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Jonathan Bisson:

Yes, I think everybody is raising some very important points here. If I could deal with the RCT issues because I think that covers both your points in many ways. I think that psychological interventions like drug intervention or any intervention are very, very powerful things and I think that as well as doing a lot of good, which we can see with a lot of people that have had psychological treatments, they have the potential to cause some individuals harm and have the potential not to help some individuals; perhaps be neutral. And my belief is that for any treatment, anything we’re going to advocate as a treatment, we should make sure that it is subjected to proper testing to make sure that it’s safe and that it’s effective, essentially.

In my opinion, the best way to do that is through a well designed, well controlled randomised controlled trial. It’s a whole different debate as to how to design a very well controlled one and we can go on to that.

But the gold standard would be to have the perfectly designed RCT of a psychological treatment so I have no qualms whatsoever in terms of advocating that we do continue to perform RCTs in this area. And indeed for the treatments that we’re not recommending at the moment, that haven’t been adequately tested, then I would certainly be an advocate of them being developed and tested through RCTs in the future.

I think to look at the debriefing thing, because it is an important thing to discuss, the Cochrane Review. My interest here is that I’m a co-author of the paper that John was quoting from then and indeed a study that I was the lead author on was one of the so-called negative trials of debriefing. And basically what we did was with the burns unit in South Wales. I’m from the Army, my background is in the army. I thought that psychological debriefing sounded like a really good idea. [For those of you who don’t know] psychological debriefing was first described in the States by a psychologist called Jeffrey Mitchell for use with fire personnel. Essentially it is a stage - usually about seven stages – which is a fairly structured intervention and the individuals go through an introduction of themselves, they discuss exactly what happened during the trauma in great detail, they look at normal reactions to a trauma – ways of looking at it– and how to seek help if they require it in the future. Is that fair John, as a sort of summary?

John Durkin:

It is but Mitchell’s model was only ever a group-based intervention, which I think varies with your study.

Jonathan Bisson:

Yes, it’s interesting that in Mitchell’s original writings it was for group or individual but certainly it’s very much accepted as being a group intervention and with helpers rather than direct victims. So, several of us have tried to adapt it for use with other traumatised populations. In our case it was with burn trauma victims. We debriefed people using individual sessions or couple sessions, and we did an RCT. Unfortunately, what we found was that individuals who were in the debriefing group, thirteen months after they’d received the debriefing, on average – this isn’t everybody; some individuals did [get] better –the debriefed group did worse than the non-debriefed group and that’s just a fact of the study.

And there was a similar study looking at road traffic accident victims, which had the same results. There were then another nine studies that have been looked at and when you put in all the information from these different studies together, on one of those charts like Stuart showed, then you get a neutral effect. And that’s the conclusion of the NICE guidelines is that these one-off interventions, if you follow up people straight afterwards, have a neutral effect. However, if you look at the studies that have pursued people up beyond a year afterwards, there seems to be a negative effect.

So for some people it seems as if it can do harm, and that’s the end of the story from my standpoint. I think the positive thing is that a lot of other things have been developed since then looking at more complex early interventions of several sessions, several of which include elements that were included in psychological debriefing and for symptomatic individuals have shown to be effective. So these are people who aren’t going through a normal reaction like the reaction you were describing but people whose symptoms are not settling, or the trajectory is going up over time rather than coming down over time.

Pam Dix:

I would just like to add, I was busy looking up one or two things within the guideline and the guideline is not intended to be a substitute for clinical judgement or flexibility in relation to the individual. So I don’t see this as a question of every person that walks through the door, the therapist is going to use the same words and going to do exactly the same kind of thing. Of course that isn’t going to happen because every traumatic experience is different. And that will partly dictate the way in which the treatment is delivered. So I don’t see that it has that inflexibility within those kinds of treatment options that are being recommended, and they are no substitute for clinical judgement. That’s what it says on Page One.

Mike Jempson:

A couple of points I’d like to make: one of them is it will be very interesting indeed to see how the Daily Mail covers the press conference at lunch time and I suspect it will be about an explosion of PTSD – drain on resources – and probably an attack on the television for retraumatising people by presenting images of awful events. That raises an interesting point about how you publicise this kind of document and it strikes me that it may be more useful, in fact, to provide testimony, especially of those people who have been through some sort of treatment, and explain what that treatment has done for them and how it works. Because from a journalist’s point of view, the headlines that can be drawn from this sort of a document are fairly limited but one of the great difficulties is understanding what these counsellors do when, as was said earlier, you get the fire brigade and the police and trained counsellors but we don’t really know what they do or what difference it makes.

