999; Bryant et al. 2003; CEBC; ISTSS]

Timing. The trials started treatment within 2 weeks of the trauma, in people who met ASD criteria. ASD covers reactions from 2 days to 4 weeks after the event. NICE NG116 recommends individual trauma-focused CBT for adults with ASD or clinically important PTSD symptoms within 1 month of a trauma, and recommends against psychologically focused debriefing for everyone exposed. [source: Bryant et al. 1999; CEBC] [uncertain: the NICE points are given as generally known and should be checked against the guideline]

Session map (1999 exposure plus anxiety management arm).

[source: Bryant et al. 1999 method]. The paper is internally inconsistent about whether exposure ran in all sessions or only in sessions 2–5. Sessions 2–5 is the version followed here. [uncertain]

Variant maps.

• Exposure only (1999 PE arm): session 1 is education plus the exposure rationale, with no anxiety management. Imaginal exposure runs from session 2, each time followed by cognitive restructuring; in vivo exposure and relapse prevention come in sessions 4–5; supportive counselling time is added so the two arms are matched for therapist time. [source: Bryant et al. 1999]
• 1998 / 2003 CBT package: education, progressive muscle relaxation, imaginal exposure (about 50 minutes per session plus daily homework), cognitive restructuring and graded in vivo exposure, over five 90-minute sessions. The 2003 report does not map these components to sessions. [source: Bryant et al. 2003]
• 2008 trial: exposure arm = vivid verbal reliving with all perceptual and emotional detail, then imaginal and in vivo exposure homework, with relapse prevention in the final session. Cognitive restructuring arm = monitoring and challenging thoughts with Socratic questioning, probabilistic reasoning and evidence-based thinking, plus homework and relapse prevention. [source: Psychiatric News 2008]
• CBT plus hypnosis (2005): six sessions, with a hypnotic induction used to help the client engage in imaginal exposure. [source: CEBC] [uncertain: the hypnosis procedure]

Phase goals and movement criteria.

• Phase 0, assessment (before session 1): confirm ASD (the developers' instruments are the Acute Stress Disorder Interview and the Acute Stress Disorder Scale, appendices of Bryant & Harvey 2000; not reproduced here). Establish physical safety and current threat. Screen for the trial exclusions: current suicidal ideation; psychosis, organic mental disorder or substance abuse; and, in the 1999 trial, brain injury (the 2003 trial included mild traumatic brain injury). Move on when ASD is confirmed, the client is safe, and no exclusion applies or it has been managed. [source: Bryant et al. 1999; Bryant et al. 2003; AUT TOC]
• Phase 1, skills and education (session 1): aim for normalised understanding and a coping toolkit. Move on when the client understands the rationale and has practised the skills at least once. Skills do not need to be mastered first. [synthesis]
• Phase 2, exposure and restructuring (sessions 2–5): aim to reduce fear and avoidance of the memory and to correct threat appraisals. Add in vivo work (session 4) once imaginal exposure is under way and the client can stay engaged with the memory for the session without dissociating or leaving. [source: Bryant et al. 1999 for timing; synthesis for criterion]
• Phase 3, relapse prevention and ending (session 5): aim for a self-management plan. After treatment, reassess with a PTSD measure. If PTSD criteria are met after the first month, move to a full trauma-focused PTSD course. [synthesis; in the 2008 trial wait-list clients were reassessed at 6 weeks]

3. Guiding principles

• Target, don't blanket. Treat people who meet ASD criteria, not everyone exposed. In practice: screen and monitor most survivors; offer this course to those at high risk. [source: CEBC; Bryant et al. 1999]
• No single-session debriefing in its place. In practice: do not run a one-off "tell me everything" session for all exposed people. Bryant & Harvey give debriefing its own chapter, separate from treatment. [source: AUT TOC] [uncertain: chapter content]
• Exposure is the engine. In practice: protect the 50 minutes of reliving in every session from session 2 on; do not let education or supportive talk crowd it out. [source: Bryant et al. 1999; Psychiatric News 2008]
• Engage with the emotion, not just the facts. In practice: ask for sensory and emotional detail and the feelings in the moment; a flat factual account is not the procedure. [source: Bryant et al. 1999; Psychiatric News 2008]
• Restructure after exposure. In practice: use the beliefs that surfaced during reliving as material for evidence-testing in the same session. [source: Bryant et al. 1999]
• Daily practice between sessions. In practice: set daily homework (skills, then exposure) and review it at the start of every session. [source: Bryant et al. 1999]
• Structured, time-limited, manualised. In practice: keep to the five-session plan and session agenda; use supervision to check fidelity. [source: Bryant et al. 1999; Bryant et al. 2003]
• Trained CBT clinicians only. In practice: do not deliver this without grounding in general CBT and exposure, plus supervision. [source: ISTSS]
• Supportive counselling is not enough. In practice: warmth and problem-solving alone do not reduce avoidance. Once the client is safe and stable, move to exposure. [source: Bryant et al. 1999; Bryant et al. 2003]
• Safety and stability first. In practice: suicidality, psychosis, substance misuse, organic conditions and ongoing danger come before early exposure. [source: Bryant et al. 1999 exclusions; synthesis for ongoing danger]
• Expect that the most distressed and the most dissociative may need adaptation. In practice: watch the people with the most severe ASD and anxiety most closely for dropout. Have strategies ready for dissociation that blocks engagement. [source: Bryant et al. 1999 discussion]
• Hand over if chronic PTSD develops. In practice: reassess at the end; refer on for full trauma-focused PTSD treatment if needed. [synthesis]

