Both of the main treatments for post-traumatic stress disorder, trauma focused cognitive behaviour therapy (T-FCBT) and eye movement desensitisation reprocessing (EMDR), postulate that arrested information processing lies at the heart of debility post trauma. The therapeutic task is therefore to elaborate the traumatic memory. But does the model stand up to close scrutiny?
- What does arrested information-processing look like?
- Is forced engagement with the traumatic memory, the only way forward, given that most people do not want to think about something horrible?
- Is there evidence beyond reasonable doubt that a noxious treatment for post-trauma debility is necessary?
- What happens when arrested information-processing is put under the microscope?
Consider that you have produced a one page document on your computer. You try to print it out, alas nothing! Various arrested information processing ‘bugs’ may have come into play. You may have forgotten to refill the paper tray. The cable at the rear of the computer may have become disconnected. With age the printer might now demand that it be a) unplugged from the mains b) the printer key depressed for 20 seconds with the paper tray out and c) the printer plugged in and the printer key depressed again. There would thus be very clear and demonstrable reasons as to why you have no printout.
But when a person is debilitated following an extreme trauma there is no such clarity. It may be asserted the extreme trauma caused the debility, but all that is known is is that debility followed a trauma. The temporal sequence does not necessarily signify causation. A failure by trauma focussed clinicians to specify the mechanisms by which arrested information-processing occurs, casts doubt that it has been operative. The injunction for trauma focused clinicians is to ‘elaborate’ the traumatic memory. Staying with the analogy, no amount of changing the contents of the one page document (elaboration) will result in a printout. Arrested information processing, in the context of trauma, sates intellectual curiosity with abstractions but is bereft of any actual detail. The evidential bar for the concept is set so low that it is possible to walk over it.
Just as the one page document is a creation, so to is the traumatic memory, but it differs in that every time the latter is retrieved it is different. It is rather like Alice in the above observation.
Any information encoded at the time of the trauma may be properly regarded as syntactic information, i.e information without any meaning – rather like being sent a text message that consisted simply of a number of symbols. A friend may at a later point give a meaning to the symbols but you may nevertheless conclude that it was a meaningless text. Importantly the meaning is subject to negotiation and is not located in a special place in the trauma itself. Plantinga, Oxford University Press (2011) says that it is essentially impossible to see how a material structure or event could have content in the way that a belief does.This takes us to a new and more useful model based on mental time travel [Scott (2022) Personalising Trauma Treatment: reframing and Reimagining. London: Routledge https://www.amazon.co.uk/Personalising-Trauma-Treatment-Reframing-Reimagining/dp/1032013125/ref=sr_1_1 crid=2T4OARM3EH4TB&keywords=personalising+trauma+treatment+paperback&qid=1653757479&sprefix=%2Caps%2C73&sr=8-1 ] and the axiom that it is not the trauma per se that is important but what it is taken to mean for today, that has significance.
The Utility and Effectiveness of Trauma-Focussed Interventions
It is true that with trauma focussed CBT or EMDR about 50% of those undergoing these treatments in randomised controlled trials fully recover from PTSD. However compliance with trauma-focussed protocols in routine practise is problematic, with only a half of patients loosely compliant with the homework [Scott and Stradling (1997) Journal of Traumatic Stress. Over 60% of veterans dropping out of trauma focussed interventions [ Maguen et al (2019) https://doi.org/10.1016/j.psychres.2019.02.027]. Not buying into the treatment rationale for trauma focussed work is the biggest predictor of non-completion [ Kehle-Forbes et al (2022)https://doi.org/10.1016/j.brat.2022.104123].
it is possible that to the extent that these treatments do work they do so for reasons other than achieving ‘full processing of the traumatic memory’. More plausibly as a side effect of these interventions they learn experientially that the ‘war zone’ map of their personal world that they have employed since the trauma, leads nowhere and they revert to a pre-trauma map. Oftentimes the prime concern of a victim is not what did happen but what could/should have happened i.e it is not the trauma per se.
Resistance To A Paradigm Shift
Rather than re-examine the trauma-focussed paradigm the likelihood is that the movers and shakers in the CBT/EMDR world will either resolutely ignore this challenge or concentrate their firepower on the inappropriateness of the computer/printer analogy, without suggesting a more appropriate analogy. An essentially fundamentalist approach is taken to the potency of arrested-information processing. Heretics should at best be marginalised.
Dr Mike Scott