Exporting trauma: can the talking cure do more harm than good?

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civil war, community, coping strategies, counsellors, crisis, cultural insight, cultural practices, culturally sensitive, culture, Depression, Genocide, group therapy, interventions, mental health issues, NGOs, post traumatic stress disorder, psychological therapy, psychosocial, PTSD, rape, talking therapy, traditional, trauma, treatment, tsunami, well-being, western

Exporting trauma: can the talking cure do more harm than good?

A few years ago Andrew Solomon had to get into a wedding bed with a ram. An entire village, taking a day off from farming, danced around the unlikely couple to a pounding drumbeat, draping them both in cloth until Solomon began to think he was going to faint. At this point the ram was slaughtered along with two cockerels, and Solomon’s naked body was drenched in the animals’ blood, before being washed clean by the village women spitting water onto him.

Solomon had been taking part in a traditional Senegalese ceremony to exorcise depression as research for his book The Noonday Demon. “I discovered that depression exists universally, but the ways that it’s understood, treated, conceptualised or even experienced can vary a great deal from culture to culture,” he says now. He describes being the subject of the ceremony as “one of the most fascinating experiences of my life”.

When in Rwanda, interviewing women raising children born of rape for another book, Solomon mentioned his experience in Senegal to a Rwandan man who ran an organisation helping these women. The Rwandan told Solomon they had similar ceremonies in his country and that the disconnect between the western and traditional approaches to treating mental health had caused problems in the immediate aftermath of the genocide. “Westerners were optimistically hoping they could heal what had gone wrong,” says Solomon. “But people who hadn’t been through the genocide couldn’t understand how bad it was and their attempts to reframe everything were somewhere between offensive and ludicrous. The Rwandan felt that the aid workers were intrusive and re-traumatising people by dragging them back through their stories.”

As the Rwandan, paraphrased by Solomon, puts it: “Their practice did not involve being outside in the sun where you begin to feel better. There was no music or drumming to get your blood flowing again. There was no sense that everyone had taken the day off so that the entire community could come together to try to lift you up and bring you back to joy. Instead they would take people one at a time into these dingy little rooms and have them sit around for an hour or so and talk about bad things that had happened to them. We had to ask them to leave.”

The best way to improve mental health after a crisis is something NGOs working in Ebola-hit countries are currently considering. International Medical Corps (IMC) recently released a report assessing the psychological needs of communities affected by the disease. IMC’s mental health adviser Inka Weissbecker is aware that they must avoid previous mistakes by international NGOs. “Whenever there is a humanitarian crisis agencies flood in,” she says. “Though with good intentions, counsellors turn up from the UK [for example] and often create more problems … It’s a very foreign concept in many countries to sit down with a stranger and talk about your most intimate problems.”

During the recovery from Haiti’s earthquake five years ago mental health researcher Guerda Nicolas was even stronger in her message to American counsellors who wanted to ease the trauma of survivors. “Please stay away – unless you’ve really, really done the homework,” she said. “Psychological issues don’t transcend around the globe.”

The fact is that different cultures have different views of the mind, says Ethan Watters, the author of Crazy Like Us: The Globalization of the American Psyche. “In the west a soldier coming home might be troubled by their battlefield trauma. They think of the PTSD [post-traumatic stress disorder] as a sickness in their mind and they take time away from responsibilities to heal. That makes sense to us and it’s neither wrong nor right but conforms to our beliefs about PTSD. For a Sri Lankan, to take time away from their social group makes no sense because it is through their place in that group that they find their deepest sense of themselves.”

While researching his book Watters spoke to anthropologists who had in-depth knowledge of Sri Lanka’s culture and history. They said that western approaches after the tsunami had done real damage in the country where there were certain ways to talk about violence due to the long-running civil war. He says: “Into that very delicate balance came western trauma counsellors with this idea that the real way to heal was truth-telling, where you talked about the violence and emotionally relived it. That’s a western idea, it makes sense here, but it does not make sense in these villages. It had potential to spark cycles of revenge violence.”

International NGOs describe dealing with the mental health of a community after a disaster as the “psychosocial” response – meaning caring for individual and collective psychological wellbeing. The UN advertises dozens of jobs under this keyword and the American Red Cross says that since the 2004 Boxing Day tsunami there has been “increasing recognition of the need for psychosocial responses”. It also says – perhaps implicitly acknowledging that mistakes have been made in the past – “we are still in the process of identifying and documenting good practices”.

As awareness has grown that the western talking cure is not always the answer, global organisations have tried to find better ways to help. In 2007 WHO issued guidelines to advise humanitarians on their work to improve mental health and psychosocial wellbeing in emergencies. Coordination between the organisations working in the post-disaster zone as a key recommendation. Weissbecker says that this is crucial. “We reach out to organisations who might not know about the guidelines to coordinate,” she says. “It’s part of every agency’s job to watch out for other organisations doing this kind of work.”

The guidelines also stress learning local cultural practices. IMC now always start with an initial assessment that looks at the understanding and treatment of mental health that exists in that country before putting any programmes in place. “We usually don’t provide direct mental health services to the affected population because we feel that most of the time that’s not culturally appropriate and not sustainable,” says Weissbecker. In many communities, she has been impressed with indigenous coping strategies. “In Ethiopia people say depression is related to loss,” she says. “So the community takes up a collection and they all give them something. This is very positive.” IMC meets with traditional healers and builds up relationships with them.

Many argue that for some mental illnesses western expertise can be genuinely helpful. In Ethiopia Weissbecker’s team discovered a man with schizophrenia who had been tied up in a goat shed for seven years. “Once this family was connected to our services he started taking medication was unchained and participating in family life,” she says. “The father held up the chains to the community and said, ‘look I used these chains on my son and now he’s part of the family again’. People will throw stones because they are understandably frightened [of people with severe conditions].”

