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.”

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

If psychosis is a rational response to abuse, let’s talk about it

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abuse, cbt, culture, diagnosis, hearing voices, medication, paranoia, psychological support, psychosis, schizophrenia, trauma

If psychosis is a rational response to abuse, let’s talk about it

There is something of a sea change in the way we understand experiences that have traditionally been labelled as psychotic. In our culture at least, experiences such as hearing voices or seeing visions have long been viewed by the medical establishment as unequivocal symptoms of mental illness. Treatment has tended to focus on the suppression of such “symptoms” using antipsychotic medication.

Research (often funded by drugs companies) has been largely concerned with the brain as a physical organ, rather than with the person within whose head it is housed, or indeed with their life experience. And, because of the presumption that psychotic symptoms are the preserve of mentally ill people, estimates of the numbers affected have been based on the numbers who have received a particular diagnosis.

But a report published last week by the British Psychological Society’s division of clinical psychology, challenges many of these assumptions.Understanding Psychosis and Schizophrenia presents a compelling case for trying to understand psychotic experiences as opposed to merely categorising them. It argues that such experiences can be understood from a psychological perspective, in the same way as other thoughts and feelings, rather than being placed on the other side of an artificial sick/healthy divide.

And, indeed, they appear to be much more common than is frequently supposed. According to the report, up to 10% of the population has heard a voice speaking when nobody was there and almost one in three holds beliefs that might be considered paranoid. Two in three people who had heard voices or seen visions did not seek help because they were untroubled by them. And, of course, there is huge diversity in the way such experiences are understood and valued in different cultures.

For those who find their experiences unwelcome and disturbing (and they can be extremely disturbing; I don’t think anyone questions that) the range of help on offer is decidedly limited. Despite the National Institute for Health and Care Excellence recommending that everyone with a diagnosis of schizophrenia is offered cognitive behaviour therapy(CBT), only one in 10 has access to it. Treatment by medication alone, forcibly if needed, is the norm.

It is widely accepted that early life experience, trauma, abuse and deprivation greatly increase the risk of developing psychosis. Indeed,research suggests that experiencing multiple childhood traumas gives approximately the same risk of developing psychosis as smoking does for developing lung cancer.

Many people object to the psychotic label because they consider their experiences a natural reaction to the abuse they have suffered, and even a vital survival tool. What they want above all is space and time to talk about their experiences and to make sense of them. It is shocking how few are given this opportunity.

Of course, psychological approaches to helping those with psychosis will not suit everyone. There are those for whom a diagnosis can come as a welcome relief. Many people find medication helpful, as treatment on its own or alongside talking therapies.

In fact, one of the most persuasive messages of the report is that people should be allowed to understand their experience in their own way, without professionals insisting on a particular interpretation.

It is a highly collaborative approach and fitting that at least a quarter of those who contributed to the report have lived experience of psychosis. Their opinions and experiences are as varied as you would expect with any group of individuals but together they comprise an enormously powerful and vivid testimony to the full range of human experience and to the many and varied ways in which we can help each other to make sense of it.

Explaining tokophobia, the phobia of pregnancy and childbirth

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anxiety, birth, childbirth, distress, fear, hyperarousal, labour, media, negative birth experience, panic, positive birth experience, post-birth PTSD, pregnancy, PTSD, social media, symptoms, tokophobia, trauma, treatment

Explaining tokophobia, the phobia of pregnancy and childbirth

For expectant mothers, it’s very normal to approach birth with a feeling of trepidation, particularly for the first baby. From the moment a pregnancy is announced, the average pregnant woman is inundated with horror stories of pain and long labours by supposed well-meaning friends, and it can be hard to focus on a positive birth experience when you don’t know what to expect.

But for some women, the fear of childbirth goes beyond trepidation into full-blown anxiety, panic and fear. Known as tokophobia, this phobia of childbirth affects somewhere between 3-8 per cent of pregnant women.

Symptoms include worries specifically about the pregnancy and birth, a fear of harm or death related to the birth, poor sleep, and a sense of hyper-arousal (rapid heartbeat and breathing, difficulty winding down). The fear of childbirth is a common non-medical reason for requesting a caesarean section, and women with this fear have a much higher rate of both caesarean delivery and use of epidural anaesthesia.

There is no clear path to developing fear of childbirth, but there are some risk factors that we know about. A history of anxiety or depression is one risk factor, as is a history of childhood abuse, be it sexual, physical or emotional abuse.

