‘What trauma means today’ published in ‘The Psychologist’, October 2022

 

Michael J. Scott on books that shaped his thinking around ‘mental time travel’ for his own new offering, Personalising Trauma Treatment: Reframing and Reimagining (Routledge)

Personalising Trauma Treatment: Reframing and Reimagining by [Michael J Scott]

The classic dictum underlying cognitive behaviour therapy (CBT) is that ‘men are disturbed not by things, but by the views which they take of things’. This is attributed to the Stoic Philosopher Epictetus (The Enchiridion Epictetus, translated by Higginson, 2020), who discussed it in the context of death. Epictetus was born into slavery and endured a permanent physical disability. In essence the Stoic philosophers were ‘centralists’ in taking the person’s view of matters as playing a pivotal role in distress. Unlike the trauma-focused CBT theorists, the ancient Stoic philosophers did not see the distress as originating in the particulars of the adversity at the time – what has, in the modern era, been termed arrested information processing. In my new book Personalising Trauma Treatment, I suggest that the key focus should be on what the trauma victim takes the trauma to mean about today, rather than having the client re-live the trauma.

Moving on from Stoic philosophers, Samuel Pepys wrote in his diary on 2 September 1666 (republished in 2003) of the start of the Great Fire of London. Five months later, on 28 February 1667, he wrote ‘it is strange to think how to this very day I cannot sleep a night without great terrors of fire; and this very night I could not sleep until almost two in the morning through thoughts of fire’. From the Restorative CBT (RCBT) perspective evinced in the book, the sights, sounds, smells of what Pepys had seen would be acknowledged and the question of what they mean for today would be asked. In essence, how relevant are these memories? Do they mean that he can’t walk the streets of London? The therapeutic focus would be on helping him realise he was safe. A prime RCBT target is helping the person regain their sense of self by gradually doing what they did before; for Pepys, writing about his daily encounters and the restoration/rebuild of London.

Moving further forward in my time capsule, the Auschwitz survivor, Edith Eger – who later became a Clinical Psychologist – was, in 2017’s The Choice, askance at the idea of deliberate re-living of the trauma. ‘Work through it? I lived it, what other work is there to do? … I’ve broken the conspiracy of silence. And talking hasn’t made the fear or flashbacks go away. In fact talking seems to have made my symptoms worse… we can choose to be our own jailors or we can choose to be free’. She did revisit Auschwitz but her sister, also a survivor, declined.

What is fascinating is Eger coped with dancing in front of the Nazi doctor, Josef Mengele, by transporting herself back to the stage on which she performed ballet. A key feature of my own book is how we do that mental time travel. The RCBT is easy to disseminate and hopefully will be useful for helping the mass of psychological casualties generated by the war in Ukraine.

Dr Mike Scott

 
 

Arrested information-processing – an illegitimate justification for toxic treatment

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

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

An Engaging Trauma Treatment

Take a look at ‘Personalising Trauma Treatment: Reframing and Reimagining’ here https://doi.org/10.4324/9781003178132. To access the abstracts of each chapter you have to first register with Taylor and Francis Publishers

Magical Beliefs About CBT…

abound.These beliefs are inculcated by initial training and maintained by sharing ‘best practices’. For example, low intensity CBT therapists operate, on beliefs such as  ‘if I go into the CBT superstore and choose a strategy it will be potent’, ‘my clinical judgement is sufficient to make the right choices’,  and ‘improvements in test scores are sufficient basis for believing the clients needs have been met ‘.  But these beliefs are not evidence-based.

 

For the past 50 years it has been taken as axiomatic that ‘arrested information processing plays a pivotal role in debility post-trauma and should be targetted’. In Personalising Trauma Treatment: Reframing and Reimagining Routledge’  (2022)https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwj2r8v8m_j2AhWxQEEAHQrjAGgQFnoECAUQAQ&url=https%3A%2F%2Fwww.taylorfrancis.com%2Fbooks%2Fmono%2F10.4324%2F9781003178132%2F I examined this issue in detail, dissented and concluded that it is the centrality accorded to the trauma that is the driving force for debility post trauma. To the extent that clients utilise the trauma as their window on themselves and their world they are likely to suffer impairment in functioning, both personally and interpersonally. It  is a magical belief that the problem lies with the traumatic memory, rather the issue is what the person takes the memory to mean for today (see youtube video https://youtu.be/3UeJ1Lux4pU) detailing how to help the client back to their old selves post trauma – Restorative CBT (RCBT).