The Rwandan that Solomon met questioned whether talking therapy helped survivors of the Rwandan genocide. “His point of view was that a lot of what made sense in the west didn’t make any sense to him,” says Solomon. But Survivors Fund, a British NGO that works in Rwanda, has found that western-style group therapy sessions have really helped women who were raped. “It’s 20 years since then but many of the women our groups have never told their story before,” says Dr Jemma Hogwood who runs counselling programmes for the charity. “A lot of women say it’s a big relief to talk,” she says.

Hogwood has been working in Rwanda for four years but hasn’t heard of traditional ceremonies like the one described by Solomon. The group therapy sessions incorporate local practices such as praying before and after, as this is something the women wanted to do. Weissbecker adds that one-on-one therapy with expats can help people who have experienced extreme violence, rape or torture. “Some of them want to talk to foreigners because they don’t trust people in their communities,” she says. “So then it’s also important for them to have that one-on-one option.”

Some feel that aid should be focussed on food, medicines, shelter, and stay away from mental health. International relations academic Vanessa Pupavac has researched the effect of the war in former Yugoslavia, and has argued that “trauma is displacing hunger in western coverage of wars and disasters … Trauma counselling, or what is known as psychosocial intervention, has become an integral part of the humanitarian response in wars.” The problem with this, she believes, is that blanket-defining a whole population as traumatised becomes “a reinforcing factor that inhibits people from recovery”. Her recent work with Croatian veterans found that the PTSD label stops them from moving on with their lives and contributing to society.

“There are more Croatian veterans on post-traumatic stress disorder pensions now than there were ten years ago,” she tells me. “The international-PTSD-framing of people’s experiences has not only inhibited recovery but has also created social, economic and political problems for postwar Croatia.” She believes NGOs should stop psychosocial programmes altogether because they disrupt communities’ own coping strategies.

But this point of view is rejected by Weissbecker and her colleagues, who don’t accept “the romantic idea that without intervention everything will be fine”. The response to mental illness in many countries is often harmful, she says: “Psychotic patients are chained. Children with developmental disorders are at risk of abuse. Mothers with depression have a higher risk of malnourished children. People with anxiety are often given benzodiazepines which can be very addictive.” The solution, Weissbecker says, is to bring together global and local expertise.

The best experts to bridge the gap between international and local experience are those who might not have a health or psychology background, but have deep knowledge about cultural differences: anthropologists. Since the Ebola outbreak there is a growing recognition of this discipline’s role in emergencies. The American Anthropological Association has asked its members to become more involved in the west African countries hit by the disease. It argues that if anthropologists had been more involved from the start of the outbreak more people wouldn’t have caught the disease due to misunderstandings over traditional burials and conspiracy theories about westerners spreading the illness.

Médecins Sans Frontières (MSF) has employed anthropologists to inform their work for years but one of them, Beverley Stringer, says there’s been a “surge” in interest in what they can offer humanitarian work. “I was at a seminar at the Royal Anthropology Institute recently where they said ‘finally the humanitarian world is interested in our perspective’,” she says. “They’re quite excited about that.”

But Stringer warns that getting anthropologists to work for NGOs should not just be a case of parachuting in an expert; aid workers and volunteers on the ground need to recognise that their own experience gives them insight. “If mums aren’t coming to get their kids vaccinated you don’t need to be an anthropologist to work out why,” she says. “My work is to encourage curiosity and to equip teams with the skills to be able to understand.”

Whether it’s through working more with locals and anthropologists – or ideally both – there is recognition that cultural insight is essential for preventing aid workers from causing damage when they are trying to do good.

“I think enlisting the anthropologists in this process – people who truly know about how to go into other countries and be culturally sensitive – is very important,” says Watters.

“One anthropologist asked me to imagine the scenario reversed. Imagine that after 9/11 or Katrina these healers come from Mozambique to knock on the doors of family members of the deceased to say ‘we need to help you through this ritual to sever your relationship with the dead’. That would make no sense to us. But we seem to have no problem doing the reverse.”

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Dispelling the nightmares of post-traumatic stress disorder

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avoidance, behaviour, cbt, distress, Ehlers and Clark, flashback, hyperarousal, interpretations, low mood, Memory, negative thoughts, nightmares, post traumatic stress disorder, psychological effects, psychotherapy, PTSD, reliving, reminders, symptoms, threat, trauma, trauma memories, traumatic event, treatment, triggers

Dispelling the nightmares of post-traumatic stress disorder

On Wednesday morning we woke to the news that a passenger ferry had sunk off the coast of South Korea, with at least four people confirmed dead and 280 unaccounted for. Meanwhile, though the search has continued for the missing Malaysia Airlines plane, relatives’ hopes of a safe landing have long since been extinguished.

Human tragedies like these are the stuff of daily news, but we rarely hear about the long-term psychological effects on survivors and the bereaved, who may experience the symptoms of post-traumatic stress disorder for years after their experience.

Although most people have heard of PTSD, few will have a clear idea of what it entails. The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) defines a traumatic event as one in which a person “experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others”. PTSD is marked by four types of responses to the trauma. First, patients repeatedly relive the event, either in the form of nightmares or flashbacks. Second, they seek to avoid any reminder of the traumatic event. Third, they feel constantly on edge. Fourth, they are plagued with negative thoughts and low mood.

According to one estimate, almost 8% of people will develop PTSD during their lifetime. Clearly trauma (and PTSD) can strike anyone, but the risks of developing the condition are not equally distributed. Rates are higher in socially disadvantaged areas, for instance. Women may be twice as likely to develop PTSD as men. This is partly because women are at greater risk of the kinds of trauma that commonly produce PTSD (rape, for example). Nevertheless – and for unknown reasons – when exposed to the same type of trauma, women are more susceptible to PTSD than men.

What causes it? In one sense, the answer is obvious: a specific trauma. Yet this is only part of the story, because not everyone who is raped or badly beaten up develops PTSD. Of the contemporary psychological attempts to answer that question, the most influential is the one formulated by the clinical psychologists Anke Ehlers and David Clark at the University of Oxford.