4. Intervention inventory

The published trial reports name the components and when each is used. They do not give scripts. Step-by-step detail beyond the named components is marked [synthesis]. It follows standard CBT practice for the stated component and does not reproduce Bryant's manual. [source for component list and timing: Bryant et al. 1999; Bryant et al. 2003; Psychiatric News 2008]

4.1 Diagnostic assessment and suitability screen

• Purpose / when: before session 1, to confirm ASD and rule out the trial exclusions. Treatment works best begun within about 2 weeks of the trauma. [source: Bryant et al. 1999]
• Steps: (1) Establish the event, its date and current safety: is the threat over, are there injuries, is there ongoing contact with the perpetrator? (2) Assess ASD symptoms with a structured interview. Bryant & Harvey's Acute Stress Disorder Interview, or the self-report Acute Stress Disorder Scale, covers dissociation, re-experiencing, avoidance and arousal; items are not reproduced here. (3) Screen for current suicidal ideation, psychosis, organic mental disorder, substance misuse and head injury (posttraumatic amnesia, loss of consciousness). (4) Note legal or compensation proceedings; in the 1999 trial, legal advice stopped two people from attending follow-up. (5) Agree the five-session contract and the daily homework expectation. [source: Bryant et al. 1999; Bryant et al. 2003; AUT TOC; steps 1 and 5 synthesis]
• Example language (illustrative): "What you're going through is common in the first weeks after something like this. Some people's reactions settle on their own, and some get stuck. The questions I'm asking help us see which way yours is heading."
• Watch for: severe dissociation, suicidal thoughts, heavy alcohol use to sleep, signs of brain injury. Each needs management or referral before exposure. People with the most severe ASD and anxiety were the most likely to drop out. [source: Bryant et al. 1999]

4.2 Education about trauma reactions

• Purpose / when: session 1 in every version. Normalise symptoms, reduce fear of the reactions themselves, and set up the treatment model. [source: Bryant et al. 1999; Bryant et al. 2003]
• Steps: (1) Ask what the client has noticed since the event. (2) Map their symptoms onto common reaction groups: intrusive memories, nightmares, numbing or feeling unreal, avoidance, jumpiness, irritability, poor sleep and concentration. (3) Explain that these are common, understandable responses to threat, and that most people's reactions ease over the following weeks. (4) Explain that avoiding memories and reminders feels protective but tends to keep fear going. (5) Give a written summary. [source: component named in Bryant et al. 1999; content of steps 2–5 synthesis]
• Example language (illustrative): "Your mind is still treating the crash as if it might happen again. That's why you jump at brakes and the pictures keep coming back. It's an alarm system that hasn't switched off yet, not a sign you're going mad."
• Watch for: relief and "that's exactly me" responses mean it is working. Shame about the reactions ("I should be over it") is material for cognitive restructuring.