So that’s something that I think should be thought about – how do you get that testimony out there so that we can really understand and explain why, for instance, some forms of counselling are useful [as well as] get over this problem about the risk factor? Nobody really understands. I think it wasn’t terribly clear this morning how many people are likely to develop PTSD if they’ve been through a trauma. One inference that I think people can take is that a lot of people are likely to be suffering from it and so the drain on resources will be huge.

The last one I’d like to make which, again I raised this one this morning, is about the impact of media coverage on people’s experience, people who have been affected by trauma. Since I run an organisation that helps people who’ve been affected by bad media coverage, I just thought it was interesting that some of the things that you were saying Pam, at the end are exactly what people described when they found themselves on the receiving end of inaccurate or unfair media coverage; this sense of being alone, helpless, nobody really understands. They’ve become almost paranoid about how the world views them and how there is no real opportunity to find other people who’ve been through the same experience so I wonder whether, in fact, some of the people we deal with are actually themselves having some sort of psychological trauma that needs counselling, too.

Pam Dix:

If I could just respond to the end of what you said and leave the beginning and the middle to others here. I’ve been on the receiving end of some exceptionally difficult media experiences in which it was very clear to me that they didn’t actually want me to tell my story but they were telling me what they wanted to hear. I have sat with many a journalist asking me questions [and] demanding I give the answer that is required, and I have learned how not to do that but that’s taken ten years. So [to] those people who are immediately experiencing trauma let’s generalise it; you have no luxury of time, you have no luxury of knowing what they’re going to do with your statements. When, after Lockerbie, I wrote to a newspaper and questioned their use of a single photograph of a dead body over a house before anybody had been identified, you see how far we have changed in the way we see images on the television and in the newspapers; constantly, different people’s traumatic experiences laid bare for us.

But I think the media needs to use some judgement and maybe needs to understand that there may be an agenda and it’s okay to run with this new agenda but you don’t have to impose one. Certainly my experience of one or two newspapers is that we would go through a process of interview about a particular aspect of Lockerbie, for example, and it became clear during the course of the conversation when the journalist said to me, ‘well, I’ll have to call my editor now, and I said, ‘Oh, I see. So I’m not giving you the headline you want?’ And she said to me, ‘You know the score.’ So I said, ’Fine, that’s okay,’ and the next day, her story appears and of course, none of the reasoned comments that I’d made were in there because it didn’t work for her.

So I would call upon the media with a plea to think about this in a positive and constructive way and what you say about the use of personal testimony is a bit tricky because that means that people have to lay themselves bare for you and we have to find the people who are willing to do that. If it’s any good to ‘anonymise’ it, you can use the testimonies that are in this guideline and if that’s not good enough then we have to think of another way. But I understand the point about humanising experience.

Stuart Turner:

I think there are some very good points. I think it would be a disaster if the message were put across that PTSD is an epidemic, it was on the increase; it’s just not true. And for incidents that happen, most people won’t develop what we describe as PTSD. It’s not the typical response, so what we’re dealing here is a mixture. It’s a mixture of people who need a human response and will recover, and we’re dealing with a proportion of people who’re going to go on to have long-term problems and they’re the group of people that these guidelines are designed for.

So that’s really important and after a road traffic accident, perhaps the proportion of people who get PTSD is really very small so it depends a bit on what sort of incident it was, as well as everything else so things don’t work in that sort of way. I think that would be a very bad message to get across.

I just want to come on to the issue of choice.. I think when we’re offering treatments there must be choice. I remember most clearly the personal experience of sitting in the anti-natal clinic debating the issue of amniocentesis. I wanted to know what the percentage chance was that this was going to give an answer that would be useful and/or it would harm my unborn child. I wanted to know the percentages. I was a patient, my wife was a patient, my child was a patient; I wanted to know and I think that’s what this will help us with.

Now what we don’t know is how some other interventions work and of course there must be clinical choice but what we can say is, ‘Look, we have some statistics now, we know some things about some treatments, let’s talk about those. We know what the good things are; we know what the side effects are.

Patricia Justice:

I’m Pat Justice. I’m a trauma specialist really; in fact I’ve just come back from Thailand and Sri Lanka working with tsunami survivors so I’ve had an overseas experience as well. But I’ve been involved in a hell of a lot of the big disasters.