They argue that PTSD develops when the person believes they are still seriously threatened by the trauma they have experienced. Why should someone assume they are still endangered by an event that happened months or even years previously? Ehlers and Clark identify two factors.

First is a negative interpretation of the trauma and the normal feelings that follow, for example believing that “nowhere is safe”, “I attract disaster”, or “I can’t cope with stress”. These interpretations can make the person feel in danger physically (the world seems unsafe), or psychologically (their self-confidence and sense of well-being feel irreparably damaged).

Second are problems with the memory of the trauma. Partly because of the way the person experiences the event, the memory somehow fails to acquire a properly developed context and meaning. As a result, it constantly intrudes. Ehlers and Clark liken the traumatic memory to “a cupboard in which many things have been thrown in quickly and in a disorganised fashion, so it is impossible to fully close the door and things fall out at unpredictable times”.

These factors change the way people behave. They may avoid situations that might spark a memory of the trauma, and will sometimes try to deaden their feelings with drink or drugs. Yet these strategies tend to entrench and exacerbate the problem.

PTSD can be treated with antidepressants or various kinds of psychotherapy, including prolonged exposure therapy and eye movement desensitisation and reprocessing. However, a recent meta-analysis of 112 studies conducted over the past 30 years found that cognitive behavioural therapy (CBT) was the single most successful type of treatment.

CBT typically comprises three main strands. First, it evaluates the individual’s excessively negative thoughts about the trauma and its aftermath – for example by helping them understand that they are not to blame or that their feelings are normal and natural. Second, the treatment works on the person’s memory of the trauma: the individual might be asked to write a detailed account of the event; relive it in their imagination; revisit the site of the trauma; or be shown how to cope with the kind of objects or situations that trigger the traumatic memory.

The final strand involves tackling the kind of behaviours that tend to fuel PTSD, for example by demonstrating that attempting to suppress a thought is futile (if you doubt it, try right now not to think of a white bear) or that avoiding a situation only strengthens one’s fear.

A course of CBT for PTSD normally involves meeting with a therapist once or twice a week over several months. Given how debilitating the problem can be, that can seem like a very long time to wait to get one’s life back on track. However, pioneering research published in last month’s issue of The American Journal of Psychiatry suggests that there may be an alternative. Instead of months, it may be possible to tackle the symptoms of PTSD in just seven days.

Anke Ehlers at the University of Oxford and her colleagues randomly assigned 121 patients with PTSD (about 60% female, 40% male) either to a seven-day course of intensive CBT; weekly sessions of CBT for three months; a type of psychotherapy known as emotion-focused supportive counselling; or to a 14-week waiting list. Participants in the first three groups all received the same amount of therapy (18 hours).

The results were striking. The intensive CBT proved almost as successful as the standard three-month course, with respective recovery rates from PTSD of 73% and 77%, and the intensive version produced its effects more quickly. For the supportive counselling group, recovery was 43% (another finding that undermines the idea that all types of psychotherapy are equally effective). Among the waiting list group, just 7% had recovered. Both courses of CBT also led to large reductions in levels of anxiety and depression.

Most importantly, the benefits lasted: 40 weeks after entering the study, about two-thirds of the CBT patients were still free from the symptoms of PTSD. The therapy isn’t easy – it confronts highly distressing events and feelings, after all – but it works.

Follow @ProfDFreeman and @JasonFreeman100 on Twitter

‘Running helps me with cope with post-traumatic stress disorder’

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anxiety, Depression, memories, PTSD, running

‘Running helps me with cope with post-traumatic stress disorder’

I am a runner – and I suffer from post-traumatic stress disorder. One of the many things I think about while I’m running, and also when I’m not, is the relationship between the two.

I have always loved to run, and I have fuzzy memories of running pretty much anywhere, anytime, as a child. We would spend family holidays in north Wales, and I remember galloping into the hills, pretending to be a horse, then sitting in the grass and watching a snowstorm move up the valley. Now in my 40s, running has become far more structured, and an essential contribution to my life and ability to manage my illness. Yet I find that some people are concerned about my need for it, which always surprises me, as it seems like a positive thing to do. One doctor recently asked me if it felt like I was running away and I answered: “What does it matter? It makes me feel better.”

Experiences of loss and repeated trauma from childhood resulted in an early onset of depression and severe anxiety, culminating in a complete breakdown at 27 from which I’ve never fully recovered. It took over 30 years of seeing multiple mental health professionals before I even had an explanation for my inability to get well (a correct diagnosis was only reached in my late30s). A good day for me is managing the walk to my son’s school, greeting teachers and other parents, then perhaps doing some food shopping, without having a panic attack. On a really good day, I might have a friend round for coffee and a chat, but by and large my life is isolated – and that’s OK. My wonderful husband enjoys taking the boys out, while I (for the most part) am the stay-at-home support. I have more than I ever dreamed possible.

Four years ago, my husband’s work took us to the US, where our second son was born, and shortly after that a friend introduced me to trail running. I have always felt at home in the mountains, and the Appalachians are breathtakingly beautiful. At first, I couldn’t manage more than a mile or two without stopping, but I nonetheless made the most incredible discovery. How to articulate this? As well as the powerful medicinal effect of being surrounded by nature, running makes life feel simple. Battling an illness such as mine is utterly debilitating all day, every day, year after year. There is no respite. Many people will know what I mean when I refer to having a dream where you are suddenly, sharply falling, causing you to wake with a jolt and a racing heart. I have this sensation many times a day while wide awake, for absolutely no visible reason – I am perpetually fearful. In addition to this, the depression (and grief) can be crippling: it slowly numbs your brain and sends your body into a state I imagine being rather like hibernation – an attempt to withdraw from the pain. Going for a run not only gets me physically moving, it also takes my thoughts out of the equation: all I have to do is keep putting one foot in front of the other and breathe.