4.3 Breathing retraining

• Purpose / when: session 1 in the anxiety management versions, practised daily. Gives a way to reduce arousal in daily life and in anxiety-provoking situations. [source: Bryant et al. 1999]
• Steps (synthesis): (1) Explain that breathing fast and from the chest increases anxiety sensations. (2) Teach slow, even breathing from the abdomen, with a slightly longer out-breath and a calming word on the exhale. (3) Practise for a few minutes in session; ask for an anxiety rating (0–100) before and after. (4) Set daily practice when calm first, then in mildly stressful moments.
• Example language (illustrative): "Let's slow it right down. In through your nose, let your belly rise, and on the long breath out say 'calm' to yourself."
• Watch for: in the anxiety management versions it is used to manage arousal in daily life. Do not let it become a way of escaping during imaginal exposure [synthesis]. Breathing retraining is not described for the 1999 exposure-only arm, the 2003 package or the 2008 trial arms. [uncertain for the 2008 trial]

4.4 Progressive muscle relaxation

• Purpose / when: session 1, practised daily. Reduces overall arousal, tension and sleep difficulty. Present in the 1998/2003 package and the 1999 exposure plus anxiety management arm. [source: Bryant et al. 1999; Bryant et al. 2003]
• Steps (synthesis): (1) Explain the tense–release principle. (2) Guide the client through the main muscle groups in turn: tense for a few seconds, then release, noticing the contrast. (3) End with a short scan of the whole body and slow breathing. (4) Provide a recording or written sequence and set daily practice, recording tension before and after.
• Example language (illustrative): "Make a fist and hold it… notice the tightness… now let it go and feel the difference as the muscles soften."
• Watch for: injured body parts (common after accidents and assaults): skip or modify those muscle groups [synthesis]. Relaxation can trigger dissociation or intrusions in a few people; keep the eyes open and shorten the practice if so [synthesis].

4.5 Coping self-talk

• Purpose / when: session 1 in the anxiety management versions. Prepares realistic, coping-focused statements for anxiety-provoking situations. [source: Bryant et al. 1999]
• Steps (synthesis): (1) Identify an upcoming anxiety-provoking situation, for example being a passenger. (2) Elicit what the client currently says to themselves ("I can't cope"). (3) Write coping statements together for before, during and after the situation. (4) Rehearse them aloud; put them on a card or phone note. (5) Practise in the week's situations and review.
• Example language (illustrative): "What could you say to yourself in the car that's true and that helps, something like 'This is anxiety. It peaks and passes. I've handled it before.'"
• Watch for: statements that promise false safety ("nothing bad will ever happen") work against later cognitive restructuring. Aim for realistic and coping-focused. [synthesis]

4.6 Rationale for exposure

• Purpose / when: session 1 in the exposure-only arm and session 2 in the exposure plus anxiety management arm, before the first imaginal exposure. Gaining informed consent to exposure is part of this step. [source: Bryant et al. 1999]
• Steps (synthesis): (1) Link the client's avoidance to their ongoing symptoms. (2) Explain that going over the memory in detail, repeatedly and for long enough, lets distress fall and helps the memory be stored as something past, not present. (3) Say plainly that distress usually rises at first, that they stay in control, and that you will guide and support them. (4) Agree a stop signal and a 0–100 distress rating scale. (5) Get explicit consent; note any contraindication (see 4.7).
• Example language (illustrative): "Every time you push the memory away, your brain gets the message that it's still dangerous. We'll go through it together, slowly and in detail, so your brain can learn it's over. It'll probably feel worse before it feels better, and you can pause any time."
• Watch for: a client agreeing only to please you. Check understanding by asking them to explain the rationale back in their own words. [synthesis]

4.7 Prolonged imaginal exposure (in session)

• Purpose / when: the core of the treatment, from session 2 to session 5. About 50 minutes of each 90-minute session are spent reliving the trauma memory, focusing on the memory and engaging with the emotional response. [source: Bryant et al. 1999; Bryant et al. 2003]. In the 2008 trial, clients verbalised the reliving in a vivid way that included all perceptual and emotional details. [source: Psychiatric News 2008]
• Contraindications / safety (before starting): do not begin while there is current suicidal ideation, psychosis, substance misuse, organic mental disorder or active danger, or when the client has not consented. These were the trial exclusions; ongoing danger is synthesis. Moderate brain injury was excluded in 1999, while mild traumatic brain injury was treated successfully in 2003. Severe dissociation may block engagement (see section 5). [source: Bryant et al. 1999; Bryant et al. 2003]
• Steps: (1) Remind the client of the rationale, the stop signal and the 0–100 distress rating. (2) Ask them to close their eyes if comfortable and describe the event from just before it began through to when they felt safe. Use first person and present tense, a common convention in exposure protocols [synthesis; the convention is not confirmed in the Bryant reports]. (3) Prompt for what they see, hear, smell, feel in the body, think and feel emotionally, especially at the worst moments. (4) Ask for a distress rating every few minutes. (5) Repeat the narrative several times within the roughly 50 minutes. In later sessions, slow down on the most distressing moments [synthesis]. (6) Do not stop while distress is peaking unless the client uses the stop signal or is dissociating; aim to finish once distress has started to come down [synthesis]. (7) Debrief: what was it like, what did they notice, what was the worst moment, which thoughts came up. This feeds straight into cognitive restructuring (4.9). [source: steps 1, 5 and the restructuring sequence from Bryant et al. 1999; others synthesis]
• Example language (illustrative): "Start just before it happened. Tell me what you see… What are you hearing now?… What's going through your mind?… Where do you feel it in your body?… You're doing well; stay with it."
• Watch for: working: distress peaks and then falls within the session, and the peak falls across sessions; the narrative becomes more coherent and detailed; the client gains a sense that the event is over. Not working: a flat, factual, summarised account (under-engagement), skipping the worst parts, escape or safety behaviours, or dissociation (glazed, unresponsive, "it's not real"). For responses, see section 5. In the 2008 trial, exposure clients reported less distress than cognitive restructuring clients by the last three sessions. [source: Psychiatric News 2008; other indicators synthesis]