Some studies have also identified patterns with age, suggesting younger mums are more vulnerable, as are those with less education, and mums without a strong social network.

However, a recent study found that one of the biggest influences women reported on their fear of childbirth was the media. Hospital-based reality television programs and medical dramas often feature storylines with dramatic emergency situations during childbirth and this may be all women know of giving birth prior to the event.

We also know that around 95 per cent of pregnant European women report searching for pregnancy and birth information online, and social media and blogs hold the potential for the circulation of misinformation that may heighten fears rather than allay them.

There is another group of women who may find pregnancy and childbirth frightening due to related fears. One of the most common phobias in adults is blood/injury phobia, often including a fear of injections. Pregnancy and childbirth is hence very confronting for these women, who may faint or experience extreme distress at even routine blood tests throughout their pregnancy.

Researchers have found that for first time mothers, a positive birth experience can often relieve the fear of childbirth so that it is no longer an issue for future pregnancies. However, whether or not women start with a fear of childbirth, a negative birth experience can make them up to five times more likely to develop tokophobia for future pregnancies.

A negative experience of birth may be due to complications, feeling out of control, dissatisfaction with care providers, or just not having the birth that was expected. Between 2-6 per cent of women report post-traumatic stress syndrome (PTSD) following a difficult birth experience. PTSD is the disorder once known as ‘shell shock’ for its affliction of soldiers following war, and is characterised by nightmares and re-experiencing of the birth trauma, avoidance of all reminders of the birth, and hyper-arousal. Without treatment, PTSD can limit family size and cause problems in women’s relationships with their partner and their child.

While we may not hear much about tokophobia and post-birth PTSD, their prevalence suggests we do need to look out for women who may be suffering both before and after birth. In addition to the distress at the time, stress and anxiety during pregnancy are linked to a higher rate of preterm birth and later behavioural problems in children.

The good news is that like all anxiety disorders, the fear of childbirth and PTSD can be addressed and treatments are available. One of the most vital elements of treatment is education on birth, whether through the obstetric care provider, midwives, or antenatal classes. Knowing what to expect and having an agreed plan with your care provider can assist to overcome some of the irrational fears.

Linked to this, a supportive and trusting relationship with the care providers who will manage the birth is essential. This is not always possible as some obstetric settings do not allow for repeated contact with the same provider, but a relationship of trust will be more likely to create a positive birth experience.

When problems do occur in pregnancy and birth, a post-birth debriefing can be useful and may help prevent the development of PTSD symptoms. Understanding what went wrong and why things happened the way they did can help with processing the events and accompanying trauma.

As with other anxiety disorders, relaxation, light exercise and slow breathing can help to calm the body and relieve the hyper-arousal that comes with the fear of childbirth. A psychologist can assist with other anxiety management techniques that can help to minimise fears.

For those who find the idea of pregnancy and birth overwhelming, it is important to know that help is available and such symptoms can be successfully treated. The first step is confiding your fears so that those around you can start to support you through what could be a wonderful journey.

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.

On the front lines: Documenting evidence of rape is a fraught task

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accountability, army personnel, asylum seekers, conflict, disclosure, evidence, humiliation, impunity, medical care, perpetrators, police, psychological services, rape, sexual assault, Sexual Violence, shame, survivors, testimony, Torture, trauma

On the front lines: Documenting evidence of rape is a fraught task

In my line of work it’s impossible not to notice the chilling impact rape has on its victims. The shame and humiliation they are made to feel means disclosure can be very difficult, even in a ‘safe’ setting such as a doctor’s examination room.

Taking statements and documenting evidence of rape for use in legal proceedings is not easy – it requires skill and experience to gather all of the required information from a survivor of such a terrible crime while respecting their rights, supporting their health care needs, ensuring their safety, their confidentiality and minimizing further traumatization. Giving this kind of harrowing testimony often comes at a personal cost to the survivor, and their courage never fails to astound me.

In the UK it is estimated that almost 90 per cent of victims of serious sexual assault never disclose it to the police, and around 38 per cent tell no one (at the time of the crime.) Yet, in the UK we have support available for survivors of sexual violence and a comparatively open society that generally supports the victim and does not stigmatise them.

Imagine then, how hard it is to disclose rape in a place like the Democratic Republic of Congo where the perpetrators of such crimes are often the police and army personnel – the very officials charged with the protection of civilians.

