Dart Center for Journalism and Trauma

This is an edited transcript ...

Mark Brayne:

Tonight’s event is very much about discussing a very specific set of scientifically grounded pieces of information. Stuart Turner who has been a leading figure in developing these guidelines will lead us off, and then hand over to Jonathan Bisson from the Cardiff and Vale Trust in South Wales. Pam Dix of Disaster Action will finish off the beginning of the discussions.

Stuart Turner:

What I’m going to do is four things. I’m going to start by talking about a personal history, I’m going to tell you some stories about me, briefly. I’m going to talk about how the evidence base has grown, how the guidelines have been developed and then I’m going to show four slides with some of the main points from the guidelines. They’re points taken from the printed version you’ve got in front of you. It’s just to emphasise because I think it’s worth doing that.

Then John, who chaired the group, will take over and talk about psychological therapies for Post Traumatic Stress Disorder and Pam from Disaster Action will talk about the perspective of the PTSD sufferer, the person with PTSD.

So let’s start. My story goes back to the 1980s and I could have put other things here as well; the Harrods’ bomb was quite a big event in my life because I happened to be in St Stephen’s Casualty when that happened and it also had implications for people close to me. But the Bradford Stadium fire I think is a really important event in the history of understanding trauma in this country and it taught us several things.

It was a huge disaster. It was a disaster in which politicians got a bit interested and that did quite a lot in the 80s, for those of you that remember the 80s, in terms of changing the scene. It was a disaster in which there was an organised police response, which was unusual at that point, and it was a disaster in which people started going round to the community and listening. They were knocking on doors saying, ‘Do you have any problems? Do you want to talk to us about them?’ That had never happened before. Now I know there are down sides to doing that but that disaster and the planning that emerged from that disaster were very influential in the way that I started thinking about my work.

Around the same time, I was also working with the Medical Foundation for the care of victims of torture. In the 80s I was a trustee but I was seeing patients there, and one thing I learnt from that was the importance of listening; that actually people could tell me the answers much more often than I could tell them the answers. They could certainly tell me about their experiences and it was very important to listen to their experiences.

Then one night, I was sitting in the Medical Foundation, which then was in the old National Temperance just by the Euston Road and there were lots of sirens. It was a very disturbed night, something was happening and I finished about 10 ‘o clock. I was really drained and on the way home I realised there was something strange going on at King’s Cross. That was the night of the King’s Cross fire, and then I got sucked in to organising the Health Service Response, working with Camden Council, to the King’s Cross fire.

So, a mixture of working with people who were survivors of torture and survivors of disaster and – well, what did we do? Well, as I recall, and I may be recalling this with the benefit of hindsight, what we did was we listened to people. We recognised that some people, but not all, had a condition called PTSD. We recognised that some people had other conditions, some people had no conditions. We listened to people’s stories and we recognised that in working with survivors we had to be prepared to focus on their experiences of trauma.

The instructions that we gave to therapists after the King’s Cross fire - [there were] people from a whole range of backgrounds and we hadn’t really had the chance to train them - but what we said to them was, ‘If you do anything, just focus on the event and go back over it and back over it and back over it because that’s the thing that is driving the problem.’

We said people need space and time. You can’t always do this in fifty minutes and I used anti-depressant medication for some people. So those were the things I was doing in the 80s and as you’ll see, some of those things still seem to be valid when I look at the evidence.

So what has changed? Well, a number of things have changed. First of all we now have a lot more evidence to go on. We have the scientific evidence of the randomised control trial (RCT). The randomised clinical trial is a well recognised and a well-used tool, which allows us to say, ‘this intervention, ignoring all of the other factors that might be relevant, this intervention does or doesn’t lead to a particular outcome.’

Now there are limitations in the RCT chiefly because you can’t always do it on the scale that you want, and it tends to be on rather specific populations. But as a tool, it’s very powerful. Then what happened was people started saying, well, there are a number of trials - can we join them together? So there’s the option of joining the numbers together to give a more powerful statistical analysis; and that’s the Meta analysis. There have been a number of improvements in trial design and I think another significant landmark was the licensing of two drugs for the treatment of PTSD.

Now some people might see that as a negative and some people might see that as a positive. I’m not making a value judgement here. But I think the marketing of those drugs has had an impact on the way people are treated in this country and we’ll come back to the drug evidence later.