4.8 Daily imaginal exposure homework

• Purpose / when: from session 2 onward. The client repeats the exposure daily in the same way as in session. [source: Bryant et al. 1999; Bryant et al. 2003]
• Steps: (1) Agree a time and private place each day. (2) Agree the duration; matching the in-session length is the default [synthesis]. (3) The client relives the memory aloud or in their head, rating distress at the start, peak and end. (4) They log each practice on a simple record. (5) Review the log at the next session. The 1999 trial did not audiotape narratives. Recording the in-session narrative for home listening is a common feature of other exposure protocols, not of this trial [synthesis]. [source: Bryant et al. 1999]
• Example language (illustrative): "Every day this week, set aside time to go through the memory the way we did today, with the same detail, and note your distress before, at the worst point and at the end."
• Watch for: skipped or shortened practice, practice only when already calm, or distraction during practice. Treat non-completion as avoidance and problem-solve it (section 5).

4.9 Cognitive restructuring

• Purpose / when: after each imaginal exposure from session 2 (all 1999 and 1998/2003 versions), or as the main treatment (2008 restructuring arm, which did less well than exposure). Identify irrational, threat-related beliefs and test them against the evidence. [source: Bryant et al. 1999; Psychiatric News 2008]
• Steps: (1) Pick out the beliefs that came up during reliving or in daily life, for example about ongoing danger, blame, or what the symptoms mean. (2) Write the belief and rate how strongly it is held. (3) Examine it through Socratic questioning (what is the evidence for and against?), probabilistic reasoning (how likely is it really, based on past events and base rates?) and evidence-based thinking (what do the facts support?). [source: Psychiatric News 2008] (4) Build a balanced alternative and re-rate the belief. (5) Set thought monitoring as homework: situation, thought, feeling, evidence, alternative. [source: steps 1 and 3 from the sources; steps 2, 4 and 5 synthesis]
• Example language (illustrative): "You said, 'I'll be hit again if I drive.' How many times have you driven safely in the years before this? What does that suggest about the odds tomorrow?" Or: "You blame yourself for not seeing him coming. What could you actually have known at that moment?"
• Watch for: belief ratings dropping and new, balanced statements appearing spontaneously. Rigid self-blame or anger that does not move may need more time on the specific hotspot belief [synthesis]. Do not use restructuring as a way to avoid exposure time.

4.10 Graded in vivo exposure

• Purpose / when: sessions 4 and 5 in the 1999 versions, and part of the 1998/2003 package and the 2008 exposure arm. Reduce avoidance of trauma-related situations, places and cues. [source: Bryant et al. 1999; Bryant et al. 2003; Psychiatric News 2008]
• Steps (synthesis): (1) List the avoided situations, for example driving, being a passenger, the road where the crash happened, going out after dark, the area of an assault, news reports. (2) Rate each 0–100 and order them into a hierarchy. (3) Start with a moderate item. Stay in the situation until anxiety has clearly fallen; don't leave at the peak. Drop safety behaviours. (4) Repeat each item several times before moving up. (5) Log ratings; review and adjust each session. Use only situations that are objectively safe now. Never exposure to real danger, for example an abusive partner.
• Example language (illustrative): "This week, sit in the passenger seat for a short trip with someone you trust. Stay in the car until the anxiety drops by about half, and write down your ratings."
• Watch for: working: lower peak anxiety across repetitions and an expanding range of activity. Not working: escape, reliance on companions or medication as a safety behaviour, or items too high on the hierarchy (refusal). Choose an easier step rather than abandoning in vivo work.

