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Post Trauma Mapping – circumventing difficulties with trauma focussed cbt

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

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The Scientist Practitioner Delusion?

‘Surviving this week as a therapist, trumps being a scientist practitioner’, there were gasps of surprise and murmurs of agreement, as I said this at a recent IAPT Workshop I was giving. I mused out loud about who had the space to collect data on a client, write it up and present it for publication. No contrary voices were raised despite the scientist practitioner model being an article of faith on CBT training courses.  Students should be invited to write an essay on ‘The Scientist Practitioner Delusion?’

The engineering narrative is a better descriptor for the overwhelming majority of CBT practitoners, rather than being invited to ape academic clinicians, for whom the scientist practitioner model is probably the best descriptor. But the concerns of the true ‘scientist practitioners’ are very different to the engineers, yet they dominate service provision, conferences etc. I remember Paul Salkovskis, Current President of BABCP, once saying to me that the membership speaks with a small voice, but this isn’t surprising, if most are powerless, stressed engineers. I debated with Paul at an Annual Conference a few years ago but he didn’t see a problem with scientist practitioner as a universal descriptor and was dismissive of the idea of engineers.

But whilst it was scientists who developed the first computers, vis a vis Alan Turing at Bletchley Park in the war years (The Imitation Game is a brilliant watch!), it was engineers who developed the personal computer that we all know. Dissemination needs a creative dialogue between scientists (scientist practitioners) and engineers.

Dr Mike Scott