Now the one thing that worries me first of all about this document is how it will be picked up because I was sitting here thinking well, everybody who’s involved in a trauma has post traumatic stress; that’s obvious at first, the shock comes in. But very, very few go on to get PTSD and it kind of stands out to me that the general public are going to say, ‘God, I’ve been in a trauma I must have PTSD, I need help.’ That’s the way it could be reported. Reporters [say] ‘Trauma – PTSD’ and I think there needs to be a clear division between what you suffer after a trauma, which is post traumatic stress – generally the shock – and not many people go on to get PTSD.

Now if we talk about debriefing, which I do do, and I use an Impact of Events Scale (IES). I don’t just do one-off things and I didn’t do that in Thailand and Sri Lanka either. But I’ve had everything translated, and we’re having follow-ups. We’ve found that incredibly useful in impact of events, which is very cognitively based, actually; cognitively and emotionally based. Then they do have follow-up and we can judge from that whether they’re likely, from their scoring, to go on to develop PTSD. And what they like with the follow-up is where they can see whether they’ve improved or not and we feed that back to them and they can actually see. So a one-off intervention is nonsense really. I don’t think you can work on that device at all.

I just reviewed a book by a woman called Noreen Tehrani, which is about workplace trauma, concepts assessments and interventions – is she here? Great! I was very pleased to see in that book that she talks about debriefing, or psychological intervention, in a very positive way. And I’m sorry to say that that isn’t reported in your trials here. I see that the NHS, what it’s going to bend up to when you’re talking about choice, you’re saying you’ve either got CBT or EMDR.

That’s what actually concerns me because when I was out doing tsunami work there was a whole group of therapists and we all got together. We started from an EMDR base but because I brought in the impact of event scales we included art therapy, drama therapy etc. And you’re talking of people who don’t speak the same language where EMDR can be very useful and we’re collecting data and they’re all being followed up. What you’re finding, for the actual survivors of it – they don’t care what you’re doing as long as you’re doing something. They don’t understand, to a large degree, what’s what and they’ve all got different ways of expressing things, and we’re going to collect data to say which survivors have had which sort of interventions or possibly they’ve had all three.

And it’s that sort of data that is more useful - not to separate out and say this is what you need and this is what you need because we don’t actually know what each individual needs. We can say that this amount of people have benefited but then there are an awful lot of people that have benefited from debriefing, in trials, who don’t come forward and say that that worked for them because they’ve just got better and gone on with their lives.

So I think when you’re talking about PTSD, which is a later problem it’s not usually until about six months later that you can actually say, for legal purposes, that this person has PTSD, you’re going to get a lot of people jumping on the bandwagon. So I think that’s where journalists need to be aware and I get lots of people here who come into my practice and say to me, ‘I’ve been told I’ve got PTSD,’ and are really frightened and worried about it. But actually when it comes down to it they haven’t got PTSD at all, they just think they have, because somebody has told them that or even the newspapers have told them that - because they’ve read the wrong information.

Mejindarpal Kaur:

I’m from a Human Development Organisation that’s doing mental health work in the tsunami area of Sri Lanka. I was particularly interested in the journalistic viewpoint, having been a journalist before - that is today’s discussion about PTSD or the reporting on PTSD? I concur with the colleague that sits at the far end to say that it’s one thing to tell journalists that these are the dos and don’ts about how to report on a situation that is so technical and another to give these journalists an opportunity to go the field, and I’m speaking from experience.

We tied up with a team of psychosocial experts from New York who had done the Armenian earthquake, but the real role we played as an organisation to provide the infrastructure was to communicate the views that Pam Dix holds about what the client needs and watch how it should be reported. Because at the end of the day the researchers wanted to take back data and a lot of things that Pam highlighted were the concerns; even though the persons may not understand what psychological counselling is, your clients are the people who feel what you think you know. Therefore there were concerns about the camera, there were concerns about the data that was being taken, and they didn’t like the word research because they didn’t want to be researched upon.

But if you think that journalists should report differently on you, then I think journalists should be given an opportunity to do front line, and I use this word because in a building like this - front line training-by-being - where the psychological counselling is taking place. We have a team out there and the documentarian who came along learnt a lot from just that experience. She went away with very little data but very happy that she understood how she was going to report on it. So if you think that the meeting today is concerned [about how] reporters should report correctly, then they should be given the training for it. And I’m not saying it in a derogatory way towards journalists but what I mean is they must be in the field because otherwise these are just terms and they will not wash with them.