Initially, my incentive was an 18-mile trail race up a mountain, with a total of around 5,300ft of ascent. Having been a 100-metre sprinter at school, this seemed like an impossible, if not ludicrous, goal, but it somehow represented my life. I knew a run of that magnitude was going to be physically and mentally exhausting, as well as painful, but I needed, at the very least, to survive it. It was a daunting challenge, and I was almost convinced that failure was inevitable, but I approached it by being scientific: reading, researching, asking advice and putting my trust in training. Even just getting out for a run could be next to impossible, due to my agoraphobia. Some runs would be particularly fast, with the extra injection of fear-induced adrenaline. And I had a very patient, kind partner for the weekend long runs, which I could never have done on my own.

On the day of the race, I kept my head down to avoid total panic among the crowd of runners at the start and set no time target: it was about getting to my family at the finish line and looking at the view from the top of the mountain; being, for once in my life, one of the achievers.

That was over a year ago, and we have now moved to yet another country, but I have brought the running with me, along with my race finisher’s shirt. Our new home backs onto 2,000ft of rugged hill, with rocky, brutally steep trails to the summit, from where miles and miles of mountain tops stretch away to the edge of the Earth. I embrace running in all weathers: sun, heavy rain, high winds, snow and hail, always with a considerable amount of ascent. As I fight my way up the climbs, I often imagine that the hill is my illness and I am going to slowly and steadily conquer it. Yet it never feels like suffering and, once at the top of the hill, I can reach out and touch the sky. At home, I am always struggling to stay afloat, fearing I will lose the battle with my illness and fail my husband and children, but all of that slips away when I am running. It is just me and the hills and some long-distant memories, and I always come home smiling and with my head full of stillness.

Malnutrition in conflict: the psychological cause

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Children, conflict, despair, displaced, flashback, hopelessness, hypervigilant, infanticide, irritability, isolation, malnutrition, natural disasters, parents, post-traumatic stress, psychological support, recovery, signs, suicide, trauma, violence

Malnutrition in conflict: the psychological cause

Treating malnutrition in humanitarian crises, such as conflict and natural disaster, is far more complex than simply curing disease and providing children with therapeutic foods. Often, post-traumatic stress disorder – common in extreme situations – hinders treatment and its success. In Bangui, in the Central African Republic (CAR), the number of children suffering from life-threatening malnutrition has tripled since the outbreak of violence in December 2013.

Each month, 180 patients are being seen in a ward that initially had just 49 beds available for malnourished children. For many weeks, two to three patients – and their caregivers – were sharing single beds, increasing the risk of cross-infection of illness and delaying recovery.

The cause of severe acute malnutrition runs far beyond economic hardship and lack of food. Many of the hundreds of thousands of people displaced by fighting have been directly exposed to death threats, witnessed the deaths of neighbours or family members, and lost nearly all of their belongings. They are often exhausted by the harsh living conditions in camps.

75% of over 1,000 case studies of the parents of malnourished children collected by Action Against Hunger between July 2013 and March 2014 presented symptoms of post-traumatic stress linked to their exposure to extreme violence. The stress prompted behavioural changes, flashbacks, fatigue, isolation, excessive irritability, and feelings of hopelessness and despair.

These experiences also provoked reactions that – while understandable, normal, and usually temporary – can be disabling enough to impact a mother’s ability to nurse and feed her child. Nurses leading pre- and post-natal sessions with women in the 12 health centres around Bangui have reported that some mothers become convinced they cannot produce milk, or fail to respond to their child’s needs, resulting in early weaning that can be fatal for babies in an already challenging environment. In extreme cases, some mothers have attempted suicide and infanticide.

Children, while too young to fully understand what they have witnessed, may develop physical symptoms such as continuous crying, refusing to eat and bed wetting. Even small babies can present signs of trauma, such as feeding and sleep disturbances, continuous crying, and poor interaction. Not recognising the signs, some parents don’t make the connection and severely scold their children. To combat this, malnourished children and their carers are receiving psychological and social support.

At the nutritional therapeutic ward of Bangui’s main pediatric hospital, Action Against Hunger’s nutritional, psychological and social teams offer free treatment for severely malnourished children from a specialised counselling team. Feeding times, medical monitoring and psychological and motor activities pace the daily routine.

When Dieumerci Tsongbele, a single parent to his six-year-old daughter Jessica, arrived at the hospital, she had been refusing food and was not interacting with others. When he joined a welcoming session led by psychological and social experts, Tsongbele and other parents learned about factors that exacerbate malnutrition, including trauma. The information evoked an emotional response from the father, who had witnessed people killed. While he managed to escape the violence, the experience had left him unable to sleep, irritable and hypervigilant. Overwhelmed by the situation, he admitted he had been less attentive to his daughter’s needs.

During the programme, Tsongbele and the other parents participated in various activities with their children ranging from toy making to baby massage, which aim to provide both parents and children with a safe space to recreate natural and vital bonds that are essential for human development. Play sessions help to limit the negative effects of malnutrition strengthen parent-child relationships. Malnutrition treatment is not simply about filling stomachs, but also restoring the desire to eat.

Names have been changed to protect identities.

Stephanie Duvergé is a Action Against Hunger psychologist in the Central African Republic. Follow @ACF_UK on Twitter.

What doesn’t kill us…

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adversity, autonomy, avoidance, cognitive processing, compassion, coping, distress, family, friends, gratitude, Grief, intrusion, measures, personal growth, positive changes, post-traumatic growth, post-traumatic stress, psychologists, psychology, PTSD, relationships, resilience, self-acceptance, Self-esteem, support, theory, trauma, vulnerability, well-being

What doesn’t kill us…

The field of psychological trauma is changing as researchers recognise that adversity does not always lead to a damaged and dysfunctional life. Post-traumatic growth refers to how adversity can be a springboard to higher levels of psychological well-being. This article provides an overview of theory, practice and research. To what extent is post-traumatic stress the engine of post-traumatic growth? How can clinicians measure change? What can help people to thrive following adversity?

