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

Tags

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.”

One in 10 do not have a close friend and even more feel unloved, survey finds

Tags

contentment, employment, family, friends, health, loneliness, love, money, relationships, well-being

One in 10 do not have a close friend and even more feel unloved, survey finds

Millions of people in the UK do not have a single friend and one in five feel unloved, according to a survey published on Tuesday by the relationship charity Relate.

One in 10 people questioned said they did not have a close friend, amounting to an estimated 4.7 million people in the UK may be leading a very lonely existence.

Ruth Sutherland, the chief executive of Relate, said the survey revealed a divided nation with many people left without the vital support of friends or partners.

While the survey found 85% of individuals questioned felt they had a good relationship with their partners, 19% had never or rarely felt loved in the two weeks before the survey.

“Whilst there is much to celebrate, the results around how close we feel to others are very concerning. There is a significant minority of people who claim to have no close friends, or who never or rarely feel loved – something which is unimaginable to many of us,” said Sutherland.

“Relationships are the asset which can get us through good times and bad, and it is worrying to think that there are people who feel they have no one they can turn to during life’s challenges. We know that strong relationships are vital for both individuals and society as a whole, so investing in them is crucial.”

The study looked at 5,778 people aged 16 and over across England, Wales, Northern Ireland and Scotland and asked about people’s contentment with all aspects of their relationships, including their partners, friends, workmates and bosses. It found that people who said that they had good relationships had higher levels of wellbeing, while poor relationships were detrimental to health, wellbeing and self-confidence.

The study found that 81% of people who were married or cohabiting felt good about themselves, compared with 69% who were single.

The quality of relationship counts for a lot, according to the survey: 83% of those who described their relationship as good or very good reported feeling good about themselves while only 62% of those who described their relationship as average, bad or very bad reported the same level of personal wellbeing.

The survey, The Way We Are Now 2014, showed that while four out of five people said they had a good relationship with their partner, far fewer were happy with their sex lives. One in four people admitted to being dissatisfied with their sex life, and one in four also admitted to having an affair.

There was also evidence of the changing nature of family life – and increasing divorce rates – in the survey, which found that almost one in four of the people questioned had experienced the breakdown of their parents’ relationship.

When it comes to the biggest strains put on relationships, a significant majority (62%) cited money troubles as the most stressful factor.

The survey also found that older people are more worried about money, with 69% of those aged 65 and over saying money worries were a major strain, compared with only 37% of 16 to 24-year-olds.

When it comes to employment, many of those questioned had a positive relationship with their bosses, but felt putting work before family was highly valued in the workplace.

Just under 60% of people said they had a good relationship with their boss, but more than one in three thought their bosses believed the most productive employees put work before family. It also appears that work can be quite a lonely place too: 42% of people said they had no friends at work.

Nine out of 10 people, however, said they had a least one close friend, with 81% of women describing their friendships as good or very good compared with 73% of men.

Teachers left to pick up pieces from cuts to youth mental health services

Tags

behavioural problems, CAMHs, Children, counselling, counsellors, early intervention, emotional difficulties, mental health issues, mental health services, school, stress, support, teachers, training, well-being, young people

Teachers left to pick up pieces from cuts to youth mental health services

As the headteacher of large primary school in the west of England, Joan Cunningham is accustomed to the demanding aspects of managing an intake from a mainly disadvantaged area. However, for the past couple of years, she says, one issue has escalated so dramatically that it is nearly at crisis point. “There is so much more pressure on schools and teachers to deal with children’s mental health and behavioural problems,” she says. “We provide as much support as we can but, with fewer resources available and a massive increase in need … the pressure has been incredible.”

Cuts to mental health and other services for young people mean teachers are increasingly having to fill the gap, even though schools do not always have the resources or training to provide the extra support pupils with mental or emotional issues may need.

“It was already hard to access the right services before cuts but its getting worse,” Cunningham says. “Teachers … are not mental health professionals, and now there is a vacuum in the services we have [traditionally] relied on. Social services departments are under more pressure due to cuts, Sure Starts … have vanished, [and] in many cases the voluntary organisations we used to be able to turn to are disappearing. Sign-posting families to where they can get help is much harder because of all of this.” At a time when families are under greater financial strain and “even very young children” are under pressure to achieve academically, she concludes, the need for support is “growing very fast”.

Child and adolescent mental health services (Camhs) have been particularly hard hit. These specialist services assess and treat children and young people with mental, emotional or behavioural difficulties. Typically, when schools cannot offer the support of their own counsellor, or when a child has especially serious difficulties, they will seek out their local Camhs for help.

In many cases, local authorities commission and fund these services, and the impact of council budget cuts on Camhs in some areas has been severe. According to research by the charity Young Minds, two-thirds of councils in England have reduced their Camhs budget since 2010. And when the charity asked NHS trusts and councils about other mental health spending targeted at children and young people, such as youth counselling or specific services for schools, more than half had cut budgets – some by as much as 30%.