A new report by Freedom from Torture reveals the routine use rape, gang rape and multiple rape to torture politically active women in official state detention centres in the country. The levels of impunity enjoyed by those who commit these crimes is breathtaking and it is this lack of accountability that the Global Summit aims to address.

The Protocol on Investigation and Prevention of Sexual violence in Conflict which will be launched by Angelina Jolie and William Hague at the Global Summit on Wednesday and will set out best practice for obtaining witness testimony of crimes of sexual violence in conflict.

It will ensure that the evidence collected is of a standard that can be used in international criminal courts to charge not just those who committed the crimes directly but also their commanding officers. Though work still needs to be done to get this document right, and to resource evidence collection, it is a very welcome step towards holding perpetrators to account both nationally and internationally.

My big concern is that while so much noise is being made about the protection of survivors of sexual violence in conflict at the Global Summit, the Home Office remains out of step.

Every week I see survivors of persecutory rape who have fled their countries and are seeking protection in the UK from the horrors that have been inflicted on them and their families. Sadly their experiences as asylum seekers rarely afford them the dignity, security and peace they need in order to be able to disclose sexual violence.

Repeated interrogation by Home Office officials about what they have been through – all too often conducted from a clear standpoint of officials’ disbelief inadequate welfare support and difficulties in accessing the medical care and psychological services they so desperately need all serve to compound their trauma.

Protection through asylum is a key element in the fight to end sexual violence and support survivors of these crimes. Accordingly, it should be at the forefront of this week’s discussions.

It’s time to listen to the voices in your head

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auditory verbal hallucination, dissociation, inner speech, trauma, voice-hearers, voice-hearing

It’s time to listen to the voices in your head

Hearing voices in your head when there’s no one around … that’s a sign of madness, right?

In the popular imagination voice-hearing is often viewed with fear and suspicion, frequently reified as a chaotic, corrupted symptom of illness. But that is changing, with a growing acceptance of voice-hearing as a profoundly human experience that can no longer be reduced to a mere symptom of psychiatric disorder. The work of Intervoice: The International Hearing Voices Network, and the enthusiastic response toEleanor Longden’s 2013 TED talk, which recounts her own journey to recovery from a demoralising psychiatric diagnosis, indicate the growing possibilities for people living with the experience to raise their voices with a sense of power and pride.

This movement towards a better public understanding of voice-hearing has been mirrored by an increased interest in the scientific issues it raises. In recent years, academics from such diverse disciplines aspsychology, philosophy, medical humanities, cognitive neuroscience, anthropology, theology and cultural studies have begun to reclaim it as a rich, diverse and complex human experience – one that offers abundant possibilities for scientific inquiry.

Take, for example, the idea that voices often relate to trauma or adversity, particularly those suffered in childhood. This view, which has found expression in the personal stories of many voice-hearers, has been supported by a growing body of scientific evidence. But why should traumatic experiences early in life lead many years later to the experience of hearing a voice, or what psychiatrists call an auditory verbal hallucination?

Recent investigations suggest that voice-hearing may provide fresh insights into traumatic memory, and how real-life conflicts become embodied in voices via dissociation (a defensive psychological response to trauma in which thoughts, emotions and memories become disconnected from one another). In turn, the experience that many voice-hearers describe – that of a disembodied “other” dynamically interacting with and intruding upon one’s sense of self – invites exploration into how representations of selfhood are generated and maintained.

Another approach that has proved fruitful is the idea that voice-hearing relates to one very ordinary aspect of people’s experience: their inner speech. Most of us report talking to ourselves silently in our heads as we go about our business, and it has been proposed that voices result when a person generates a bit of inner speech but, for whatever reason, doesn’t recognise it as their own. This view has received support from numerous studies with voice-hearing psychiatric patients, including findings that similar networks in the brain are activated when people hear voices as when they produce inner speech.

Many problems remain however, including the fact that we know very little about the phenomenal properties of ordinary inner speech, such as whether it has the qualities of a dialogue or a monologue, whether it is fully expanded like ordinary conversation or whether it sometimes has a compressed, note-form quality. Voice-hearing itself comes in an even more baffling array of varieties, from experiences that have the fullperceptual force of listening to a person speaking to those that are much more ephemeral and thought-like.