Mark Brayne:

I just need to respond briefly to your question about what the meeting is about. This is the struggle we have with the Dart Centre in a sense, that it is both about the content – it is about understanding trauma and the best support for [the] public, but also for journalists in keeping themselves well. But it’s very much about the reporting of trauma, the journalism. So it’s about the journalists and the journalism. We do the splits sometimes but it’s about both.

Sean Perrin:

Hi, I work with Bill Yule in the Child Traumatic Stress Clinic but I also run a post-graduate diploma programme to train child analysts and mental health specialists to do CBT and it’s one of the few in the country and they come from all over the country. My hope is that the NICE guidelines will impact all those people working in the NHS who see folks who’ve been traumatised and suffering as a result. They’re interested in being warm and empathic and listening and supporting, they don’t set those things aside. They often have had training in a range of different kind of approaches: family therapy, psychodynamic therapy and other things but feel very de-skilled when they have a traumatised individual in front of them and don’t feel they can turn to other folks within the services where they work to say, ‘how do I help this person get better?’

And I hope that the NICE guidelines will help them to realise that there is something worthwhile to do that they can add on to what they already do and help make people better. Because there’s a lot of mental health specialists out there who really feel they’re struggling and don’t get the support from their local services in trying to do things like CBT.

Mark Brayne:

Noreen? Noreen has just brought a book out called Workplace Trauma?

Noreen Tehrani:

Thank you. I didn’t actually come for a plug but thank you anyway. I’m really pleased that we are moving forward in getting evidence-based practice. However, I think the place where I move slightly away from the NICE guidelines is that evidence based practice doesn’t have to be RCTs. I really think, particularly for the journalists who would like to have case studies, we should be looking at a full range of different ways of looking at effectiveness including case studies. Although I think in the medical model RCTs are something which is the gold standard, it certainly isn’t the gold standard everywhere. And particularly in organisations I think you should be looking at much more triangulation, where you’re looking at three or four measures of success rather than a single measure which may, just by the very fact of the way you have to use it, lose a lot of the very important quality data that you would get in something like a case study.

Mark Brayne:

We’re getting very close to the end. Before coming to the panel for a very brief summary comment from each of you to some of these interesting points that have just been raised, is there anybody from the journalistic side for whom this is perhaps, a lot of jargon or new, or who has got big question marks. I’d be very interested to hear any observations about what you might have learnt tonight or might be taking away?

Brian Kelly:

I’m a freelance cameraman. I don’t really have any questions about what you were talking about. When the Iraq war happened I elected not to go. I’ve covered a lot of war zones and I decided not to go. I thought that would be the end of it but instead what happened is I ended up going through a whole period of having tears [and] emotional trauma and this was relating back to other war zones I had worked on. Through a friend I went to see Dr Mark Collins who amongst other things uses EMDR. Mark and I talked about this and I was thinking about telling people how fantastic EMDR was and it worked very well in getting me through a traumatic experience.

But thinking about it in more detail, it would have been completely ineffective used totally on its own. I probably went to see him for six to eight times and we actually only did EMDR twice and the other times we just talked because the EMDR is incredibly effective. I think it’s effective because trauma is like a flashbulb in your face and that experience goes right in and it’s frozen in there and it gets frozen in the part of your brain that is affected by the eyes. So doing the eye movement releases it, makes it a pastel colour, and makes it something you can deal with. All that works but you can’t use it in isolation so I can understand why people are concerned about you having a process where you’re going to say: ‘Oh, we’re going to use these things, we’re going to give these pills, we’re going to do …;’ it’s got to be a combination of a whole bunch of stuff.

I would have been interested in hearing about how people feel about us journalists going in and sticking microphones into people’s faces; does it help or doesn’t it help? And I think again, in the end it’s just an individual case. Sometimes it helps.

Mark Brayne:

We’re going to go to the panel now. Pam, do you want to start?

Pam Dix:

Just to say thank you first of all. Many of you are familiar with journalism and trauma and we’ve already seen a book published well over a decade ago called The Media and Pan Am 103; for those of you who haven’t seen it I recommend that you have a look. It’s about the experience of the journalists covering that particular incident and how they felt about what they did and what they saw and how that related to the events as they unfolded. You might find that interesting.

For me there is a bit of a conflict of the issues around trust, confidentiality and privacy. The media need to know [and] portray the real story and the people whose rights may be transgressed through that process and it’s a very difficult balancing act really between the two things. That’s really all I would say but it’s certainly true to say too, I suppose that when you go in the door and sit down with somebody, you’re not just going to do one thing. It just doesn’t happen that way; that’s not real life. And real life will be replicated in the surgery as well. I think we have developed this very strong terminology around these things and it makes it sound like you just go in the door and you have ten sessions of this and you do it this way and that’s it and you walk out the door. We all know it isn’t really quite like that. Thank you very much for the evening.