Suffering is universal: you attempt to subvert it so that it does not have a destructive, negative effect. You turn it around so that it becomes a creative, positive force.
Terry Waite, who survived four years as a hostage in solitary confinement (quoted in Joseph, 2012, p.143)

Scientific interest in positive changes following adversity was sparked when a handful of studies appeared in the late 1980s and early 1990s, reporting positive changes in, for example, rape survivors, male cardiac patients, bereaved adults, survivors of shipping disaster, and combat veterans. Then, the topic of post-traumatic stress disorder (PTSD) was relatively new (following its introduction in 1980 by the American Psychiatric Association), and was attracting much research interest. The relatively few observations of positive change were overshadowed by research on the ways in which trauma could lead to the destruction and devastation of a person’s life.

But interest in how trauma can be a catalyst for positive changes began to take hold during the mid 1990s when the concept of post-traumatic growth (Tedeschi & Calhoun, 1996) was introduced. It proved to be popular and became the descriptor for a field of inquiry attracting international attention from researchers, scholars and practitioners (see, Calhoun & Tedeschi, 2006; Joseph & Linley, 2008a; Weiss & Berger, 2010). Over the past decade it has developed into one of the flagship topics for positive psychology (Seligman, 2011). This article aims to provide a state-of-the-art review of the psychology of post-traumatic growth.

What is post-traumatic growth?
After experiencing a traumatic event, people often report three ways in which their psychological functioning increases:
1.    Relationships are enhanced in some way. For example, people describe that they come to value their friends and family more, feel an increased sense of compassion for others and a longing for more intimate relationships.
2.    People change their views of themselves. For example, developing in wisdom, personal strength and gratitude, perhaps coupled with a greater acceptance of their vulnerabilities and limitations.
3.    People describe changes in their life philosophy. For example, finding a fresh appreciation for each new day and re-evaluating their understanding of what really matters in life, becoming less materialistic and more able to live in the present.

Several self-report psychometric tools were published during the 1990s to assess positive changes following trauma, the first such measure was the Changes in Outlook Questionnaire (Joseph et al., 1993), followed by the Posttraumatic Growth Inventory (Tedeschi & Calhoun, 1996); the Stress Related Growth Scale (Park et al., 1996), the Perceived Benefit Scale (McMillen & Fisher, 1998), and the Thriving Scale (Abraido-Lanza et al., 1998). Each of these measures asks respondents to think about how they have changed since an event and to rate the extent of their change on a series of items.

Using such measures of perceived growth, and open-ended interviews, a large number of studies have shown that growth is common for survivors of various traumatic events, including transportation accidents (shipping disasters, plane crashes, car accidents), natural disasters (hurricanes, earthquakes), interpersonal experiences (combat, rape, sexual assault, child abuse), medical problems (cancer, heart attack, brain injury, spinal cord injury, HIV/AIDS, leukaemia, rheumatoid arthritis, multiple sclerosis) and other life experiences (relationship breakdown, parental divorce, bereavement, emigration). Typically 30–70 per cent of survivors will say that they have experienced positive changes of one form or another (Linley & Joseph, 2004).

Practitioners in health, clinical and counselling psychology will encounter patients daily whose lives have been affected by such events. Up to now practitioners may have drawn on theories of post-traumatic stress to help their patients. A pressing theoretical issue therefore is the relation between post-traumatic stress and post-traumatic growth. How can these new ideas improve how we work with patients?

Theory and practice of post-traumatic growth
Research is now untangling a seemingly intricate dance between post-traumatic stress processes and post-traumatic growth. The most successful attempt to date is organismic valuing theory, which explains how post-traumatic growth arises as a result of post-traumatic stress. This is a person-centred theory that draws together information processing and social cognitive theories of post-traumatic stress with research on self-determination theory. The theory shows trauma leads to a breakdown in self-structure, signalled by the experiences of post-traumatic stress indicating the need to cognitively process the new trauma-related information. People are intrinsically motivated towards processing the new trauma-related information in ways that maximise their psychological well-being (Joseph & Linley, 2005, 2006).

Organismic valuing refers to how intrinsic motivation is experienced by the person. One woman who was caught up in a fatal shooting in which her close friend was killed, and who had suffered from considerable post-traumatic stress for several years, said how she woke early one morning after a night of restless sleep and got up to look at a picture of her children:

In the silent wee hours of the morning, I sat staring at their picture and began to sob. Through my sobs, I heard the real voice of wisdom I believe we all possess. It was my voice, the voice that knows me best, but a voice that had become muted. Guess what. No one is coming to change the situation. No one will rescue you. No one can. It’s up to you. Find your strength. I realised that as long as I remained a victim, I too made my family a victim. My anxiety could only teach them to be anxious. I was robbing them of happiness and a positive outlook on the world. I had come to the intersection of intersections. I could choose to end my life or I could choose to live. I needed to live for my family – and later I understood most importantly, for myself. (quoted in Joseph, 2012, p.142)

Post-traumatic growth involves the rebuilding of the shattered assumptive world. This can be illustrated through the metaphor of the shattered vase. Imagine that one day you accidentally knock a treasured vase off its perch. It smashes into tiny pieces. What do you do? Do you try to put the vase back together as it was? Do you collect the pieces and drop them in the rubbish, as the vase is a total loss? Or do you pick up the beautiful coloured pieces and use them to make something new – such as a colourful mosaic? When adversity strikes, people often feel that at least some part of them – be it their views of the world, their sense of themselves, their relationships – has been smashed. Those who try to put their lives back together exactly as they were remain fractured and vulnerable. But those who accept the breakage and build themselves anew become more resilient and open to new ways of living.

These changes do not necessarily mean that the person will be entirely free of the memories of what has happened to them, the grief they experience or other forms of distress, but that they live their lives more meaningfully in the light of what happened.