Perhaps most importantly, the view of voices as disordered inner speech does not ring true with many voice-hearers’ experience. And yet, at some level, an explanation of voice-hearing must have something to do with how language operates in the brain. Perhaps the biggest challenge facing research in this area is to try to link, and draw on the relative merits of, the trauma and inner speech models. How can adverse experiences early in life, perhaps through the complex, multifaceted mechanisms of memory, lead to alterations in the way words are processed in the brain, and in turn to the sense that one’s self has been overtaken by other selves? Whatever the future for research in this area, it will require a continued focus on voice-hearing as a complex, heterogeneous phenomenon with many scientific secrets to reveal.

I was sold by Mum and Dad to make images of child abuse

Tags

abuse, Children, dissociation, family, parents, relationships, sexual exploitation, support, Trafficking, trauma

I was sold by Mum and Dad to make images of child abuse

One of Raven Kaliana’s earliest memories is being taken to a family portrait studio by her parents, at around the age of four. The studio was in the basement of a department store in a town 50 miles from their home. Once they had arrived, they waited for another couple to arrive with their own child.

“Would you like to have your picture taken with this cute little boy?” her mother asked, before the parents left the kids with the photographer and retired to the cafe upstairs. But while they sat eating ice cream, the images being made in the studio down below were far from happy family portraits. Raven and her companion had just been sold into the child abuse industry.

It was to be the beginning of a 15-year ordeal, which saw Raven regularly trafficked by her parents and other members of an organised crime ring from her home in a middle-class suburb in the American north-west to locations all over the US and abroad. In her teens, the crimes were often perpetrated in Los Angeles, where many film studios provided ample opportunity for the underground child abuse industry in the 70s and 80s.

Her father, precariously self-employed after losing his teaching job, was violent towards her younger brother, but since she had become the family breadwinner, Raven was granted a peculiar status. “My father always favoured me because I brought in the money – I was supporting our whole family. My younger brother was jealous because of my dad’s special treatment of me.

“My father was also quite affectionate towards me whereas he would beat my brother to a pulp. Although he did hit me, he wanted me to stay intact because the less scars I had, the more I was worth.”

Inevitably, as she grew older, Raven’s value to her abusers decreased and subsequently the kinds of films she was required to take part in became more extreme and violent.

Yet from a young age, she had learned from her parents to rationalise and deny what was going on within the family. “It’s the same way that someone who has a problem with alcohol will rationalise their behaviour – ‘It’s only this many drinks. It’s before noon but, oh well, just today’.

“I remember my mother saying things like, ‘Oh, they’ll never remember it,’ like people do when they get their babies’ ears pierced. I told myself that my parents meant well, that what I was going through was what was necessary to help my family. It was paying our mortgage.”

As we sit talking in a central London cafe, there are two large suitcases on the floor next to us, both full of puppets she has made. A graduate of the puppetry course at the Royal Central School of Speech & Drama in London, Raven turned to this artform as a way of telling her story without the gaze of an audience focusing on her directly – something she finds too uncomfortable.

Her adult life has been driven by the belief that it is important for survivors of child sexual exploitation and trafficking to tell their stories, in order to make people realise that these aren’t crimes that happen “somewhere else, to someone else”. She moved to the UK to create Hooray for Hollywood, an autobiographical play in which the children are represented by puppets, while the adults – their parents – are only shown up to waist height, from a child’s eye view. This critically acclaimed drama has toured the UK, Poland and France, and has been made into a film.

One of the most shocking aspects of Hooray for Hollywood is the banality of the adults’ conversation, as they rationalise the choice they have just made to sell their children, from the cosy confines of a cafe. These appear to be ordinary people, struggling a little to make ends meet; not monsters or weirdos, but the kind of people who might be your nextdoor neighbours.

“You hear about a perpetrator being processed in a certain way, you hear about the police getting hold of the images, but you don’t hear about the reality for the children in those images – whose children are they? How did they come to be in this situation? And how have they been traumatised or damaged by what happened?”

Through her organisation Outspiral, Raven recently launched a national campaign to raise awareness of sex trafficking and familial abuse. She now uses the film of Hooray for Hollywood for public education and training for professionals working in social services, education, law enforcement and children’s charities.