So, NICE is the National Institute for Clinical Excellence and it has techniques for developing guidelines based on scientific evidence. It involves the establishment of a guideline development group – a group of people who know something about the field and a group of people who know how to analyse data. So it brings together different sorts of people to cooperate and I think that’s a very powerful junction.

When we looked at how we were going to set about our work we said we’re not interested just in knowing if a particular treatment works or not. In other words, is a particular treatment better than doing nothing? That didn’t seem very helpful. What we said was we’re interested in knowing if it works to a degree that makes sense as a meaningful result. So you might say it could work if it caused a difference in a scale of point one; but a difference in a scale of point one might mean nothing in a clinical setting. It might mean nothing to a survivor. What we had to find out was whether it made a difference that was sufficient to make sense to a survivor as a useful outcome of treatment. So we weren’t just interested in the statistical significance but in how clinically meaningful the result was; and we discussed that in some detail and set some thresholds.

Our aim was to apply the scientific evidence to treatment decisions - really to improve care; not for people in disasters, not for refugees, not for assault victims, but for this very particular group of people who do go on to develop PTSD and I think that’s important. The guideline focused on PTSD and was obviously restricted to those interventions that had been subjected to this sort of scientific technique. But there may be other treatments that work that haven’t been subjected to this technique. We don’t know that. But what we have to go on is the evidence that we do have and recommend treatments that have been tested properly. So that was the process.

Now I’m not going to go into any detail on the statistics, so don’t worry, but I thought I’d just show you some of the statistics that we had to pore over and we had lots and lots of these, I promise you.

This is a chart showing the results of a number of drug trials. What you can see on here is the Meta analysis so it’s joining together three different trials in one analysis. The three trials were all on this side of the line so the statistics all favoured drug over doing nothing. What we’ve got at the black diamond is the result of aggregating those data into one pooled result. What this analysis shows is that this doesn’t meet our threshold of a clinical meaningful result. So although the statistics favour the drug, it isn’t at a level that makes it a clinically meaningful result. If you treated someone with that drug, they might notice some change but it wouldn’t be very much and then you have to ask yourself, is it worth doing that, is it not worth doing that? There are some value judgements to apply, which we’ll come on to.

And then really, what I was going to show now are four slides just showing some of the main conclusions. As I’ve said, there are limitations to these guidelines. They’re only for PTSD and they’re only looking at interventions that have been looked at in a scientific way. But what it says is, debriefing should not be used, should not be the routine practice. The evidence doesn’t support debriefing. It says, in the early phase after a major incident, where the symptoms are mild then it may be reasonable to wait and see because [for] many people in that situation, their symptoms will gradually recover.

Now that isn’t to say that there aren’t other things that should be done. We know that support is helpful, we know that there are other things that wouldn’t necessarily be called treatments that might help people to [make] their natural recovery. I think what we’re saying here is that you don’t necessarily need to medicalise.

From audience:

Can I just say that I think the focus there is on single session interventions and I think often debriefing, which I know is a bit of a dirty word in some ways, but when it includes follow up, can be very successful. A lot of the research has shown that a single session debriefing is what’s gone wrong, in terms of the outcome.

Stuart Turner:

I’m sure we’re going to have a debate on debriefing at the end but let me just go on to the next slide. What the next slide says - what the evidence says - is if you have severe problems at the beginning then a multi-session treatment can be helpful. But the evidence says that treatment should be cognitive behavioural treatment. That’s the only treatment that stands out as being supported by the evidence for severe symptoms in the early phase.

The guideline says, importantly, everyone without exception, with PTSD should be offered the opportunity of active treatment. The guideline recommends two on the basis of evidence: one is trauma-focused CBT and the other one is a treatment called eye-movement desensitisation reprocessing – EMDR. Those are the recommended first-line treatments for PTSD.

What about poor drugs? Drug treatments, as we looked at them, were disappointing. Drug treatments for PTSD should not be used as a routine first-line treatment even in primary care, never mind in secondary care. This means that we need to rethink how we make accessible trauma focused CBT and psychological therapies in the primary care setting, which is going to be a big challenge I think, for the NHS.

