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
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
this was the title of a one day workshop that I gave on Wednesday March 4th 2020 to the Chester and North Wales Branch of BABCP. My video commentary on the day can be accessed here
and the Powerpoint presentation can be accessed here
The theoretical background to this new approach to a 1st line treatment for PTSD is described in my paper PTSD An Alternative Paradigm ptsd an alternative paradigm.
any comments gratefully received.
Dr Mike Scott
that’s one of the clinical implications of my just published paper ptsd an alternative paradigm. On March 4th I am giving a One Day Workshop titled ‘Getting Back To Me Post Trauma’, elaborating further on the clinical implications of this work. The day is organised by Chester and North Wales BABCP at Chester Rugby Club.
My work addresses the problem that with cognitive processing therapy, 42% of people drop out of treatment. Most between sessions 2 and 5. In the traditional CPT protocol homework at sessions 3 and 4 involves clients writing detailed accounts of their trauma, which often does not go down well. I also found that in exposure therapy barely half comply with listening to a trauma tape. I argue that the case for trauma focussed interventions is not proven and there is a more user friendly way of going about things.
Dr Mike Scott
by the advent of stabilisation groups and overvaluing trauma focussed CBT. In the wake of an extreme trauma IAPT clients can be referred to stabilisation groups. Such groups will often meet weekly for 6 weeks and participants are encouraged not to talk about the trauma but rather about its effects. However there is no empirical evidence that such groups make a real world difference. In support of such groups the work of Judith Herman [ Group Trauma Treatment in Early Recovery (2019) Guilford Press] is often cited, her groups are for those in ‘early recovery’ but there is no specification of what is meant by ‘early’ or from what the person is recovering. IAPT’s assessment process is as vague as Judith Herman’s.
Sienna, a Civil Servant had a horrendous rta and after an IAPT telephone assessment was referred to a stabilisation group, she assumed it was for PTSD. The group made no difference to her functioning, nor did the 3 individual sessions of trauma focusssed cbt afterwards. Sienna dropped out of the TFCBT because it was too painful but she never did have PTSD!
But the problems in the treatment of PTSD are not confined to IAPT. Although trauma focussed CBT (TFCBT) is the NICE recommended treatment for PTSD, inspection of the randomised controlled trials reveals that on average only one in two people recover. NICE’s guidance can be overvalued, with clinicians continuing to pursue TFCBT when it is clearly not working. With a parallel insistence that they confront the scene of their trauma. Client’s are often more pragmatic thinking that they could get by without re-exposure to the scene, but with the therapist urging the client not to be ‘defeated’. Given the power imbalance the client is unlikely to be able to effectively voice their opinion. There is a pressing need for creative solutions when TFCBT doesn’t work and for a re-examination of the theory on which the latter rests.
I am proposing to run a ‘Getting Back To Me’ workshop next year.
Dr Mike Scott
Group CBT treatments for PTSD leave 70% of participants still suffering from the condition and it appears less effective than individual PTSD. Further, other active group treatments appear as effective as group CBT for PTSD, but are slightly better able to retain people, probably because they are not trauma focussed, see link below to the Sloan et al (2018) study:
Groups/classes are a great attraction for Organisations pre-occupied with numbers and waiting lists, reflecting the prime concerns of Clinical Commissioning Groups. IAPT has a penchant for running groups/classes without an evidence base for effectiveness. For example, it offers trauma victims a Stabilisation Group, here is how two participants fared:
Mr X had two accidents within weeks of each other and attended a 6 week course. My independent assessment found the course had no effect on his mild PTSD and mild depression and he was then put on a waiting list for individual CBT. The group sessions began with 12-15 participants and went down to 4 people. Topics covered included calming down after nightmares, mindfulness and deep breathing. Nevertheless he described the course as ‘helpful’ but was given no diagnosis at any point either in the telephone assessment or on the course.
Mr Y attended a 6 week course with initially 8-10 people and 3-4 dropping out before the end he also found the course ‘helpful’, albeit that he felt that he was not back to his usual self after the course. My independent assessment revealed that he was still suffering from PTSD after the course and he received a letter stating ‘ have now success fully completed the Stabilisation Symptom Management Course … .. you have opted to complete therapy at this time discharged you from the service’ but IAPT made no attempt at reliable diagnostic assessment before or after the course, patronisingly ‘success’ is now defined as completing an IAPT course!