The biggest challenge, she says, is getting the bystanders in the child’s life – neighbours, relatives, teachers, care workers, counsellors – to consider the possibility that a child might be a victim of this form of abuse. Child abuse is such a taboo subject, and the concept of parents being complicit in the crime so unthinkable, that frequently there is a failure to recognise that it might be going on. Yet since Raven’s childhood, the internet has led to an explosion in the industry, which now has a worldwide market value of billions of dollars, according to the UN.

Britain’s Child Exploitation & Online Protection Centre, a division of the police, says the number of indecent images of children in circulation on the internet runs into millions, with police forces reporting seizures of up to 2.5m images in single collections alone, while the number of individual children depicted in these images is likely to be in the tens of thousands. The commonest way that offenders found their victims was through family and personal relationships.

A report by the NSPCC highlighted the particular psychological suffering that children who have been sexually abused within the child abuse industry endure, especially through the knowledge that there is a permanent record of their sexual abuse: “There is nothing they can do about others viewing pornographic pictures or films of themselves, and sometimes their coerced sexual abuse of others, indefinitely.”

For Raven, the psychological effects of her abuse have been extreme. From an early age she began to experience dissociative amnesia – a psychological phenomenon common in victims of inescapable trauma, in which painful experiences are blocked out, leading to gaps in memory. “I started putting things into little rooms in my mind, and it was like: OK, we don’t look in that room,” she says. “When there’s no relief, there’s no one stepping in to save you, and it’s clear you’re just going to have to endure something, then your mind just does that. As a child, dissociation is a serious survival advantage, but in adulthood it can become a disability.”

It was at the age of 15 that the coping mechanisms of denial and dissociation began to break down. “At school, I started getting flashbacks – like remembering being in a warehouse the night before – and I could feel in my body it was true, but it was terrifying because I didn’t want those things to be true.”

Astonishingly, she passed through most of school without anyone picking up on what was happening at home. “I got good marks at school, so teachers tended to think everything was fine. Most survivors I’ve known who experienced extreme abuse did very, very well at school, actually, because that was their sanctuary, a place they could go to be safe.”

Eventually, however, a teacher noticed that Raven was getting thinner. Her mother, by now separated from her father but still facilitating the abuse, had simply stopped buying food for her. “The teacher invited me to stay after school and talk with her one day, and she asked, ‘Tell me the truth, are you anorexic? Bulimic?’ And I started laughing.”

Raven confided some but not all of what was happening at home, but begged the teacher not to report it for fear of reprisals. What the teacher did do, however, was to help her find the wherewithal to move out of home eventually, get a job in a restaurant, and start saving up for college.

At university, Raven finally made a break from her family, changed her name and started to get counselling – the beginning of a long road to recovery that still continues. “I got into a support group for rape survivors, and it was a great help because all of a sudden I was around other people healing from abuse, too. It also gave me some perspective about how the things that had happened to me were really on the extreme end. I saw people completely devastated by one experience of being raped by a stranger, so it was sobering to realise, ‘Oh, I’ve been raped by hundreds of people.'”

Once she was in a safe environment, finally the rage about what had happened to her bubbled to the surface. “I couldn’t believe how angry I was when I first escaped – so angry. In one support group they let us take a baseball bat to a punching bag and told us to think about a specific abuse event and imagine that we were fighting back against it, and that was very helpful.”

She also saw an integrative bodywork therapist, who used touch, guided movement and vocal expression. “Her premise was that post-traumatic stress is a physical reaction in your body, and that reconnecting the symptom to the source helps you let it go, helps you release it, and that you don’t have to talk out every single thing that ever happened to you. It was very helpful for me because there were a lot of strange things that my body was doing. For example, I used to find any kind of physical touch excruciating – even if someone brushed me in the street I would shudder. She told me that was called armouring, which happens when your body makes a shield out of its muscles to protect the bones and internal organs during physical abuse.”

The therapy made it possible for her to move on and start to enjoy life. “I realised that it is possible to get your life back. I started to gain an appreciation for life and a recognition that I only have so many breaths, so I’ve got to use them well.”

But Raven believes she will always need counselling and that her experiences have made it difficult not to fall into a pattern of emotionally abusive romantic relationships.

Perhaps surprisingly, sex has not been a significant issue, but love is inextricably connected for her with betrayal, as the people who were meant to love her most as a child were the ones who orchestrated her abuse.

Yet, incredibly, she says she felt love for her parents as a child and still does, although she has cut all contact with them. Despite their behaviour, she believes they did love her.

