Coping with the aftermath of trauma: NICE guidelines on post-traumatic stress disorder have fundamental flaw

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7507.50-a (Published 30 June 2005) Cite this as: BMJ 2005;331:50
  1. Derek A Summerfield (derek.summerfield{at}slam.nhs.uk), honorary senior lecturer
  1. Institute of Psychiatry, Maudsley Hospital, London SE5 8AP

    EDITOR—Gersons and Olff discuss coping with the aftermath of trauma.1 The guidelines from the National Institute for Health and Clinical Excellence (NICE) that they mention conclude that early psychological intervention or debriefing does not prevent post-traumatic stress disorder, and might even be harmful.2 A significant reason for this is that a professional intervention can unwittingly embed a preoccupation with a traumatic event in the mind of the survivor (although intending the opposite) and thus impede forward momentum in getting back to normal.

    Yet NICE is recommending trauma focused psychological therapy—which sits on the same conceptual territory as debriefing—as first line treatment for people identified as having post-traumatic stress disorder. I agree that formal cognitive behaviour approaches would be appropriate for a minority who develop, say, a handicapping phobic avoidance pattern after a traumatic event. But re-exposure to the details of the traumatic event, and the emotions evoked by it, is highly problematic as the standard therapeutic principle underpinning the whole specialism of traumatic stress and its body of practice.

    I have seen numerous men after prolonged treatment at clinics for traumatic stress in London who have clearly been made worse. They have had repeated courses of therapy based on this re-exposure principle, with the result that a preoccupation with the past, a victim mindset, and erosion of a sense of personal agency and competence, have become highly salient as their sick role and sickness absence has extended, sometimes for years. This professionally directed attention to the past, and to “emotion,” has become fundamentally antitherapeutic. The same thing has been noted on many US veterans of the Vietnam war with “chronic post-traumatic stress disorder.”

    What is needed is a pro-rehabilitation approach, tackling the future, aiming through graded normalisation to enable them to resumption of roles and activities that formerly had signified health and competence.3 4 These NICE guidelines are storing up problems for the future.


    • Competing interests None declared.


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