The cuts mean local authorities’ Camhs spending is increasingly redirected towards more serious cases of mental ill-health, at the expense of early intervention services. “Draining money from early intervention services is short-sighted and just stores up problems for the future,” says Sarah Brennan, chief executive of Young Minds. “The result is Camhs feels it is being asked to respond to an enormous number of issues and schools feel Camhs has left them high and dry.”

Chris Harrison, national executive member and former president of the NAHT, says part of the problem until recently has been that targets in education have allowed children’s wellbeing to slip down the agenda. “The issue of mental health [in schools] has been coming to the fore over the past four or five years; there’s a real groundswell of interest, but it isn’t yet a priority in schools. We need to accept that preparation for life is about more than academic results.”

Research by the Teacher Support Network, a charity focusing on teachers’ wellbeing, shows around half of teachers feel pupil behaviour is worsening. Its survey of over 800 teachers also found almost two-thirds were stressed as a result.

The cuts to Camhs mean schools are struggling to provide professional support on site. Some have set aside cash from the Pupil Premium to pay for a regular counsellor. Andy Bell, deputy chief executive at the Centre for Mental Health, says that an “ad-hoc” system of support relies too heavily on the initiative of individual heads or teachers, and is undermined by unsatisfactory and arbitrary access to funds. “We see raising awareness of this issue as a major priority,” he says. “When we conducted research on child behavioural problems we found that three-quarters of parents asked teachers for help … However, some schools are better equipped than others. Many have virtually nothing by way of [professional] support, while others have full-time counsellors.”

Inadequate and underfunded services mean undue stress is being put on teaching staff, who may feel they are not trained or qualified to tackle many of the emotional or mental health problems that come up.

And with anecdotal evidence suggesting the number of young people experiencing mental health problems is rising, the crisis in Camhs is set to get worse. In 2004, the last year that government statistics were centrally collected on the prevalence of mental ill-health among children and young people, 1.3 million children were deemed to have a diagnosable mental illness. The economic downturn, coupled with government austerity and exam stress, means this figure is now probably much higher. And with NHS England estimating that only a quarter of children and young people with a problem are ever seen by mental health services, the figures are just the tip of the iceberg.

Politicians are becoming more aware of the scale of the problem. The health select committee has begun a parliamentary inquiry into Camhs, which campaigners hope will push mental health in schools higher up the agenda when it is published this year. “What we need is a consistent, national system that is accountable. What we need is for Camhs to be transformed.” says Bell.

Harrison says more needs to be done to ensure heads and schools have access to effective support services. “Schools and heads are battered at the moment. We want the government to look at the evidence. It’s common sense. There is overwhelming evidence that students learn better and are more effective in environments where they are supported and their teachers are supported.”

For now, charities and campaign groups are having to help schools themselves. Young Minds offers guidance on its website for teachers and is about to pilot a helpline for school staff, while the anti-stigma campaign Time to Change is running a project promoting pupil wellbeing and offering practical guidance for teaching staff. “Pupils are under much more stress these days and so are staff, yet teachers don’t have training in mental health – or spare time,” says Moira Clewes, lead teacher on health at Sandwich technology school, Kent, one of the schools piloting the project. “We are breaking down misconceptions around mental illness. Students are opening up. Teachers are grateful for advice. You’d be amazed at the impact this is having.”

A Department for Education spokesperson points to a range of initiatives, including the MindEd website, launched in March, designed to help people working with children, including teachers, “to recognise when a child needs help and how to make sure they get it”. The Department of Health says it has a “priority” focus on children’s mental health and, among other things, has put additional cash in to “talking therapies”, adding that it is liaising with the DfE to improve links between schools and Camhs.

For Cunningham, while any help is welcome, she is adamant that “nothing short of a clear, coherent and properly funded approach nationally will work for schools and for children”.

• Some names have been changed

Mind over cancer: can meditation aid recovery?

Tags

anxiety, Cancer, Depression, meditation, mindfulness, present, recovery, well-being

Mind over cancer: can meditation aid recovery?

Cancer leaves many scars. For survivors, the wounds that run deepest are often those left on the mind. Fear, anxiety and depression are common during recovery. But instead of popping a pill, could practising a few minutes of mindfulness a day be as effective as any drug?

While Buddhists have been practising the meditation technique for more than 2,000 years, medical science is finally beginning to catch up, discovering the extent to which focusing the mind on the present moment can help treat a range of mental conditions associated with cancer recovery.

In the largest trial to date, published last year in the Journal of Clinical Oncology, breast cancer survivors who practised mindfulness were found to have increased calm and wellbeing, better sleep and less physical pain. Clinical trials by Oxford University have shown that mindfulness is as effective as antidepressants, and in patients with multiple episodes of depression can reduce the recurrence rate by 40-50% compared with usual care.