Drug treatments may be helpful for a number of people including people who prefer that option. Some people don’t want to talk about it and they do want help. It’s perfectly fine; patient’s choice, user choice is a key element of any guideline. So they should be available in some situations and we say which drugs seemed to be the best. For children, the guideline says trauma focused CBT is really the only treatment that stands out in the evidence, and it should be offered to older children with severe symptoms in the first month and to all children with PTSD whose symptoms persist.

So that’s a summary of some of the main points in the guideline. I’m going to hand over to John and he’ll talk more about psychological treatments and he may pick up debriefing.

Jonathan Bisson:

I was just going to focus primarily on psychological treatments for established PTSD. I’m very happy for us to have a chat about debriefing but perhaps we can do that later.

I think one of the interesting things when I first came into looking at PTSD was that lots of different psychological treatments are used to treat it. That’s true of many conditions but certainly in the treatment of PTSD a lot of treatments were used and very few of them seemed to have a sound evidence base for their use. So when I first came into it, cognitive behavioural therapy was probably used as much as anything else.

Mark Brayne:

Jonathan, can I just ask you to briefly explain for the journalists in the audience, what cognitive behavioural therapy and EMDR, are?

Jonathan Bisson:

Cognitive behavioural therapy is a treatment that involves looking at an individual’s thinking. For example, cognitive is for thinking, so a cognition is a thought and a behaviour the action, that’s where the behavioural bit comes from. For somebody with PTSD a classical cognitive behavioural treatment would be asking them to think about the trauma and go through it in great detail again, so exposing themselves to something they’ve already been through. An analogy is somebody that’s got a fear of spiders and they may be asked to look at a picture of a spider, then see a small spider, bigger spiders and then eventually sit in a room with spiders and you’ve got it really sorted out then [If an individual tolerates this].

With PTSD, what we often do is gradually increase exposure to the situation the individual has been through. The cognitive side of that is that a lot of individuals who have been through traumatic events will have cognitions; thoughts that are distorted as a result of their suffering, for example. A very common one is individuals who feel guilty about things they think they should have done differently during the actual trauma, whereas in reality that’s not true; it’s a distortion. So cognitive behavioural therapy will often use techniques to try and help an individual challenge these distorted patterns of thinking.

Eye movement desensitisation and reprocessing is another, what we call, trauma focused therapy in that the emphasis of the therapy is on the traumatic event, but it’s done in a different way. So if you go for a session of EMDR you’ll probably be asked to sit opposite your therapist. You’ll be asked to bring a picture up in your mind about the most distressing part of the event and you’ll be asked to let your therapist know how that makes you feel. It might be something like, ‘I am out of control.’ You’ll be asked where you feel that in your body, so it may give you a butterfly feeling in your stomach, and then you’ll be asked to focus on those three things: the picture, the thought and the actual feeling and then the therapist will start moving their fingers from side to side and ask you to follow them with your eyes.

It sounds weird, doesn’t it? I thought it sounded really weird when I first heard about this but it certainly does seem to work for some people. The theory is that as you move your eyes from side to side and you think about these things they gradually get easier, That’s certainly the experience that I’m sure several of us have had who have practised this; that for some people it does help things to get easier. We don’t know exactly how it works but clearly there is an overlap between that and the trauma focused cognitive behaviour therapy.

Group therapy, I think that’s fairly self-explanatory but that uses different schools of psychological thinking to actually try and help people. Psychodynamic therapy delves a bit more back into the past and uses relationship issues, often from one’s childhood and tries to look at factors like that. In-patient treatment, well, psychological treatment, has been provided on an in-patient basis and is advocated as being best provided by some individuals on an in-patient basis. We’ve then got psychosocial rehabilitation, which is perhaps a psychological treatment for individuals with more chronic difficulties, hypnosis, marital and family therapies and then creative therapies like art therapy, drama therapy, which often involves expressing emotions and feelings through other media.

Within the NICE guidelines, what we found was that there was a paucity of evidence for several of the different groups that I mentioned there. So, for example, there were no randomised controlled trials of in-patient therapies specifically so we haven’t got that as a separate therapy, or of the creative therapies. There is just an absence of randomised controlled trials. But what we did find were trials looking at trauma focused therapies provided on a one-to-one basis and we’ve got the trauma focused CBT and the EMDR coupled in that grouping; then individual, one-to-one non-trauma focused therapies. So stress management and relaxation work would be classical examples of that. That would really involve perhaps listening to a tape that tells you how to relax; to tense up your muscles and then relax them down but not actually focusing on the trauma at all.

