Crisis counselling interventions do not work

I have always been sceptical about the usefulness of providing trained counsellors to help those impacted by incidents of major trauma. It is almost commonplace, nowadays, to hear in news reports that trained counsellors have been drafted in to help deal with the emotional carnage following a major incident. Such considerations for those affected may indeed be well intentioned but that is not the point. I have often wondered if such decisions to draft in a cadre of specialists might actually be counter-productive for the resilience of those affected by such events.

I was interested, therefore, to hear the recent statements from the President of the Royal College of Psychiatrists when he cautioned against the automatic provision of crisis counselling interventions for those affected by major public incidents including the recent terrorist attacks in Manchester and London.  Sir Simon Wessely, a specialist in the treatment of post-traumatic stress disorder (PTSD), believes that research has demonstrated that the routine screening of survivors as a way of seeking to find those most in need of psychological support has proven to be ineffective.  The research indicates that a policy of implementing routine counselling could potentially traumatise those who would otherwise have recovered from their experiences. There was a wider risk of “professionalising distress”, he cautions, in encouraging those going through sadness or grief to think there was something wrong with them,

This reminded me of the time when I worked at a national charity, offering a telephone sign-posting service for people affected by problem gambling. Managers would offer a debriefing telephone consultation (which alarmingly usually involved one’s line manager providing the debriefing) immediately following a shift in the misguided belief that debriefing was an appropriate tool of self-care to support helpline advisors to cope with potentially difficult material. They would almost pressurise people to take advantage of the debriefing service and there was little awareness of the risks associated with such early interventions or that such support, if it is to be effective, should be voluntary.

Most people who have been affected by major incidents will benefit from a normal healing process whereby they learn to cope by using their own support networks. The research would appear to show that affected individuals mostly get better by talking to and sharing experiences with friends, family and colleagues. Sir Simon suggests that only a minority will need specialist help and such need will only become evident after a period of what he terms “watchful waiting” (which could be a period of up to 12 weeks when the needs of individuals are properly assessed).

The provision of early counselling for those affected by major public events may, of course, be well intentioned. However, early counselling risked overwhelming survivors as well as possibly interfering with psychological defence mechanisms, which aim to protect against too much reality and horror. There is also a risk of pathologising distress and potentially undermining the resilience of individuals, if there is a rush to intervene too early. Further, with the power of suggestion, there is a risk that individuals might experience possible ill-effects merely from the thought that they might occur.

The people who need reassurance might be those who have unresolved and unprocessed trauma from the past which gets triggered by witnessing major public incidents of disorder. The risk for such individuals is that they will feel unsafe and might seek to engage in unhealthy safety seeking behaviours as a way of avoiding the heightened feeling of threat. In such instances it is vital that these people have the support to go about their business in a normal way and help in dealing with their hyper-vigilance. Therapy can help with dealing with historical trauma, acknowledging cognitive distortions as well as helping to reconnect with an internal safe place.  But crisis counselling should not be the first thing we think about for those who were unfortunate to witness the unpleasantness associated with major public incidents.

See also

Kings College study on returning soldiers

 

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Working with Trauma in Psychotherapy

I attended an amazing course today on how to work with Trauma, which was run by Mark Brayne.  Mark is a psychotherapist, journalist, and author. After a first career as a foreign correspondent,  when he worked as a BBC and Reuters foreign correspondent and editor, he qualified in psychotherapy and since 2002 has specialised in working with trauma. His enthusiasm for his work knows no bounds and his lectures and courses seem to end so soon – such is the level of engagement with the material.

I was the only trainee there, as most participants were experienced therapists. One had flown in from Dubai especially to attend the course, another from Switzerland and another had just returned from North America. I attended the course primarily because Mark had given a 90 minute lecture on trauma a few weeks back at my College but I wanted more.

This one day event offered an opportunity to explore the issues in greater depth than in a standard lecture. Trauma, it could be argued, is behind so much of the presenting issues that clients bring to therapy whether in the form of anxiety, depression or addictions and should be prioritised in psychotherapy training. Indeed, I would welcome a weekend or a week on treating trauma.

So what is trauma?

Trauma is any threat to life or identity, mostly unexpected and which overwhelms the defences.  There is extreme helplessness involving fear and horror. Trauma is the piercing of body and psyche defences and survival involves fight/flight/freeze.

Traumatic symptoms will invariably comprise of the following: Intrusion (the inability to keep memories of the event from returning), Avoidance (or numbing) (an attempt to avoid stimuli and triggers that may bring back those memories), Hyper Arousal (similar to jumpiness. It may include insomnia (trouble sleeping), a tendency to be easily startled, a constant feeling that danger or disaster is nearby, an inability to concentrate, extreme irritability, or even violent behaviour).