4.11 Relapse prevention

• Purpose / when: final session (sessions 4–5 in 1999; the last session in 2008). Prepare for setbacks and continue progress on their own. [source: Bryant et al. 1999; Psychiatric News 2008]
• Steps (synthesis): (1) Review what changed and which strategies helped most. (2) Predict high-risk times: anniversaries, court dates, medical appointments, media coverage, a new stressor. (3) Normalise brief symptom returns as lapses, not relapse. (4) Write a personal plan: early warning signs, the exposure, restructuring and skills to use, and when to seek help. (5) Arrange reassessment and say how to re-contact the service.
• Example language (illustrative): "If the memories flare up around the court case, that's a setback, not starting over. What would you do first?"
• Watch for: the client can state the plan in their own words. Residual avoidance at the end should be added to the self-directed hierarchy.

4.12 Homework review at the start of each session

• Purpose / when: every session from session 2. Progress on skills and exposure practice is reviewed each session. [source: Bryant et al. 1999]
• Steps (synthesis): (1) Look at the log first. (2) Praise any attempt. (3) Note trends in distress ratings. (4) Explore missed practice without blame and identify the obstacle. (5) Revise the homework.
• Example language (illustrative): "Let's look at your record. What did you notice about your distress from Monday to Friday?"
• Watch for: repeated non-completion signals avoidance (section 5).

4.13 Hypnosis-facilitated exposure (2005 variant)

• Purpose / when: an optional add-on tested by Bryant et al. (2005). CBT combined with hypnosis was used to help clients engage in imaginal exposure, motivated by the 1999 finding that acute dissociation may impede exposure. [source: CEBC; Bryant et al. 1999 discussion] CBT plus hypnosis showed an extra reduction in re-experiencing compared with CBT alone. [source: CEBC]
• Steps: a hypnotic induction precedes imaginal exposure, with suggestions to engage fully in the memory. [uncertain: the 2005 method section. Do not use without hypnosis training; induction wording is not given here.]
• Watch for: reserve for trained hypnotherapists. Monitor for increased dissociation rather than engagement. [synthesis]

4.14 Supportive counselling (comparison condition, not the active treatment)

• What it was: the trials' control condition. Education about trauma, general problem-solving, an unconditionally supportive therapist stance, and a diary of current problems and mood. Exposure and anxiety management were specifically avoided. [source: Bryant et al. 1999; Bryant et al. 2003]
• Use: described here so clinicians can recognise when their own work has slid into this mode. In the trials, supportive counselling left far more clients with PTSD than exposure-based CBT did. [source: Bryant et al. 1999 abstract] Supportive contact is appropriate while the client is not yet safe or stable enough for exposure. [synthesis]

5. Handling problems

The sources give little problem-handling guidance. Bryant & Harvey (2000) has a chapter on treatment obstacles, which is not drawn on [uncertain]. Unless a source tag appears, the guidance below is [synthesis].