The implication of organismic valuing theory is that post-traumatic stress is the catalyst for post-traumatic growth. Helgeson et al. (2006) conducted a meta-analytic review concluding that greater post-traumatic growth was related to more intrusive and avoidant post-traumatic stress experiences. As intrusion and avoidance are generally seen as symptoms of PTSD at first glance this result would seem to suggest that post-traumatic growth is indicative of poor mental health, but consistent with organismic valuing theory Helgeson et al. suggest is that these constructs reflect cognitive processing:
Experiencing intrusive thoughts about a stressor may be a signal that people are working through the implications of the stressor for their lives, and these implications could lead to growth. In fact, some might argue that a period of contemplation and consideration of the stressor is necessary for growth to occur. (p.810)

It is in this sense that post-traumatic stress can be conceptualised as the engine of post-traumatic growth. This is also the conclusion of a recent study by Dekel and colleagues (2012), who set out to shed light on the interplay between PTSD and post-traumatic growth. Using longitudinal self-report data from Israeli combat veterans who were studied over 17 years, with assessment at three time points, the researchers found that greater PTSD in 1991 predicted greater growth in 2003, and greater PTSD in 2003 predicted greater growth in 2008.
However, it also seems that the relationship between post-traumatic growth and post-traumatic stress is a function of the intensity of post-traumatic stress. Butler et al. (2005), for example, in their study following the attacks of September 2001, found that greater post-traumatic stress was associated with greater post-traumatic growth, but only up to a point, above which post-traumatic growth declines.

Could there be a curvilinear relationship between post-traumatic stress and post-traumatic growth? Low levels of post-traumatic stress reactions indicate that the person has been minimally affected, thus one would expect minimal post-traumatic growth. A moderate level of post-traumatic stress is indicative that the individual’s assumptive world has in some way been challenged triggering the intrusive and avoidant experiences, but the person remains able to cope, think clearly, and engage sufficiently in the necessary affective-cognitive processing needed to work through. A high level of post-traumatic stress, however, where a diagnosis of PTSD might be considered, is likely to mean that the person’s coping ability is undermined and their ability to affectively-cognitively process and work through their experience is impeded. The inverted U-shape relationship between post-traumatic stress and post-traumatic growth has been reported in several studies (e.g. Kunst, 2010).

Thus, through the above research and theory we are developing a new understanding of psychological trauma that integrates post-traumatic stress and post-traumatic growth within a single conceptual framework which can guide clinical practice. A new constructive narrative framework that can guide practitioners is the THRIVE model (Joseph, 2012). THRIVE consists of six signposts (see box). Starting with ‘taking stock’, the therapist works with the client to alleviate problems of post-traumatic stress sufficiently so as to enable them to engage in effortful cognitive processing. Then follows five further signposts in which the therapist can work alongside the client. Post-traumatic growth provides practitioners with a new set of tools in their armoury for working with traumatised patients. 

New directions
Each of the measures mentioned above provides a particular operational definition of the construct, and they tend to be only moderately inter-correlated. Unlike, for example, the construct of post-traumatic stress disorder, which has an agreed definition provided by DSM around which measurement tools can be developed, there is no gold standard definition of post-traumatic growth. One suggestion arising from organismic valuing theory is to reframe post-traumatic growth as an increase in psychological well-being (PWB) as opposed to subjective well-being (SWB) (Joseph & Linley, 2008b). Traditionally, the focus of clinical psychology has been on SWB, which can be broadly defined as emotional states. Clinical psychology has been largely concerned with the alleviation of negative emotional states. With positive psychology in the background, clinical psychologists are now also concerned with the facilitation of positive emotional states. But post-traumatic growth does not refer to a positive emotional state but to an increase in PWB, defined as high levels of autonomy, environmental mastery, positive relations with others, openness to personal growth, purpose in life and self-acceptance (see box).

The topic of post-traumatic growth has also attracted interest from quantitative researchers in personality and social psychology. People may say they have grown, but have they really? There is a limitation to the above-mentioned measures, which is that they rely on retrospective accounts of change – that is, asking people to report on what positive changes they perceive themselves to have experienced since an event. We might refer to this as perceptions of growth to distinguish from actual growth, as measured by calculating the difference between state measures of psychological well-being before and after trauma.

Research suggests that the strength of association between actual and perceived growth is moderated by the degree of distress: for those who are most distressed there is a weaker correlation, but for those who are less distressed there is a moderate association (Gunty et al., 2011). It may be that perceptions of growth are at times illusory and a way of coping with distress (Zoellner & Maercker, 2006). Therefore researchers do need to be wary of always taking reports of growth at face value, particularly in the immediate aftermath of a crisis when people are most distressed.

However, while we may question people’s perceptions of growth, there is no question that actual post-traumatic growth occurs, as this has been demonstrated in before-and-after studies (e.g. Peterson & Seligman, 2003). What is now needed are more prospective longitudinal studies able to document the development of growth over time, how both actual and perceived growth co-vary over time and how they relate to other variables – both as outcome variables in order to understand the development of growth, and as predictor variables in order to understand the consequences of growth. Research shows that greater post-traumatic growth is associated with: personality factors, such as emotional stability, extraversion, openness to experience, optimism and self-esteem; ways of coping, such as acceptance, positive reframing, seeking social support, turning to religion, problem solving; and social support factors (Prati & Pietrantoni, 2009). But now more sophisticated theoretically informed designs are also called for in which we can begin to understand the factors that mediate and moderate post-traumatic stress and thus lead to post-traumatic growth. As an example of the directions that social and personality researchers may pursue, in one recent study it was found that emotion-focused coping mediated the association between subjective ratings of distress and post-traumatic growth and that emotional intelligence moderated
the association between emotion-focused coping and post-traumatic growth (Linley et al., 2011). While there is much that can be learned from quantitative research, there is also a need for qualitative research to explore new contexts (e.g. Splevins et al., 2011) and interventions (e.g. Hefferon et al., 2008).

