Getting Back To Me Post Trauma

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

‘PTSD – Swap War Zone Glasses For Specs Used A Week Before Trauma’

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

  

The Treatment of PTSD Has Been Destabilised……

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 

Groups and Trauma

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:

https://www.dropbox.com/s/qoly0wkquhzu44x/Simply%20Effective%20Group%20CBT%20All%20Appendices.pdf?dl=0

Stabilisation Groups


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:

https://www.dropbox.com/s/ys0ogfo3k93qmwb/Ptsd%20Group%20treatments%202018.pdf?dl=0

I will be circulating this blog to the BABCP, Group CBT Special Interest Group, anyone interested in joining can contact Nicola at nicoladrurywalker@fastmail.com

Dr Mike Scott

‘Optimal Outcomes Are Not Being Obtained Using Current Gold-Standard , Trauma Focused Interventions…..’

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:

https://www.dropbox.com/s/aexz30a6t04apen/PTSD%20%20trauma%20focussed%20CBT%20dogma%202018.pdf?dl=0

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

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

 

 

 

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