• Overwhelming distress or early dropout. In the 1999 trial, people who dropped out had more severe ASD and higher anxiety than those who completed. The authors suggested the most distressed may not be amenable to early intervention and may need different strategies. In the 2008 trial, a few clients in each active arm withdrew because of high distress. [source: Bryant et al. 1999; Psychiatric News 2008] Response: pace the exposure. Start with a shorter, less detailed pass of the narrative and build up to full reliving over the session; keep the eyes open; check ratings more often. Spend more of session 1 on anxiety management skills. If the client still cannot tolerate exposure, offer monitoring with skills support and revisit exposure later, rather than pushing on. [synthesis]
• Dissociation blocking engagement. The 1999 authors noted acute dissociation may impede exposure, which led to the hypnosis trial. [source: Bryant et al. 1999] Response: grounding in the room (describe the room, hold a cold or textured object, feet on the floor), eyes open, a shorter narrative focused on one segment, and frequent check-ins. Then return to the memory. Hypnosis-facilitated exposure only if trained (4.13). [synthesis]
• Under-engagement (flat, summarised account). Response: slow down, ask for sensory and emotional detail at the worst moments, and check for avoidance such as skipping parts or distraction. Re-explain why engagement matters. [synthesis; engaging with affect is required in Bryant et al. 1999]
• Homework non-adherence. Response: review the log every session. Explore missed practice without blame as part of the same avoidance pattern. Reduce the task to an achievable step. Set a fixed time and place; if needed, involve a support person for in vivo tasks, then fade them out. [synthesis; daily homework required in Bryant et al. 1999]
• Ongoing threat or unresolved danger (abusive relationship, perpetrator at large, unsafe workplace). Response: put safety planning first. Do in vivo exposure only to situations that are objectively safe. Restructuring should help the client tell realistic threat from overestimated threat. [synthesis]
• Physical injury, pain and medical treatment. Response: adapt relaxation and in vivo tasks to physical limits. Expect medical appointments to be reminders, and use them as in vivo opportunities. Coordinate with the medical team. [synthesis]
• Mild traumatic brain injury. The 2003 trial delivered the full package to people with mild TBI (posttraumatic amnesia under 24 hours) with good results. It did not describe adaptations and did not measure cognitive impairment. [source: Bryant et al. 2003] Response: give written session summaries, shorter segments and memory aids for homework. Where amnesia leaves gaps, base the narrative on what the client remembers and what they have learnt since, without filling the gaps by imagination. [synthesis]
• Legal or compensation proceedings. Two 1999 participants did not attend follow-up on legal advice. [source: Bryant et al. 1999] Response: clarify confidentiality and record-keeping at the outset. Keep the treatment focus on recovery. Plan relapse prevention around court dates. [synthesis]
• Suicidality, psychosis, substance misuse emerging during treatment. These were trial exclusions. [source: Bryant et al. 1999] Response: stop or pause exposure. Do a standard risk assessment; for suicidality this includes safety planning and lethal-means counselling (secure or remove means; involve supports). Arrange appropriate care. Resume trauma work only when stable. [synthesis]
• Grief, guilt and anger as dominant emotions (for example, someone died in the crash, or the client was the driver). Response: identify the guilt and responsibility beliefs at hotspots and work them with evidence-testing (4.9). Allow time for grief. Exposure alone may not shift guilt. [synthesis] [uncertain: not addressed in the sources]
• Ruptures (client feels pushed, angry at the therapist after exposure). Response: name it, ask directly, validate, and renegotiate pace and control (stop signal, agreed duration), while keeping the rationale. Collaboration and the client's choice are what make exposure acceptable. [synthesis]
• Stuck: symptoms unchanged by session 4–5. Response: check the dose (was the full 50 minutes done? daily homework?), the hotspots (were the worst moments avoided?) and the beliefs (is an unaddressed belief maintaining fear?). After five sessions, reassess. If PTSD criteria are met beyond the first month, refer for or continue a full trauma-focused PTSD treatment rather than repeating the brief course. [synthesis]
• Client is improving on their own / does not meet ASD. Response: do not start the course. Offer information, support and monitoring, with a clear route back if symptoms persist. Do not offer single-session debriefing. [synthesis consistent with principle 1; NICE point uncertain, see section 2]

Sources

Sources:

• Bryant et al. 1999, Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques (abstract)
• Bryant et al. 1999, full article page (method details)
• Bryant, Moulds, Guthrie & Nixon 2003, Treating acute stress disorder following mild traumatic brain injury
• Psychiatric News 2008, Prolonged exposure therapy helps ward off PTSD (report of Bryant et al. 2008)
• CEBC, Cognitive Behavioral Therapy for Acute Stress Disorder (CBT for ASD)
• ISTSS, Cognitive Behavioral Therapy for Acute Stress Disorder treatment materials
• AUT Library record, Acute Stress Disorder: A Handbook of Theory, Assessment, and Treatment (table of contents)
• NICE NG116, Post-traumatic stress disorder (recommendations page did not render; NICE points marked [uncertain])

Books and papers cited (not drawn on in full):

• Bryant, R. A., & Harvey, A. G. (2000). Acute Stress Disorder: A Handbook of Theory, Assessment, and Treatment. American Psychological Association.
• Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, T., & Basten, C. (1998). Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 66, 862–866.
• Bryant, R. A., Moulds, M. L., & Nixon, R. V. D. (2003). Cognitive behaviour therapy of acute stress disorder: a four-year follow-up. Behaviour Research and Therapy, 41, 489–494.
• Bryant, R. A., Moulds, M. L., Guthrie, R. M., & Nixon, R. D. V. (2005). The additive benefit of hypnosis and cognitive-behavioral therapy in treating acute stress disorder. Journal of Consulting and Clinical Psychology, 73, 334–340.
• Bryant, R. A., Mastrodomenico, J., Felmingham, K. L., et al. (2008). Treatment of acute stress disorder: a randomized controlled trial. Archives of General Psychiatry, 65, 659–667.