Jonathan Bisson:

I concur with what Pam says about that. I think it’s always worrying to me that we seem to be on other sides of the fence sometimes and I don’t think we are. I think we’ve got a lot more in common than we have apart. I think it’s a challenge to us all to work together and do what we all want to do, which is to help people who’ve been through traumatic events. I think there is a long way for us to go and I think there are a lot of things that we need to look at. Hopefully, when the next guidelines come out, we’ll all feel that we’ve moved the thing forward.

Just to end, from a personal standpoint, with regard to more journalistic comments, I think we often focus on the negative aspects of reporting but I think there’s a flip side to that coin as well, and several individuals that I’ve seen have spoken very, very positively about certain people that have interviewed them. And I think there is a right way of going about things which probably has an awful lot in common with the right way in going about trying to treat people, from our perspective. And it’s great to see the very positive work that Dart are doing; I’ve known them from the other side of the Atlantic and it’s great to see Mark taking it forward so strongly on this side. Thank you.

Stuart Turner:

Yes, I’d like to thank Mark and Dart as well. Just picking up one or two things. The guideline, even the short guideline, does emphasise that PTSD is a minority response. There’s a balloon in the short guideline, which clearly says that. So there is a distinction between trauma and PTSD. I think in a way I’d echo John’s comments, it’s good to see passion. I have to say I’m a clinician; I’m not primarily a researcher and I’ve worked in this field for a long time. I feel so passionate that when people are presented with a problem that they’re treated with respect; that they’re treated in the ways that Pam has said – with humanity. I argue very strongly for human rights perspectives in all our work but I also think that they should be treated in a way where they are told what sorts of things are likely to work best for them.

Now no-one knows if this treatment will work best for this individual but we can say in general, the evidence says to look at a group of people. This treatment is likely to work in this percentage and this treatment is likely to work in that percentage, so what odds would you like to take? I think that’s what we need.

I had to author the chapter on the drug treatment [and] from the previous research, my guess was the drug treatments would come out about the same as the psychological treatments because that’s what previous research had suggested. When we went into it, and we were lucky, we had access to a couple of trials that hadn’t been published and some other stuff, it didn’t. I think what we need to do is we just need to be really honest about what the limitations are - the strengths and limitations are - of the evidence that we have.

What we concluded was, it didn’t work, they didn’t work as well. The two psychological treatments where we had evidence did seem to work well, those were the treatments that we’ve advocated for those people with PTSD. But in any individual situation, what you’re going to be doing, is saying to the person, ‘Look, this seems to work reasonably well. These didn’t work quite as well but maybe that’s what you want.’ It’s not saying there’s a blanket ban on other treatments but actually these ones seem to be the best. Getting that into the GP surgery, getting psychological therapies of that sort into the GP surgery; getting it implemented. These are huge tasks and I just feel so passionate that I see people day in and day out who have had this sort of problem for years, and they’ve been banging their heads against a brick wall trying to get access to that sort of help and they’ve hit barrier after barrier and I just don’t think we should accept that any longer. If these guidelines are a step forward, then I think that’s a useful thing to do.

Mark Brayne:

Thank you all very much. Just a couple of things I want to say before we conclude. One is to introduce those who don’t know the Frontline Club. It is an exceptionally important and valuable space in which journalists and those interested in journalism and who deal with journalists can meet and talk about the craft and have this kind of debate. I can’t think of anywhere else in London where we could do this. So special thanks to Vaughan, Pranvera and their team who own and run the club. If anyone would like to consider membership they would be vigorously encouraged so to do.

The dialogue on trauma and journalism continues on the Dart website, and in events here too. We’re very grateful indeed for your enthusiastic support. Spread the word; this really matters. The journalism of trauma is immensely important and I’ve been gratified at the intensity of the passion that’s gone on behind this. Yes, there are different understandings of how best to approach individuals who’ve been through trauma but we’re all on the same page in our passion to improve the kind of support that people get and the way that this is represented in the media.

As a former journalist, as a journalist in recovery, I’m absolutely passionate now as a psychotherapist in meeting and supporting individuals who’ve been through trauma and I love EMDR; it works for me. But sometimes I might sit with somebody for a very long time before we do any EMDR at all. It’s much, much richer than that.

Thank you all very, very much indeed and special thanks to our three panellists. You’ve been brilliant.