Coping with the aftermath of trauma
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7499.1038 (Published 05 May 2005) Cite this as: BMJ 2005;330:1038
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As clinicians working with survivors of torture, we were interested
to read the recent editorial on the NICE PTSD guidelines1. While we too
welcome the inclusion of a section on refugees and asylum seekers, much of
which is relevant and helpful, we would contend that the 'phased model',
while attractive in its simplicity, in fact oversimplifies work with this
client group, and should be advocated with caution. While an understanding
of common phases is helpful, we contend that a more fluid and flexible
model better addresses their varying and overlapping problems.
This is particularly true of children, both unaccompanied and in
families. In our experience, trauma work can and often must be undertaken
early on, regardless of social and legal circumstances (so called 'phase
1' problems). Furthermore, we, like the authors of the editorial, agree
with Summerfield2 that any psychological interventions for this population
must take into account the socio-cultural and political context of the
individual - both past and present. We would certainly argue that there is
only a limited place for'orthodox' CBT of the type recommended in the
guidelines, and that psychotherapeutic approaches which address context
and meaning as well as trauma focused work are more likely to be
effective. Indeed, there is an argument to be made - and one that
Summerfield goes some way to making - that we still do not know the
'normal' psychological response to the extreme events experienced by many
refugees, and it does indeed belittle their suffering to construe it in
purely psychopathological terms.
William B Hopkins consultant psychiatrist and psychotherapist
Abigail Seltzer consultant psychiatrist
Jocelyn Avigaad, principal family therapist
Medical Foundation for the Care of Victims of Torture
1 Gersons BPR, Olff M. Coping with the aftermath of trauma. BMJ
2005;330:1038-9
2 Summerfield D. The invention of post-traumatic stress disorder and
the social usefulness of a psychiatric category. BMJ2001;322:95-8
Competing interests:
None declared
Competing interests: No competing interests
Gersons et al cite my BMJ paper on the importance (and it is central)
of the active conceptualising and meaning-making a person undertakes in
determining what happens after an adverse experience. (1) They might have
gone on to point out that by definition the narrow biomedical focus
largely endorsed by NICE in their recently published PTSD guidelines
cannot capture this meaning-making and thus misses the boat for most of
those affected.
The basic weakness of the PTSD model is the assumption that the
mental state and psychosocial functioning of a survivor can be wholly
explained, even years later, by the characteristics of the traumatic event
itself. This is in defiance of the whole psychiatric canon, which sees
psychiatric disorder as arising multifactorially. A range of studies, and
certainly my clinical experience with survivors over many years, strongly
suggests that pre-event characteristics (eg. previous psychiatric history,
trait neuroticism, intelligence level, the presence of religious or
political commitment) and post-event characteristics (eg. what the event
means to the person, the presence of social support ) account for more of
the variance in symptoms than do the event characteristics alone.(2)
Gersons et al quote the risk of developing PTSD after trauma as up to
one in seven in men and one in three in women. These figures are absurdly
inflated: here we see the over-pathologisation that will flow naturally
from a psychiatric category with diagnostic criteria that are largely
nonspecific, and which has poor sensitivity and specificity.
The NICE guidelines, as Gersons et al note, state that early
psychological intervention or debriefing does not prevent PTSD and might
even be harmful- this latter concern has arisen out of a number of studies
in UK, notably of burns victims and road accident survivors. A significant
reason for this potential for harm is that a professional intervention can
unwitting embed a preoccupation with a traumatic event in the mind of the
survivor (though intending the opposite), and thus impede his or her
capacity to look forwards and make active efforts to getting back to
normal life.
Yet NICE is recommending trauma focused psychological therapy- which
sits on the same conceptual territory as debriefing- as first line
treatment for those identified as suffering from PTSD. I agree that
formal cognitive behavioural approaches would be appropriate for a
minority who develop, say, a handicapping phobic avoidance pattern
following a traumatic event. But it is becoming clear that re-exposure to
the details of the traumatic event, and the feelings evoked by it, is
highly problematic as the core therapeutic principle underpinning the
whole specialism of traumatic stress and its body of practice. I have seen
a number of men who have been in prolonged treatment at traumatic stress
clinics 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, has become highly salient as
their sick role and sickness absence has extended- sometimes for years- at
the hands of the traumatic stress clinic. This professionally directed
attention to the past, and sometimes the remote past, has become
fundamentally anti-therapeutic. The same thing has been noted on many US
Vietnam war veterans with “chronic PTSD”. What these men needed was a pro
-rehabilitation approach, addressing the future, aiming through graded
normalisation to enable them to resume the roles and activities which
formerly had defined for them what it meant to them to be healthy and
competent. This would be recovery in its truest and broadest sense, not
just something happening between the ears of the person (in his or her
psychology, and subject to technical intervention) but in his or her lived
life. These NICE guidelines are capable of storing up problems for the
future, I’m afraid.
1. Summerfield D. The invention of post-traumatic stress disorder and
the social usefulness of a psychiatric category. BMJ 2001; 322: 95-98.
2. Bowman M. Individual differences in posttraumatic stress: problems with
the DSM-IV model. Can J Pstchiatry 1999; 44: 21-32
Competing interests:
None declared
Competing interests: No competing interests
Re: A fundamental flaw in NICE guidelines
Reaction to the rapid responses regarding the editorial ‘Coping with
the aftermath of trauma, NICE recommends psychological therapy for post-
traumatic stress disorder BMJ 2005; 330:1038-1039
Both rapid responses, from Summerfield and from Hopkins et al.,
criticise the narrow biomedical approach of the NICE guidelines.
Especially Summerfield argues the guideline is ‘fundamentally flawed’
because the problems of a person, even many years after traumatic
experiences, is framed within the diagnosis of PTSD. Psychological
treatment for PTSD than does not pay attention to the whole life situation
of such a person. Summerfield, on the basis of his clinical observations
recommends a rehabilitative approach for traumatized people. Hopkins et
al., working with refugees, also state such an approach ‘indeed does
belittle their suffering to construe it in pure psychopathological terms’.
Both comments in fact have a much wider significance in their warning for
not seeing a patient but only a ‘disease’. But where regarding other
diseases like diabetes doctors are obliged to pay attention also to the
disease itself to improve the condition of the patient, regarding
posttraumatic stress disorder the ‘denial’ of the disorder is seen as
morally necessary to ‘respect’ the ‘survivor’ of a trauma.
And it seems especially in those working with refugees often it is
felt as a humiliation to give a person a diagnosis of PTSD and even
treatment as if such a survivor is disabled to go on with his or her life.
In fact it is a partly understandable but also peculiar dilemma. People
who survive the most terrible situations show strong ness and they should
be respected. But they also quite often suffer from the symptoms of PTSD
which makes their adaptation to new circumstances difficult or even
impossible. In the NICE guideline this dilemma is in the small chapter on
refugees acknowledged. Those who are working with refugees and after war
and terror should not forget the wholeness of a person and the
complexities of day to day life but should also respect the need for
psychological treatment to help the patient to adapt better to all the
difficulties around.
Berthold Gersons & Miranda Olff
Competing interests:
None declared
Competing interests: No competing interests