Conclusion

The idea of post-traumatic growth has become one of the most exciting topics in modern psychology because it changes how we think about psychological trauma. Psychologists are beginning to realise that post-traumatic stress following trauma is not always a sign of disorder. Instead, post-traumatic stress can signal that the person is going through a normal and natural emotional struggle to rebuild their lives and make sense of what has befallen them. Sadly it often takes a tragic event in our lives before we make such changes. Survivors have much to teach those of us who haven’t experienced such traumas about how to live.

Box

THRIVE
Taking stock (Making sure the client is safe and helping them learn to manage their post-traumatic stress to tolerable levels, e.g. through exposure-related exercises).
Harvesting hope (Learning to be hopeful about the future, e.g. looking for inspirational stories of people who have overcome similar obstacles).
Re-authoring (Storytelling, e.g. using expressive writing techniques to find new perspectives).
Identifying change (Noticing post-traumatic growth, e.g. using the  Psychological Well-Being Post-Traumatic Changes Questionnaire  to track change).
Valuing change (Developing awareness of new priorities, e.g. positive psychology gratitude exercise).
Expressing change in action (Actively seeking to put post-traumatic growth into the external world, e.g. making a plan of activity for following week that involves doing concrete things).

BOX: Assessing growth
Think of how you yourself have been influenced by events in your own life. The Psychological Well-Being Post-Traumatic Changes Questionnaire (PWB-PTCQ) was developed to assess post-traumatic growth as defined by an increase in PWB. The PWB-PTCQ is an 18-item self-report tool in which people rate how much they have changed as a result of the trauma. A short six-item version is shown below.

Read each statement below and rate how you have changed as a result of the trauma.

5     = Much more so now
4     = A bit more so now
3     = I feel the same about this as before
2     = A bit less so now
1     = Much less so now

1.    I like myself
2.    I have confidence in my opinions
3.    I have a sense of purpose in life
4.    I have strong and close relationships in my life
5.    I feel I am in control of my life
6.    I am open to new experiences that challenge me

People may find it useful to use the PWB-PTCQ to gain insight into how they have changed. Often these dimensions of change go unnoticed in everyday life but deserve to be flagged up and nurtured. Clinicians will find the new tool useful as it allows them to bridge their traditional concerns of psychological suffering with the new positive psychology of growth following adversity (see Joseph et al., 2012).

Stephen Joseph is a Professor at the University of Nottingham and Honorary Consultant in Nottinghamshire NHS?Trust
stephen.joseph@nottingham.ac.uk

References

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Butler, L.D., Blasey, C.M., Garlan, R.W. et al. (2005). Posttraumatic growth following the terrorist attacks of September 11th, 2001: Cognitive, coping and trauma symptom predictors in an internet convenience sample. Traumatology, 11, 247–267.

Calhoun, L.G. &Tedeschi, R.G. (Eds.) (2006). Handbook of posttraumatic growth: Research and practice. Mahwah, NJ: Lawrence Erlbaum.

Dekel, S., Ein-Dor, T. & Solomon, Z. (2012). Posttraumatic growth and posttraumatic distress: A longitudinal study. Psychological Trauma: Theory, Research, Practice and Policy, 4, 94–101.

Gunty, A.L., Frazier, P.A., Tennen, H. et al. (2011).Moderators of the relation between perceived and actual posttraumatic growth. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 61–66.

Hefferon, K., Grealy, M. & Mutrie, N. (2008). The perceived influence of an exercise class intervention on the process and outcomes of posttraumatic growth. Journal of Mental Health and Physical Activity, 1, 32–39.

Helgeson, V.S., Reynolds., K.A. & Tomich, P.L. (2006). A meta-analytic review of benefit finding and growth. Journal of Consulting and Clinical Psychology, 74, 797–816.

Joseph, S. (2012). What doesn’t kill us: The new psychology of posttraumatic growth. London: Piatkus Little Brown.

Joseph, S. & Linley, P.A. (2005). Positive adjustment to threatening events: An organismic valuing theory of growth through adversity. Review of General Psychology, 262–280.

Joseph, S. & Linley, P.A. (2006). Growth following adversity: Theoretical perspectives and implications for clinical practice. Clinical Psychology Review, 26, 1041–1053.

Joseph, S. & Linley, P.A. (2008a). Psychological assessment of growth following adversity: A review. In S. Joseph & P.A. Linley (Eds.) Trauma, recovery, and growth: Positive psychological perspectives on posttraumatic stress. (pp.21–38). Hoboken, NJ: Wiley .

Joseph, S. & Linley, P.A (Eds.) (2008b). Trauma, recovery, and growth. Positive psychological perspectives on posttraumatic stress. Hoboken, NJ: Wiley.

Joseph, S., Maltby, J. Wood, A.M. et al. (2012). Psychological Well-Being – Post-Traumatic Changes Questionnaire (PWB–PTCQ): Reliability and validity. Psychological Trauma: Theory, Research, Practice and Policy, 4(4), 420–428

Joseph, S., Williams, R. & Yule, W. (1993). Changes in outlook following disaster: The preliminary development of a measure to assess positive and negative responses. Journal of Traumatic Stress, 6, 271–279.

Kunst, M.J.J. (2010). Peritraumatic distress, posttraumatic stress disorder symptoms, and posttraumatic growth in victims of violence. Journal of Traumatic Stress, 23, 514–518.

Linley, P.A., Felus, A., Gillett, R. & Joseph, S. (2011). Emotional expression and growth following adversity: Emotional expression mediates subjective distress and is moderated by emotional intelligence. Journal of Loss and Trauma, 16, 387–401.

Linley, P.A. & Joseph, S. (2004). Positive change processes following trauma and adversity: A review of the empirical literature. Journal of Traumatic Stress, 17, 11–22.

McMillen, J.C. & Fisher, R.H. (1998). The Perceived Benefits Scales: Measuring perceived positive life changes after negative events. Social Work Research, 22, 173–187.

Park, C.L., Cohen, L.H. & Murch, R.L. (1996). Assessment and prediction of stress-related growth. Journal of Personality, 64, 71–105.