“When I screen my film, a lot of times in the Q&A session afterwards people want to know: how could parents do this to their own children? I tell them that abuse is generational: my parents were also abused themselves, so that was normal to them. They had dissociated in the same way I did; they were in denial. Unlike my generation, they didn’t have access to counselling when they were young, and weren’t born in a time when child abuse was beginning to be acknowledged by society. It’s important to recognise that they weren’t born evil – they were damaged.”

Raven thinks that the way in which child abusers such as Jimmy Savile are demonised is counterproductive. “Demonising the perpetrators elevates them to the realm of the surreal. We need to shift that, so people recognise that they are very sick humans and that there’s a context for their crimes.

“Only then can we tackle the source of this suffering.”

 Outspiral.org.uk

Soldiers more likely to be convicted of violent offences, report reveals

Tags

alcohol abuse, anger, anxiety, armed forces, combat, Depression, mental health issues, Military, military personnel, PTSD, support, trauma, treatment, troops, veterans, violence, violent behaviour, violent offence, vulnerability

Soldiers more likely to be convicted of violent offences, report reveals

Young British men who have served in the armed forces are three times more likely to have been convicted of violent offences than their civilian peers, according to a study published on Friday.

The report in the Lancet, the first to marry the experiences of almost 14,000 military personnel with details on the Police National Computer, also shows how troops who have been in combat are more likely to be involved in violent offending back in the UK.

The study’s authors believe this raises questions about how the military and the NHS supports serving and former troops, some of whom end up abusing alcohol or developing severe mental health illnesses following tours in Iraq and Afghanistan.

Drawing on a random sample of 13,856 serving and ex-personnel mostly from the army, researchers from King’s College London looked at criminal offending rates and the possible links between them and post-traumatic stress disorder, anxiety, depression and other mood disorders.

The study found that of 2,700 men serving in the armed forces under the age of 30, 20.6% had been convicted of a violent offence, compared with 6.7% in the general population. Men who had seen combat in Iraq and Afghanistan were 53% more likely to commit a violent offence than those in non-frontline roles. And personnel who had multiple experiences of combat had a 70% to 80% greater risk of being convicted of acts of violence.

Violent offences covered a broad range of acts, from verbal harassment to homicide. They did not include incidents of domestic violence.

“More frequent exposure to traumatic events during deployment increased the risk of violent offending,” the report says. “We noted a strong link between PTSD and violent offending. Combat veterans with PTSD and other mental health concerns frequently present with problems of anger and aggression.” However, it also notes that troops who volunteer and are trained for fighting are not chosen randomly.

“In the UK, infantry units have traditionally promoted aggression as a desirable trait and such units frequently recruit individuals who are socially disadvantaged and are likely to have low educational attainment.”

Dr Deirdre MacManus, who led the study, said: “Our study found that violent offending was most common among young men from the lower ranks of the army and was strongly associated with a history of violent offending before joining the military. Serving in a combat role and traumatic experiences on deployment also increased the risk of violent behaviour.”

Prof Sir Simon Wessely, who co-authored the study, added: “We are suggesting there is a problem that needs to be looked at, but just as with post traumatic stress disorder this is not a common outcome in military populations.”

Screening within the armed forces to identify at-risk individuals would not work, he argued. For every correct prediction there were likely to be five that were wrong.

Dr Walter Busuttil, director of medical services at Combat Stress, said: “These findings will help us to identify which veterans are most vulnerable and in need of appropriate care and treatment after leaving the armed forces. We are planning courses for anger management and domestic violence. We are about to establish programmes that deal with alcohol abuse linked to PTSD.

“It would be grossly unfair and inaccurate to characterise all veterans living with PTSD as potential criminals. As noted in the report the vast majority [83%] of serving and ex-serving UK military personnel do not have any sort of criminal record, and the likelihood of violent behaviour is lower among older veterans [aged over 45] than in the general population. What we require now is continued public education to reduce any negative connotations with seeking help for mental health issues, as well as sustained funding for services for veterans.”

The Ministry of Defence has introduced a series of initiatives to encourage serving personnel to come forward if they fear they might be suffering from trauma or the early stages of anxiety or depressive illness, and has committed £7m to improve support services.

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

Abraido-Lanza, A.F. Guier, C. & Colon, R.M. (1998). Psychological thriving among Latinas with chronic illness. Journal of Social Issues, 54, 405–424. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd edn). Washington, DC: Author.

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