Part of the course involved watching videos of the Twin Towers attack from 2001 and the G8 Summit that took place in Genoa, when riot police dished out savage beatings to protesters on the streets of the Italian city.  We were asked to monitor our thinking processes, feelings and physical sensations whilst we watched the videos. The videos  showed graphic close up footage. I felt dizzy as I witnessed the Italian riot police pound their batons into the protesters who were dragged along the street like pieces of dirt. Therapists need to be able to survive the trauma brought by clients in order to create a safe containing space.

The course dealt with EMDR as a treatment model. EMDR, it was noted, should only be practiced by a qualified mental health professional – with additional accredited training in EMDR.  That professional will most usually incorporate the therapy into their usual practice such as a Cognitive Behavioural Psychotherapist who may include EMDR in their CBT practice, particularly when treating trauma.  So, if you are in training you will need to wait until at least two years following qualification before applying for EMDR licensing.

I have always been fascinated by the brain. Did you know that the Amygdala performs primary roles in the formation and storage of memories associated with emotional events. When assessing the role of the Amygdala think of it as the control desk in the brain.  It will flash red warning lights at perceived threats.However, sometimes an event occurs, such as a trauma, which is simply too large or difficult for the brain to process.

EMDR also has the potential to cause serious psychological damage by triggering extreme traumatic memories. It is, therefore,  not an appropriate approach for a self-help book. So, be careful about engaging with bilateral tapping on your own.

How EMDR works

EMDR therapy is only interested in feelings NOW. What is in the past is done with. During EMDR sessions you will remain in control, fully alert and wide-awake. This is not a form of hypnosis and you can stop the process at any time. It is possible to use EMDR as a stand-alone treatment, but most often this would be for treating the psychological consequences of single event traumas.

Think of the mind as being like a factory or a massively complicated control centre.  One of its jobs is to process life events so that they can become memories. Because the event isn’t processed, it is prevented from becoming a memory and, therefore, it remains a current problem, rather than one that’s in the past. Memory involves what happened, an image association, negative thought, feeling and physical sensation. What usually happens with an unprocessed event? We get ‘flashbacks’ when present day situations or events that remind us of the original trauma get triggered. During periods of distress, we tend to press the factory’s STOP button. We also avoid situations which are likely to trigger these ‘flashback’ experiences, reinforcing the lack of processing.

We need to expose ourselves to thinking about and imagining the traumatic event, and/or gradually exposing ourselves to real situations which we normally avoid – if we are to effectively treat the traumatic event so that our ‘factory’ can process them into memories.

This process will result in experiencing distress, but will also cause the factory to effectively process the traumatic event, which will greatly reduce the distress in the long-term.

When the brain is profoundly threatened it will imagine the worst. When wounded or injured it generates massive amounts of opiates.  Sometimes, people become adrenaline junkies. Do you know people who are almost addicted to the high they receive from engaging in extreme sports activities, or high risk sexual behaviour? This behaviour may well be covering up untreated trauma.

What helps recovery?

The most valuable recovery tool for anyone suffering from the effects of trauma is a support system of family and friends.  Most people will not need counselling after a traumatic event as they will heal through their own processes. Professor David Richards research from 1997 on the prevention of post-traumatic stress after armed robbery showed that 80% of those who witnessed an armed robbery will heal on their own.

I sense I will go on to research this area and will try to get more training in treating trauma, as it fascinates me.

I learned more about mirror neurons at the course

Attending courses such as the one I attended help you see things more clearly.  For instance, have you ever seen people working with corpses?  They can appear to be very matter of fact in how they deal with the body. This is possible if they don’t know any personal details of the dead person.  It would be harder if they knew the person. Furthermore, I learned more about mirror neurons during the course (or counter transference).  Researchers argue that mirror neurons may be important for understanding the actions of other people, and for learning new skills by imitation. Emergency services workers will try not to talk about their work to family at the end of a working day or they risk dragging loved ones into the circle of trauma.

What is NOT recommended for the treatment of trauma

  • Psychological debriefing: This risks retraumatizing people who might not have been directly affected by an event.
  • Ineffective psychological treatments
  • For PTSD, drug treatments NOT a first line treatment (different for depression)

What IS recommended

The aim of EMDR therapy is to normalise and validate and the therapist will do this by displaying empathy whilst focusing on the trauma.
If you are affected by any of these issues consult the links below for help.

Resources

DSM IV criteria for Post Traumatic Stress Disorder
The European Society for Traumatic Stress Studies (ESTSS)
The International Society for Traumatic Stress Studies (ISTSS)
The European Network for Traumatic Stress (TENTS)
United Kingdom Psychological Trauma Society (UKPTS)
The IES-R is a 22-item self-report measure that assesses subjective distress caused by traumatic events
The Master and his Emissary Iain McGilchrist is a psychiatrist and writer who works privately in London 
Mark Brayne is a psychotherapist specialising in trauma

 

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My interview with Dr Michael Katz editor of Dream Yoga and the Practice of Natural Light

I have uploaded another link to an interview with Dr Michael Katz, speaker at the Gateways to the Mind conference on lucid dreams in London at the weekend.