Background to Stabilisation Groups
The impetus for the IAPT stabilisation groups probably derives from the Institute of Psychiatry 10 week programme teaching coping strategies for dealing with symptoms of PTSD, but in which trauma histories are not discussed . The programme uses cbt, mindfulness and relaxation techniques. But with no published study on effectiveness. IAPT has run a cut down version of this, just 6 sessions. Robertson et al at the Traumatic Stress Clinic offer 5-8 weeks of 2 hour group sessions for up to 10 people for refugees with a focus on managing hyper-arousal, anxiety, re-experiencing and dissociation but again there are no outcome studies. Like in IAPT it is intended as part of a phased treatment model but there is no evidence that it in any way adds to established treatments for PTSD.
Evidence Based Delivery of Group CBT
The Trauma Groups run in the UK bear no resemblance to those described in the Sloan et al (2018) study. The latter involved 14 2hr sessions and an adequate dose of treatment was regarded as attendance at 10 or more sessions. Though only a minority of study participants recovered from their PTSD there were high levels of satisfaction with both the trauma focused CBT intervention and with the non-trauma focused intervention. The trauma focused intervention involved writing about their trauma in 2 sessions and at home for homework. Further the trauma focussed group treatment was based on a group programme developed originally for victims of road traffic accidents. Interestingly both the trauma focused group CBT programme and the comparison Present Centred Therapy had bigger effects on coexisting generalised anxiety disorder and depression than on PTSD, the main target!
There are evidence based group protocols for depression and the anxiety disorders described in my book Simply Effective Group CBT (2011) London: Routledge.
The content for the group sessions I detailed in the book can be downloaded by clicking the link below:
I will be circulating this blog to the BABCP, Group CBT Special Interest Group, anyone interested in joining can contact Nicola at firstname.lastname@example.org
according to a recent editorial in the American Journal of Psychiatry, by Dr Robin L Aupperie, he continues ‘evidence is mounting that non trauma focused therapies may have at least equal efficacy for the treatment of PTSD’. See the link below:
he points to only 30-40% of veterans with PTSD losing their diagnostic status following trauma focussed cbt. Dr Aupepperie raises doubts about ‘the presumed essentiality of trauma processing for the effective treatment of PTSD’. I have also raised doubts about it in a paper ‘PTSD an Alternative Paradigm’ which is under submission.
But there is a need to tread carefully in that there needs to be replication studies of the non-trauma focussed interventions in real world settings i.e not just with patients volunteering for a treatment, and across a broad range of settings i.e civilian and military. Nevertheless it does raise an eyebrow when a study comparing 8 individual sessions of mantram therapy with 8 individual sessions of present centred therapy [ Borman et al (2018) Am J Psychiatry, 175:979-988] concluded that 59% of the former no longer met criteria for PTSD at 2 month follow up compared to 40% in the latter. However psychology in general is replete with studies that have not been replicated [ Chris Chambers The 7 Deadly Sins of Psychology (2017) ‘After spending fifteen years in psychology and its cousin, cognitive neuroscience, I have nevertheless reached an unsettling conclusion. If we continue as we are then psychology will diminish as a reputable science and could very well disappear’] because positive outcomes are more likely to be published [ the file drawer problem] and the originators of a theory/intervention tend to be very charasmatic, creating a placebo effect. I have a feeling that the replication crisis is not taken as seriously in clinical work, with a paucity of studies in real world settings, using ordinary therapists and employing gold-standard assessments.
Just a footnote: the mantram therapy involved the repetition of a spiritually meaningful word, initially in non stressful situations e.g before bed, then applying this flashbacks and when woken from nightmares. The idea is to slow down thoughts and induce relaxation. The present centred therapy discusses current stresses and the problem solving of them in a non formal way. But in neither intervention was there a trauma focus.
Dr Mike Scott
Here is the Powerpoint Preserntation:
Do get back to me any questions
Dr Mike Scott
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?
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
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