Personalising Trauma Treatment : Reframing and Reimagining book cover

 ‘All disorders are maintained by a negative belief system, making CBT appropriate’, this belief underpins the extension of CBT to the treatment of long-term conditions. But it would not stand up in Court. It would be suggested that the idea is promulgated to satisfy the acquisition of power by service providers. A relatively newly emergent,  magical belief is that ‘if children are taught the elements of CBT model/adaptive coping it prevents the development disorder’ this may or may not be true but dogmatism here has no place. 

In the Middle AgesIn it was believed that the earth was the centre of the universe and planets such the sun  and moon orbited it in circles. This geocentric view of the universe persisted for a long time after it became evident that the earth was not at the centre  and that orbits were elliptical rather than circular. Unfortunately the power of the current Teflonocracy will likely lead to the persistence of these magical beliefs for some time to come.

Dr Mike Scott

Restorative CBT for Post-traumatic Stress Disorder and Beyond

New youtube video https://youtu.be/3UeJ1Lux4pU detailing how to help the client back to their old selves post trauma – Restorative CBT (RCBT). Not only for those who have developed PTSD but also for those who have acquired other disorders, whether singly or in combination. The video is based on my new book ‘Personalising Trauma Treatment: Reframing and Reimagining’, available from amazon https://images-na.ssl-images-amazon.com/images/I/5141wjLVgrL._SX331_BO1,204,203,200_.jpg. and published by Routledge.

RCBT is likened to restoring a dilapidated property but in some instances it may be a rebuild on the same site, for those who feel they have never functioned well. Mental time travel to a trauma/s is inevitable but it is what the person takes it to mean about today that is crucial for possible ongoing psychological debility. It is the centrality accorded to the trauma that is pivotal in the development of disorder. The book is replete with metaphor making for ease of dissemination. For example, PTSD clients are invited to consider that they are wearing a pair of ‘war-zone’ glasses and are invited to practice swapping these for the ‘spectacles’ that they would have worn in the weeks before the trauma.

It is suggested that a) there is no credible evidence that traumatic memories are  different in kind to ordinary autobiographical memories and b) traumatic memories do not have unique neural basis. Consequently there is no need for clients to relive their trauma. It is much easier for clinicians and clients to consider the adaptiveness of a memory than to relive it to the point of desensitisation. In randomised control trials, trauma focused interventions result in recovery in about 50% of cases. However in routine practice because of comorbidity and population differences, the proportion is likely to be significantly less. Further to the extent that trauma-focussed interventions work, they may do so simply because the client collects experimental evidence that they are not in a ‘war zone’. There is then ample justification for approaching the psychological sequelae of trauma from an RCBT perspective.

 

Dr Mike Scott

 

 

Post Trauma, Quality Treatment Shouldn’t Be Traumatic – New Book

Personalising Trauma Treatment is about helping trauma victims back to their old selves and focuses on altering the perception of the centrality of the trauma.

In this book, clients are taught to rediscover their sense of self by reframing the trauma. Within this new framework the focus is on the client’s mental time travel from the trauma to today and reimagining their future. The therapeutic targets are the thoughts and images (cognitions) that interfere with day-to-day functioning. It does not assume that arrested information processing lies at the heart of the development of PTSD, with a consequent need for the client to re-live the trauma. For those clients who were abused in childhood, their experiences are viewed through a particular central window, but other ‘windows’ may make for more appropriate engagement with their personal world and a reimagining of their view of themselves. Treatment delivery options from telephone consultation, group work and videoconferencing are discussed. With illustrative examples, the author highlights the pathway to recovery for a wide range of clients with the comorbidity often found in real-world settings.

The book will be essential reading for therapists and other mental health professionals working with trauma survivors.

Michael Scott identifies the paradox, coolly critiques the evidence, and illustrates and emphasises the collaborative and crucial role of the creative, empathic, and restorative therapist in enabling the client’s natural resilience and preferences for today and tomorrow, without pathologizing normality, imposing supposed processing, and unconstrained by complacent diktat. — Greg Wilkinson Formerly: Editor, The British Journal of Psychiatry and Professor of Liaison Psychiatry, The University of Liverpool; Currently, Consultant Psychiatrist, Liverpool University Dental Hospital and Liverpool University Hospitals NHS Foundation Trust.

