A Gentler Approach to Fergal Keane’s Post-Traumatic Stress Disorder

Last night the BBC broadcast the experiences of its’ intrepid reporter, Fergal Keane, in battling with PTSD and alcohol. He has performed an invaluable service in normalising responses to extreme trauma. In the program he described being sometimes wiped out for days after a session of EMDR. Fergal showed great fortitude in continuing with such treatment. But it raises the question the question of how many others would persist? Particularly if they were not attending an exalted Private Hospital. 

Unfortunately the treatment that he had had  is predicated on the assumption that he needs to confront  all the horrors that he experienced in different lands.  Fergal returns to Rwanda and relives the smells and sights of extreme traumas. He feels guilty that he left Rwanda in the first place. Fergal is annoyed with himself that he left a hotspot in Ukraine at the beginning of the current conflict. In the program he is reunited with an adult from Rwanda who as an older child escaped under a blanket hidden by younger children. He is amazed that  she has not suffered his debility. De facto she has not seen her traumatic memory as relevant to her day-to-day functioning in the UK, but works in mental health. The key point I make in ‘Personalising Trauma Treatment: Reframing and Reimagining’ Routledge 2022 is that traumas only need to be confronted in the sense of addressing their relevance for today. Thus this lady might well write to Priti Patel about the obscenity of routing refugees to Rwanda, whilst not letting the traumatic memory be her central window through which she views the world.

In the programme the EMDR therapist is seen trying to replace Fergal’s thought ‘I am going to die’ whilst under a mortar attack in Lebanon, with the installation of a positive thought ‘I survived’. But this replacement is unnecessary, more parsimoniously it could  have been pointed out that he made a negative prediction and was wrong and may have developed a penchant for making negative predictions that turn out to be wrong. He would be advised to have second thoughts when he makes negative predictions or damns himself.  Fergal appears to believe that he has to be successful in his endeavours encountering horrors rather than just do what he can. He berates himself  for returning to war zones but I think he’s simply trying to ensure that horrors don’t have the last word – a noble task if ever there was one!

The programme featured groups for survivors and whilst they are useful, groups to resolve PTSD appear not to be effective. Interestingly one group member highlighted the problem with a sequential approach to PTSD treatment, an insistence that drink problems is sorted 1st before PTSD. People want treatment for all their conditions now. 

 

Dr Mike Scott

Who Arrested Information Processing?

Was it Freud, Horowitz, Foa, Resick, Shapiro, Brewin or Ehlers? Arrested information processing has long been held as pivotal in the development of PTSD, but in my Workshop, ‘CBT for PTSD and Beyond’ to be delivered at the Lakeside Centre, Crosby, Liverpool on October 4th 2018 under the auspices of Merseyside BABCP I question this.

 

There is also a paper ‘PTSD An Alternative Paradigm’ in submission.

Dr Mike Scott

Organisations Bias Diagnosis and Treatment Pathways

Organisations find the diagnosis they were set up for, creating a label that is passed on without critical re-appraisal – ‘sticky labels’. Resulting oftentimes in inappropriate treatment. Culprits are not only the obviously dedicated services such as those  for Autism Spectrum Disorders (ASD) but missionaries of monopoly training bodies such as EMDR and IAPT. The danger is that the Organisations do not seriously consider a contradictory diagnosis.

 

Recently I saw a 14 year old, two years ago a panel decided that he met criteria for ASD. No individual clinician in the ASD pathway had been definitive about an ASD diagnosis, and the possibility had only been raised when he was aged 11. His social communication was in fact good, interrupting mum appropriately in the Consultation. He clearly had behavioural problems, but there had been no consideration of a possible alternative DSM-5 diagnosis of ‘conduct  disorder with limited prosocial emotions’, instead the Panel concluded ‘will need to be taught social skills methods which suit his ASD needs’ but this has never happened in the intervening 2 years. When Panel decisions are made there is a need to be wary as they make riskier decisions (groupthink). His GP has now suggested that he be guided to a general counselling service for adolescence. No chance it seems of CBT appropriate to his and/or his mum’s needs!

In similar fashion EMDR therapists find PTSD everywhere and IAPT finds a mix of anxiety and depression ubiquitous resulting in poorly targetted treatment.

Dr Mike Scott

What If Information Processing Models of PTSD are Wrong?

Consider that only a small minority of those experiencing an extreme trauma experience PTSD, consider also that most people experiencing such an event try not to think/talk about it, is it really plausible that PTSD arises from arrested information processing? If not why are we subjecting clients and therapists to a painful procedure, trauma focussed CBT/EMDR,  that they are likely to default from?

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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, nevertheless compliance in routine practise appears much less . But 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.

Dr Mike Scott

From Disaster to Functioning

Talk at Health and Wellbeing at Work Conference, NEC, Birmingham March 6th 2018. My key themes are:

  • ‘Saving Normal’ and watchful waiting in the immediate aftermath of a disaster.
  • Critical Incident Stress Debriefing is unproven and may be harmful.
  • The dangers of trauma focussed CBT/EMDR when a person does not actually have PTSD
  • Daring people to gradually do what they did before – resetting the alarm (amygdala)
  • Poor recovery rate in IAPT for treating trauma responses 10%
  • Ubiquity of rules of thumb for treating trauma victims probably leads to an almost universal low recovery rate
  • Dr Mike Scott

Heading Towards the Iceberg – The Mental Health Service’s Response to The Grenfell Fire

‘Three quarters of those living closest to the Grenfell Tower are suffering from PTSD, with 40% suffering in buildings a little further away’ (BBC Radio 4 December 14th 2017). But these figures from Grenfell Health and Wellbeing are highly improbable, numerous studies of responses to natural disasters show the incidence of PTSD is 30-40% amongst direct victims of disaster  and 5-10% in the general population [ Galea et al (2005)]. The rampant overdiagnosis of PTSD opens up the prospect of swathes people enduring trauma focussed CBT (or EMDR) quite unnecessarily. The spectre of inappropriate help rivals the sight of the Tower.

This gross overdiagnosis has come about because counsellors have gone door to door, ‘if they thought it appropriate’ the questions on a PTSD screening questionnaire  were asked and using a cut off a diagnosis of PTSD was made. This method on its’ own is highly unreliable, a screen has to be followed by a reliable standardised diagnostic interview  to establish true prevalence.

The interviewed clinician claimed that their approach was a ‘first’, but actually it is reminiscent oF IAPT’s approach to assessment, resulting in a treatment, that by my independent assessment, has a 10% recovery rate -‘the tip of the iceberg respond’.

 

 

The mental health services are it seems like the like the Titanic heading towards the iceberg, hopefully unlike the crew they will heed warnings and take a new direction.

 Galea et al (2005) ‘The Epidemiology of PTSD After Disasters’ in Epidemiological Reviews

 

Dr Mike Scott