Andy Puddicombe’s 20 years of practice were put to the test when he was diagnosed with testicular cancer last April. While the mindfulness expert and former Tibetan Buddhist monk expected the physical pain after surgery to remove his right testicle, he was surprised by the emotional and mental impact of recovery.

“The biggest shock about recovery is that there is no end point,” he says. “People often talk about having beaten cancer, but I find that hard to relate to. I would say that nature has simply taken its course and I am very fortunate that it didn’t spread.”

Puddicombe, who aims to demystify meditation with his Headspace app, explains that mindfulness allows us to step back from our thoughts and feelings and view them with a different perspective. It would be very easy, he adds, to get caught up in negative thinking or feelings of anxiety and depression. But mindfulness gave him enough space to be able to embrace these emotions without getting lost in them.

“Rather than it being a terrible experience, it became a transformative one,” he reveals. “It may sound a bit fluffy, but the reality is anything but. In fact, it was life-changing.”

Psychotherapist Elana Rosenbaum has been practising and teaching mindfulness stress reduction techniques since the early 1980s. She believes her ability to focus the mind on the present moment and break patterns of negative thought helped her survive an aggressive form of non-Hodgkin’s lymphoma which required bone marrow transplant surgery to remove.

She explains that recovering from cancer was a frightening experience. Once she had finished her treatment, she felt lost without the help and support of medical staff. Mindfulness helped her to face those fears.

Rosenbaum, who helps others use mindfulness in cancer recovery at the University of Massachusetts medical school, says: “People think you are the same. They think you have gone back to what used to be normal. But you’re really different. It’s a new normal and you don’t know what that is. I have had several recurrences of the cancer and I live with uncertainty, but it’s not my focus. Mindfulness helps me to value this moment.”

Nice, the UK’s National Institute for Health and Clinical Excellence, approved a technique developed by Cambridge and Toronto Universities for the management of depression in 2004, which means the therapy is already available on the NHS.

Headspace’s chief medical officer, Dr David Cox, prescribes cancer recoverers a dose of 10 to 40 minutes mindfulness practice a day. But once you are proficient at that, you have to remember to be mindful in anything and everything you do as much as possible, whether that’s walking the dog or washing the dishes.

He believes the link between mind and body has been neglected for far too long and it is a breath of fresh air for many doctors that someone is finally asking the question. Cox says medical professionals have known about the benefits for a while and mindfulness offers a “glimmer of hope” for tackling the spiralling cost of healthcare on the NHS. Because sufferers of depression tend to be more apathetic about looking after themselves and taking medication, compliance with treatment is therefore worse.

One of the reasons that mindfulness is really catching on is that it can be delivered in a way that is entirely secular, stripped of any religious connotations, making it entirely acceptable to the wider population.

“Around 30 years ago, yoga was probably sniffed at a little bit and now it’s much more mainstream,” Cox adds. “To me, it’s the perfect storm for something that can really help a vast number of people. I hope in five years’ time it will have the same level of acceptance as brushing your teeth every day, eating your five a day and doing 30 minutes’ exercise.”

GPs to prescribe self-help books for mental health problems

Tags

anxiety, books, Depression, GPs, library, mental health issues, prescription, self-help, well-being

GPs to prescribe self-help books for mental health problems

People in England with mild to moderate mental health concerns, including panic attacks, anxiety and depression, are to be prescribed self-help books which they can borrow from their local library.

Titles such as The Feeling Good Handbook, How to Stop Worrying and Overcoming Anger and Irritability will be among the 30 prescription titles that libraries across England will stock in an attempt to improve the wellbeing of the nation.

The scheme was announced on Thursday at the British Library and has been developed over the past year by the Reading Agency charity. Its chief executive, Miranda McKearney, said of the project: “There is a growing evidence base that shows that self-help reading can help people with certain mental health conditions to get better.”

She said 6 million people in the UK suffered from anxiety and depression, and around two thirds of those people were not receiving any treatment.

The Books on Prescription scheme is being rolled out across GPs’ surgeries and libraries in England in May and is based on a similar scheme in Wales pioneered by the Cardiff-based clinical psychologist Professor Neil Frude.

Denmark has gone down the same road and Frude said New Zealand had just become the first country in the southern hemisphere to take it up.

“It is wonderful that it’s spreading,” he said. “I’m a little disappointed it has taken this long to get to England to be honest.”

Frude first set up the scheme in Cardiff in 2003 and the Welsh assembly took it nationwide in 2005. It was borne out of frustration at knowing the value of the books, but knowing that so many people either weren’t aware of them or could not get hold of them. It was a simple idea, he said. “The doctors are already there, the books are already there and so are the libraries. It just needed joining them up.”