Dr Scott offers a unique and refreshing perspective on working with those affected by trauma, particularly when they don’t neatly fit into a PTSD ‘box’ but have nevertheless come to be defined by their experiences. Taking a critical eye to evidence-based practice, and at turns thought-provoking and light-hearted, he combines up-to-date theory and clinical pearls with a robust critique of the modern realities of service delivery. Full of rich clinical examples and dialogue that brings the reader into his therapy room, he takes you step-by-step through his clinical decision making and interventions.Highly recommended! — Sharif El-Leithy, Principal Clinical Psychologist, Traumatic Stress Service  

In Personalising Trauma Treatment: Reframing and Reimagining Dr Scott delivers an approach to treatment grounded in pragmatism and real-world functioning. After considering the pitfalls of poor assessment he guides the reader through the process of detailed and accurate diagnosis questioning whether treatments work for the supposed reasons they give. This book is a must for all IAPT & CBT therapists, counsellors and clinical psychologists involved in the care of individuals suffering with trauma. — Sundeep Sembi, Consultant Clinical Neuropsychologist, Psychology Chambers Ltd

https://www.routledge.com/Personalising-Trauma-Treatment-Reframing-and-Reimagining/Scott/p/book/9781032013121 utm_source=individuals&utm_medium=shared_link&utm_campaign=B021841_ca1_1au_7pp_d875

 

Psychological Therapy With Long Term Conditions

Improving Access to Psychological Therapies (IAPT) therapists working with long term conditions (LTC’s) have confidence and organisational, issues Carroll et al (2021) DOI: 10.1111/bjhp.12475. Whilst therapists working in secondary care, with LTC’s, face fewer obstacles to multidisciplinary working, with a focus primarily on the LTC and not on the associated depression/anxiety as in IAPT. Further the metrics for outcome in secondary care are likely to be much broader than in IAPT. LTCs by their very nature, wax and wane with a consequent impact on availability and concentration, creating a need for any therapy to be long term. But IAPT has a major focus on access and waiting times, such that any treatment is usually brief, comprising on average of 6 sessions, thus the service cannot readily accommodate working with LTCs.

The focus in the Carroll et al (2021) is on how the psychological treatment for those with LTC”s can be best integrated into primary and secondary care. They note however that the model they use to identify barriers and facilitating factors to implementation, first requires, evidence that the chosen intervention/s are effective. But they do not address this point. This is crucial, where is the evidence that the psychological therapies for disorders that are comorbid with LTCS make a real world difference?

A case has long been made that it is a matter of basic humanity to offer to accompany a person with an LTC if they so wish. A host of Charities have formalised this. The support may be social, e.g befriending, groups and/or instrumental e.g help with DWP application. The case for profferring ‘support’ is I think uncontestable. But many with LTC’s are wary of being defined by their condition. A dedicated support group may serve as a further reminder of their condition. They may decline involvement in such a group, but this is not necessarily a matter of avoidance, simply that they do not wish to define themselves or their world through the lens of their LTC. If psychological difficulties are grafted on to their LTC they may be even more likely to decline involvement with psychological therapists because it is an LTC type lens (a variant) through which they are being encouraged to view themselves and their personal world with perceived deleterious consequences. Arguably the LTC lens used in secondary care is likely to be less problematic than that used in IAPT. But the issue of centrality has not been systematically addressed with regards to LTCs. In the authors forthcoming work ‘Personalising Trauma Treatment: Reframing and Reimagining’ to be published by Routledge the issue of centrality [ Bernsten and Rubin (2006) (2007)] is addressed in detail with regards to trauma.

There is a distinction between long term physical health conditions and medically unexplained symptoms (MUS), the former are open to objective identification e.g diabetes, the latter are not. In considering the former the therapist feels that they are on solid ground, albeit that it is largely the domain of the medic, with whom there may be fruitful dialogue. But when it comes to MUS the therapist is in a fog, where are the signposts? There is no reference book for translating best practice with LTCs to clients with MUS. Because of this there is likely to be recourse to a powerful body insisting that the way forward is ‘x’ but without any evidence, a recipe for disaster. IAPT”s juxtaposition of LTCs and MUS, smacks more of pragmatism to secure maximum funding, rather than seriously addressing a clinical problem. Where is the therapeutic alliance in addressing MUS symptoms? What is the goal, What are the agreed tasks? Whither the bond, when the therapist covertly believes that the client is somatising and the client believes there physical symptoms are as real as toothache?

