From an evolutionary perspective the problem with PTSD is not so much the traumatic memory but that the latter furnishes a maladaptive map, as if the sufferer is operating in a ‘war zone’. This suggests a different treatment focus to the often resisted trauma focussed CBT. The goal of treatment is to construct an adaptive map, this involves ‘scouting’ to ascertain where if anywhere the ‘real and present dangers’ are. PTSD sufferers are often operating like Tony Blair on the ‘dodgy dossier’, if the weapons of mass destruction are not found in one place there is a rush to somewhere else thinking ‘they must be here’.
For clients resistant to trauma focussed CBT (TFCBT), post trauma mapping readily enhances the therapeutic alliance. Alliance problems are a bigger problem in delivering trauma focussed cbt in routine practice than have ever been acknowledged in randomised controlled trials, resulting in therapists feeling deskilled. Steve Stradling and I found that in routine practice only just over half of clients comply, even loosely defined, with a trauma focussed CBT [ Journal of Traumatic Stress (1997)]. There is a gap between what the scientist practitioners in the randomised controlled trials find and what the routine clinician/ ‘engineer’ finds in routine practice. Such mapping can be insufficient to resolve the PTSD but in passing the person becomes so acquainted with talking about the trauma that shifting from the ‘shallow end’ to exercising in the ‘deep end’, trauma focussed CBT is seemless.
From an evolutionary perspective the only function of memory is to to help us better anticipate future events, there is no value in memory per se. It may transpire that trauma focussed CBT is not actually essential for recovery from PTSD, certainly we do know that TFCBT is not necessary and is often experienced as ‘toxic’ for those traumatised but not suffering from PTSD e.g simple phobia, depression. Making it very important to carefully delineate the psychological sequelae of trauma.
Dr Mike Scott