Peterson, C. & Seligman, M.E.P. (2003). Character strengths before and after September 11th. Psychological Science, 14, 381–384.

Prati, G. & Pietrantoni, L. (2009). Optimism, social support, and coping strategies as factors contributing to posttraumatic growth: A meta-analysis. Journal of Loss and Trauma, 14, 364–388.

Seligman, M.E.P. (2011). Flourish. New York: Free Press.

Splevins, K.A., Cohen, K., Joseph, S. et al. (2011). Vicarious posttraumatic growth among interpreters. Qualitative Health Research 20, 1705–1716.

Tedeschi, R.G. & Calhoun, L.G. (1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 455–471.

Weiss, T. & Berger, R. (Eds.) (2010). Posttraumatic growth and culturally competent practice: Lessons learned from around the globe. Hoboken, NJ: Wiley.

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PTSD: The pain of reliving trauma years after the event

Tags

anxiety, Depression, dissociation, flashback, Memory, PTSD, rape, Refugees, reliving, sexual abuse, stress, Therapy, Torture, trauma, war

http://blogs.independent.co.uk/2012/03/29/ptsd-the-pain-of-reliving-trauma-years-after-the-event/

One of my first experiences of PTSD came as a psychologist working with African and Kurdish refugees.

Many had fled oppressive regimes and been referred to our service by their GP suffering severe anxiety, depression and stress. We discovered the root of the problem often lay in terrible personal experiences including rape, torture and witnessing the murder of loved ones.

These mental scars have a long and insidious reach in the shape of PTSD whose victims can repeatedly relive a traumatic event years after the original incident took place.

I remember my shock the first time I worked with a woman who, as she described what had happened to her, lost all sense of where she was. She verbally and physically tried to fend off an imaginary attacker as well as crying and shaking with fear as part of her episodic ‘flashbacks.’

The problem can be complicated by people having great feelings of shame and guilt about what happened as if they were somehow to blame. PTSD’s victims can also include perpetrators of violence who, on reflection, feel enormous regret for their actions.

Soldiers are the most high profile casualties of PTSD but it is even more prevalent among the civilian population.

It can affect anyone involved in a near death experience and includes ‘single incident’ traumas, such as a car crash, earthquake or tsunami.

The recent sinking of an Italian passenger ship that made headline news is another example as were the terrorist bombings on London’s transport network.

It’s important to recognise that PTSD symptoms are a perfectly normal part of the healing process when they occur immediately after a trauma. Our mind is often too pre-occupied with survival to process what happened at the time so revisits the experience helping us make sense and gain perspective on what happened. In the normal process of producing memories the mind knits the various strands of an experience together based on our senses, such as sight, sound, touch and taste as well as other aspects of what we were experiencing at that time.

It also puts a ‘date stamp’ on the memory so we know when and where something has happened. When a trauma is occurring the mind is using all of its energy to keep us alive so memories often don’t get properly formed.

In the hours, days and weeks following the trauma bits of the semi-formed memory will ‘pop’ into consciousness. This can be upsetting but gives the mind the opportunity to link the various fragments together to form a normal memory.

In cases of PTSD, the healing process effectively gets stuck and, like a scratched CD, the mind repeatedly replays the trauma.

This produces a vicious circle in which the distress generated by the memories continues to stop the brain’s ability to process the memories to a level that they cause less discomfort. As a result, patients find themselves vividly reliving the experience over and over with the same intense feeling of fear they experienced during the original incident. These ‘flashbacks’ can be triggered by something that the victim associates with the original trauma, such as a sound, colour or smell.

Sensory triggers can create powerful positive and negative anchors in our minds. You could be having a bad day at work when an old friend rings and your mood switches in an instant because the sound of their voice triggers a past association of feeling good. Likewise, hearing a favourite song on the radio often makes you feel better because you associate it with a previous experience of wellbeing.

This is also true of traumatic experiences, particularly when the ‘date stamp’ has not been associated with the memory so rather than being reminded of the events it can feel exactly as if they are happening again.

A refugee suffering PTSD may link the sound of footsteps echoing down a corridor with those of events years before when their protagonist came to torture them. The smell of burning rubber and smoke may bring back the experience of watching the family home burnt to the ground by soldiers or a family member killed in front of you.

PTSD creates a vicious circle in which the distress caused by the partially formed memories stops the brain from processing them to a level where they are less intrusive. This round-robin can lead to a number of associated conditions including anxiety, depression and stress as well as ‘avoidance’ where someone will increasingly isolate themselves to avoid triggering a flashback.

Flashbacks or vividly ‘re-living’ aspects of past events are one upsetting response to trauma. Another is ‘disassociation’ where the victim’s mind psychologically removes them from an experience. This can be emotionally protective at the time but if this dissociation happens when memories of the trauma are triggered it can be hugely upsetting and disruptive to normal day-to-day life. People experiencing this can often ‘lose’ pieces of time from their day and have no recollection of what happened to them unless someone tells them.

In our clinical work we tend to see this type of response in people who have gone through repeated trauma as a child, such as prolonged periods of sexual or physical abuse.

You can imagine that to ‘remove’ themselves mentally may be the only way that a child is able to escape what is being done to them. It serves to protect the child when nothing else can but also leads to problems later in life.

Medication can help reduce stress in some patients but the main treatment for PTSD is a ‘talking therapy’ in which the patient works with the therapist to help their mind find a way process the bits of trauma memory in a more complete way.

A number of question marks remain. Why are some of us more resilient to the effects of PTSD than others? And what role do the corrosive effects of guilt, grief and shame have on recovery?

It is an often distressing area to work in as a therapist but also incredibly rewarding in helping patients first understand what is happening to them and then interrupt the cycle of PTSD symptoms.

It is, for some, the start of the long journey back to more ‘normal’ day-to-day life helping them regain control over aspects of their lives they thought they may have had lost forever.