In this interview I chat with Dr Michael Katz psychologist, former Yantra Yoga instructor, author, photographer, and long time student of contemporary masters of Tibetan Buddhism and Bon. He is best known as having authored the introduction and edited the popular book Dream Yoga and the Practice of Natural Light by Chogyal Namkhai Norbu. Katz is also the author of a book of poetry “The Crossing” (out of print), a fictional novel “The White Dolphin” and a non fiction book about lucid dream experience “Memories, Lucid Dreams, and Clarity”.

The interview took place at the Gateways to the Mind conference on lucid dreams in London in November 2012 organised by Archetype Events. But rather than chatting at the conference venue I joined Michael in his hotel bedroom for a cup of tea. As Michael sat cross legged on his bed and as Lucid dreamer Olga worked the kettle in the background I started by asking Michael about his presentation at the conference.

Click here to listen to the interview with Dr Michael Katz.

 

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My interview with Robert Waggoner, author of Lucid Dreaming

This weekend I attended Gateways to the Mind conference on lucid dreaming which took place in London. The event was held in the grand location of the Royal Geographical Society in Kensington. I had the pleasure of chatting to Robert Waggoner author of Lucid Dreaming: Gateway to the Inner Self.

The interview took place at the conference. Robert Waggoner  was one of the speakers at the event and demonstrated how we can all benefit from the non-physical realities.  Robert taught himself a simple technique to become consciously aware in the dream state. This took place over 30 years ago. Since then, lucid dreaming, or the ability to become consciously aware while dreaming, has been proven by the pioneering research of Dr Keith Hearne, University of Hull, and Dr. Stephen LaBerge, author of Exploring the World of Lucid Dreams  at Stanford University.

Many see lucid dreaming as an important psychological and therapeutic tool. In the interview Robert tells us how he became involved in lucid dreaming, what motivated him to write the book and how lucid dreaming can be potentially used as a treatment tool for clients with anxiety or even post traumatic stress disorder.

I started by asking Robert how he came to write his hugely influential book. Click here to listen to the interview on Youtube or click here for the Podomatic episode.

You’ve been listening to an interview with Robert Waggoner.  For more podcasts please visit noelbell.net/podcasts   

 

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Treating Trauma

I am looking forward to the part of the course that will deal with the treatment of trauma.  I have always been curious about the treatment models offered to victims of trauma, both adults and children.

Yesterday I heard the shocking story of a family killed by gunfire near Lake Annecy in the French Alps.  The story took an extraordinary turn with the discovery of a four-year-old girl who was hiding, alive and unharmed, in the leg space behind the front seats. Another girl, found shot near the car, is in a medically-induced coma.    The girl who was found away from the car – thought to be seven or eight years old – was shot three times and seriously injured. What struck me was how these unfortunate children can learn to cope with these horrific events.  All of this made me think of what kind of support systems are in place for those, particularly children, suffering from trauma.

The other morning I heard the interesting BBC One to One interview between broadcaster Paddy O’Connell and Sir Al Aynsley-Green, the first Children’s Commissioner for England (2005-2010).  Throughout his professional life he has championed services for children and in 2000 was appointed Chair of the NHS Taskforce for Children.  In the interview they discussed the impact of trauma in their own young lives.

What is PTSD?

During the course of our everyday lives, any of us can have an experience that is potentially overwhelming, scary and beyond our control. For instance, we could find ourselves in a car accident, be the victim of an assault or be witness to an accident. According to the Royal College of Psychiatrists, most people, in time, recover from bad experiences like this without needing help. However, with some people, such traumatic experiences have the potential to set off a reaction that can last for many months or years. This is what is known as Post-traumatic Stress Disorder, or what is commonly referred to as PTSD. According to the American Department of Veteran Affairs, Post-traumatic Stress Disorder (PTSD) is a mental health problem that can occur after someone goes through a traumatic event like war, assault, or disaster. Emergency and rescue workers are more likely to have such experiences given their exposure to horrifying scenes.

Check out the following list of resources for sources of help.

Resources

Assessing Trauma ISTSS offers a number of assessment resources, including assessment measures and testing manuals
EMDR is an acronym for ‘Eye Movement Desensitisation and Reprocessing’.
The Childhood Bereavement Network (CBN) Helping those working with bereaved children, young people and their families across the UK
The Childhood Wellbeing Research Centre an independent research centre with funding from the Department for Education to provide research, analysis and expert advice on the issues that promote or inhibit childhood wellbeing
Thomas Coram Research Unit (TCRU) carries out research related to children and young people in and outside their families
The Centre for Child and Family Research (CCFR) is an independent research unit based in the Department of Social Sciences at Loughborough University
Nice guideline for treatment of PTSD UK site
The RCGP Adolescent Health Group  established in 1993 (as the ‘RCGP Adolescent Working Party’) to promote improved standards of care for young people in primary care
Resource links for PTSD
CRUSE Bereavement Counselling charity
Acute Stress Disorder Structured Interview (ASDI)

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