Carroll, S., Moss-Morris, R., Hulme, K., & Hudson, J. (2021). Therapists’ perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions. British journal of health psychology26(2), 307–324. https://doi.org/10.1111/bjhp.12475

Berntsen, D., & Rubin, D. C. (2006). Centrality of Event Scale: A measure of integrating a trauma into one’s identity and its relation to post-traumatic stress disorder symptoms. Behaviour Research and Therapy, 44, 219–231. https://doi.org/10.1016/j. brat.2005.01.009

Berntsen, D., & Rubin, D. C. (2007). When a trauma becomes a key to identity: Enhanced integration of trauma memories predicts posttraumatic stress disorder symptoms. Applied Cognitive Psychology, 21, 417–431. https://doi.org/10.1002/acp.1290

Dr Mike Scott

‘Intensive Care PTSD’

this was the banner  headline on the BBC News today, January 13th 2021. It followed the announcement of a study by Prof Neil Greenberg, which revealed that staff had been ‘traumatised’ by the first wave of the pandemic. This in turn led for Paul Farmer Chief executive of MIND to call for ‘the right support at the right time’ on BBC radio 4 today. The Government has promised an extra £15 million so that extra support can be given.  But what sort of support?

In the press release accompanying publication of his study in the journal Occupational Medicine, Professor Greenberg notes ‘Further work is needed to better understand the real level of clinical need amongst ICU staff as self-report questionnaires can overestimate the rate of clinically relevant mental health symptoms’. His study was based on a web survey of ICU staff about half of whom responded, about half whom met the ‘threshold’ for PTSD, severe anxiety or problem drinking. There is a clear need to go beyond self-report measures.

I am currently writing a book ‘Personalising Trauma Treatment: reframing and reimagining’ to be published by Routledge. In this work I suggest that the initial conversation with trauma victims   should include ‘Gateway Diagnostic Interview Questions’ , with regard to Covid an appropriate subset would be:

Depression (evidence that at least one of the answers to the following questions is in the affirmative)

1. During the past month have you often been bothered by feeling, depressed or hopeless?

2. During the past month have you often been bothered by little interest or pleasure in doing things?

 

Panic Disorder

1. Do you have unexpected panic attacks, a sudden rush of intense fear or anxiety?

2. Do you avoid situations in which the panic attacks might occur?

 

Post-traumatic Stress Disorder

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you

1. Have had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the events may have caused?

Evidence that at least three of the answers to the symptom questions above are in the affirmative

Alcohol Dependence (evidence is that the response to the first three of the following questions is in the affirmative)

1. Have you felt you should cut down on your alcohol/drug?

2. Have people got annoyed with you about your drinking/drug taking?

3. Have you felt guilty about your drinking/drug use?

4. Do you drink/use drugs before midday?

Asking GDIQ questions encourages the person to furnish possible examples of the impact of the symptom on their life, so that they feel listened to. Reference can then be made to other  diagnostic symptoms for the particular disorder, to tease out whether there are sufficient impairing symptoms for that disorder, to merit that diagnostic label.  Use of GDIQ’s is part of a conversation, it is not a rapid fire interrogation or checklist. As a supplement to the GDIQ people can be asked whether this is something that they want help with, as they might not want to verbalise that they want to sort the problem out themselves, but are too polite to express this. 

The NICE recommended treatments are diagnosis specific, thus there is a recommendation of trauma focussed CBT for PTSD. But those traumatised by Covid are likely to find it toxic to be pushed to describe in graphic detail the horrors encountered. In my book I argue that this is unnecessary, rather that what is of key importance is to assess what the person takes their memory of being in ICU means about today. It is not the event that causes PTSD but the mental time travel to the worse period and the significance given to it  for today. This approach  is much less challenging for whoever is  accompanying the effected medical staff and family/friends who have seen horrors.

 

Dr Mike Scott