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.

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Children are ‘upset’ by online violence, study finds

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abuse, behaviour, Children, Cyberbullying, family, internet, sexting, social media, social networks, violence, young people

Children are ‘upset’ by online violence, study finds

Children are as upset by violent videos on YouTube that feature animal cruelty or beheadings and by insensitive Facebook messages from divorced parents as they are by online bullying and pornography, according to the biggest survey of young British people and their internet use.

The research will be unveiled by the UK Council for Child Internet Safety (UKCCIS) on Tuesday – the 10th annual Safer Internet Day – when a charter of rights and responsibilities for children online will also be launched. The findings suggest that government policy, spearheaded by David Cameron, to block sexual content and pornography through parental controls and filters via internet service providers only goes part of the way to securing the online safety of children.

The survey, conducted for the council by academics, asked 24,000 children 25 questions about internet use, including “have you ever seen anything online that has upset you?” Hundreds of schools around Britain were enlisted to help canvass the children, who were aged up to 16.

Andy Phippen, professor of social responsibility at Plymouth University, who helped to devise the report, said: “Upset is caused by a broad range of issues, very varied, and not all sexual content.” One memorable answer from a primary school child who was asked what most upset him was “when my Dad told me on Facebook he didn’t want to see me any more”.

The report, Have Your Say, is consistent with research Phippen was already carrying out. The examples he heard included: a video of a zebra being killed, “someone swearing at me”, “a picture of my baby brother, who I don’t live with any more”, and a picture of a cat that “looked like my pet that had to be put down”.

Phippen said: “There is no silver bullet to crack child safety online. Government’s obsession with filtering is OK, but too narrow.”

Sonia Livingstone, professor of social psychology at the London School of Economics, told the Oxford Media Convention last month that LSE research, which asked 8,000 children aged nine to 16 about the disturbing things they had seen on the internet, supported this picture. She added: “There is a lot of attention given to pornography and bullying on social media, but they also mentioned beheadings, flaying, cruelty to animals.”

Professor Phippen agreed: “Any channel used for communication is potentially a channel for upsetting content, but certainly YouTube is the most prevalent as far as video content is concerned.”

Livingstone said that the issue of online bullying was not covered by efforts to filter out inappropriate content. “Filtering is only about content on established websites”, while filtering and blocking controls could be very clunky to use and problematic.

However, Have Your Say also finds many positive aspects to the internet. The survey shows that what under-11s do most is play games on sites such as Moshi Monsters, followed by schoolwork and keeping in touch with friends. For older children, social networking takes over from playing games.

“I think, in this age group, violent images and upset from abusive nasty comments from their peers are the concerns. It is spoken about as so and so is so mean to me. Cyber bullying – they don’t use that term,” said Phippen. Evidence from the children of being groomed or facing predatory behaviour online is also scanty.

Accessing pornography online, the main concern of parents responding to a government consultation last autumn, did not feature highly in the teenagers’ responses. But there is a growing problem of “sexting” messages in school, when pupils share personal sexual content via smartphones and tablets. Phippen said one answer was better education. “You come back to media literacy. About understanding how to conduct yourself online and what the impact can be of behaviour, when you don’t see the impact of your behaviour, on the victim in front of you.”

Time to lay responsibility at the rapist’s door

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behaviour, blame, challenge, low self-esteem, perpetrators, prevention, rape, relationships, responsibility, Sexual Violence, support, Teens, vulnerability, women

Time to lay responsibility at the rapist’s door

A 15-year-old boy was describing to me and a group of 12 other young men his relationships with teenage girls. He held firm with his opinion that if a girl came round to his house it implied that she wanted to have sex. But there was one boy in the group who, even in the face of pressure from the others, was certain that “even if she’s naked, she’s not supposed to be raped”.

I was interviewing the young men about their experiences of relationships for the Female Voice in Violence project, and it was clear that the majority of the boys did not understand the concept of rape. They could not see it.

Would you “see” rape? This is the question being asked in the second stage of a government campaign to raise awareness of abuse in teenage relationships. The initiative is launched at a time when there is an increasing focus on young women’s experiences of sexual violence. To date, those shouldering the responsibility of rape prevention have been the victims: girls are blamed for making themselves vulnerable to rape, and their low self-esteem or a craving to belong is the reason, we are told, that they place themselves in situations where they may be victimised. Now, however, it is the turn of those who commit sexual violence to be challenged to recognise it.

It is right that girls are supported to reduce their vulnerability. However, there is a growing sense of frustration among girls, and some services that work with them, that this vulnerability is communicated as the cause of sexual violence. The message they hear is that girls are raped because they are vulnerable. Where, they ask, is the space to consider the responsibility of those who are perpetrating abuse? So a campaign that challenges the perpetrators to ask whether they see rape is welcome.

Girls have told me they are relieved that they are not once again being told to modify their behaviour in order to avoid abuse. Those same girls would call for services to support victims of sexual violence; these are essential. However, providing services to pick up the pieces, or reduce vulnerabilities, will never, on their own, prevent sexual violence. Until the behaviour of rapists is understood and challenged the abuse will continue.

The campaign signals a move to reframe and revisit questions about how to prevent sexual violence, so it is crucial that the response on the ground is able to mirror this. While investment has been made in services for boys and men who commit forms of violence such as gun and knife crime, little attention has been given to preventing their use of sexual violence. This needs to change.

Young people’s views are shaped by a mosaic of messages, images and attitudes. Professionals need to be supported to challenge these ideas in order to stem the development of abusive attitudes and behaviours.

Challenging the ideas that normalise sexual violence, from the outset, should underpin any such preventive work. The inclusion of men and boys in this debate is critical. The young man who condemned rape in the face of peer pressure is not a one-off. We need to understand the difference in attitudes between young men. Only then will we move from seeing rape to stopping it.