In Wales now, 30,000 self-help books are borrowed every year and three of the 10 most borrowed books in the country are self-help.

There is a wealth of evidence to show that prescribing such books does work, the latest being research published in the journal Plos One which showed that people who used them over a year had measurably lower levels of depression.

Of course, there are good books and bad books and hunting through them can be dizzying: typing “self-help” into Amazon brings back more than 250,000 results.

“There is no shortage of books but some of them are atrocious and some of them are absolute gold,” said Frude. He quoted the American system where self-help books are rated from five-star down to one-star and then dagger – a book that will make you feel worse.

In England the project is being led by the Reading Agency’s director of research, Debbie Hicks. She said all but two local authorities in England were behind the scheme, which had also been endorsed by the Department of Health and crucially, the Royal College.

The full list of 30 books was signed off on Wednesday and will be circulated to all the library authorities next week. The list of conditions includes anger, anxiety, binge eating, depression, anxiety, obsessions and compulsions, panic, phobias, self-esteem, stress and worry. There will also be books prescribed to people who suffer chronic pain or fatigue, or perhaps have relationship problems.

Next year the agency would like to start including books targeted at children and young people.

Hicks said: “All the evidence does suggest that it does work and we have been extremely rigorous in putting together our list, making sure there is an evidence base for each book – that they have been used and found to be effective.”

She stressed that the list would not be set in concrete. “This is a starting point and we will evolve and develop it.”

Hicks said all the authorities had committed to buying the books and some would have collections in every library, while all of them would have them available.

How many books they may need is not yet clear. “The demand is likely to build as the scheme develops,” she said.

The prescription scheme is being run in parallel with the agency’s promotion called Mood Boosting Books. It hopes that, as well as reading the self-help books, people might join reading groups or just read books such as Frances Hodgson Burnett’s The Secret Garden, or Bill Bryson’s Notes from a Small Island, and discover that that puts them in a better mood. A new list of mood boosting books will come out in May.

The use of good self-help books is endorsed by the National Institute for Health and Clinical Excellence, although Frude said Nice does not say which books should be used, whereas it would with particular drugs.

“They are not for everybody,” Frude said. “And of course we are not talking about people with serious illnesses, but one in six of us will have a diagnosable mental illness in our lifetime.”

The books on prescription scheme was announced as part of a new national approach to library services drawn up by the Society of Chief Librarians. They revealed details of four “universal offers”, or promises, that libraries will provide services in the areas of health, reading, information and digital.

The society’s president, Janene Cox, said libraries, many facing the threat of closure and budget cuts, were having to evolve more quickly than ever before. “Local authorities have never faced such challenging times and confronted with these, we do have to think innovatively, act collaboratively and manage creatively to ensure the sustainability and future development of our services.”

More: The medicinal power of literature: Books on prescription to be introduced

 

What doesn’t kill us…

Tags

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Zoellner, T. & Maercker, A. (2006). Posttraumatic growth in clinical psychology. Clinical Psychology Review, 26, 626–653.

Men risk health by failing to seek NHS help, survey finds

Tags

access, employment, men, treatment, well-being

Men risk health by failing to seek NHS help, survey finds

Many men are leaving their well-being to chance, sometimes with “shattering consequences”, according to research that suggests they are far less willing than women to access NHS services.

A study by the National Pharmacy Association (NPA) has found that men are much less likely than women to take advantage of primary care services, including community pharmacies. They are also unwilling to consult a pharmacist face-to-face or seek treatment when sick.

Men visit their GP four times a year compared to six times for women, according to the NPA. On average they visit a pharmacy four times a year compared with 18 for women. More men than women admit that their understanding of medicines is poor, and they are twice as likely to take a new prescription medicine without first reading the patient information leaflet or seeking professional advice.

The review also found that nearly nine in ten men do not like to trouble a doctor or pharmacist unless they have a serious problem. As a result, men are less likely to access disease screening or seek professional support for healthy-living initiatives such as stop smoking schemes. In the three months to June 2012, 10,000 more women than men in England set a date to quit smoking, the NPA found.

“Our review shows that men aren’t taking full advantage of the support to maintain good health which is available free of charge on their doorsteps,” said Mike Holden, chief executive of the NPA. “Men tend to be driven by what they see as their immediate healthcare needs, and focus rather less on long-term wellbeing.”

The review, compiled to coincide with the start of Ask Your Pharmacist Week, suggests men’s reluctance to consult health experts will have wide-ranging implications for the nation’s health in the future because a number of treatable conditions will go unaddressed. By 2015, 36% of men are likely to be obese compared with 28% of women. Alcohol disorders are also twice as common in men.

The NPA suggested employment patterns could have a bearing on men’s attitudes to health services. Men are twice as likely as women to have a full-time job and are more than three times more likely to work over 45 hours per week, making getting to a surgery or pharmacy more difficult.