Supportive therapy, non-directive counselling - being available to somebody but not directing them at all and often not using anything to do with the trauma itself - psycho-dynamic therapies and hypno-therapy - we lump those all together. I’m sure we’d all agree that’s not an ideal lumping together but there was only one trial for each of these different things so it’s difficult to look at them separately.

And then finally we’ve got group treatments. There were a few trials that looked at CBT provided on a group basis, often to groups of ten people, sometimes to more than that. So those are our groupings and those are the scores. Stuart said we weren’t going to discuss statistics and we’re not, but the bottom line here is that the higher your bar is up the graph, the more effective you’ve been shown to be as a treatment. And there’s a slight caveat here; we only have the confidence that the trials actually give us. So [with] some of the higher bars, it may be that the true result is somewhat lower than that, just because of the variability within the trials that have been done. [Does] anybody want to hazard a guess at which are our top two? The A and the B came out just about equal – this is a measure of PTSD, the CAPS (Clinician-Administered PTSD Scale). I guess we’re all going to be guessing the same sort of things.

Well, just to keep us in suspense for a little bit longer there were two studies in there that looked at other therapies and you can see seventy-two individuals were included in those studies. So when we’re looking at these studies we’re not talking about very large numbers of people. The biggest number by far was the trauma-focused cognitive behavioural therapy. These are well-designed, randomised, controlled trials; one hundred and twenty-two in the EMDR group. In fact, those are the charts so the trauma focused CBT and the EMDR came out the strongest, and in fact there is no real difference between those two groups, even though the EMDR group is a bit higher. The stress management group came out a bit worse but still seemed to have an effect and the other treatments didn’t come out as well, and the group CBT came out somewhere in the middle.

What we also did was to look at if trials had compared one treatment with another treatment, which obviously gives us some idea whether one is superior over another. We did have some evidence for trauma focused CBT being superior to stress management and other therapies when they did a head-to-head trial against one another. There wasn’t really any evidence to show that there was a difference between TF-CBT and EMDR.

So I think the bottom line is that with our recommendations, we’ve been able to justify them through the literature that we’ve looked at, and at the first line are the trauma-focused therapies. And I think, in all honesty, it’s very difficult to put our hands on our hearts and say that one is superior to the other. If you really continue to analyse in more detail there’s a little bit more evidence in certain areas for the trauma focused CBT, but that may represent the fact that there are more people included in those studies at the moment.

These therapies, to be effective are usually provided over eight to twelve sessions, which I think is an important point, and the sessions usually take between sixty and ninety minutes. I think a lot of us advocate using slightly longer sessions when we’re dealing with trauma-laden materials or if we’re doing exposure work with an individual. Sixty minutes is often not enough to really go through the trauma and make sure that the individual is feeling that they’ve come down after having gone through what is often a very emotional session.

The non-trauma focused psychological treatments, we argue should not be routinely offered. Now that’s not to say that they are ineffective treatments. In fact there’s probably not been enough studies done yet for us to say definitively one way or the other whether they are effective or not. But I think one of the big arguments is that when we do have the existence of proven effective treatments, it seems logical to argue that we should be offering those to people that suffer from this condition.

So I think there are a few discussion points and I know we’re going to discuss things later. I’ve mentioned the top three ones there. I think the fact that the trauma-focused therapies do seem to fare better than non-trauma focused therapies on direct comparison suggests that there is a specific effect. It’s something more than just meeting up with people and chatting with them for an hour over ten to twelve sessions, whereas if you do better than having nothing at all you can’t really say that.

And I think there are several future directions and things that we need to consider coming out of the recommendations. There are really major training implications to train up people to provide these treatments that have been shown to be effective; and also to offer adequate supervision [to those] who are going to be providing them.
And then, I think there’s also the challenge of developing even more effective treatments in the future.

And with that, I’ll hand over to Pam.

Pamela Dix:

I think what I’m here to do this evening is to present a different kind of human face to those who are on the receiving end of both a traumatic experience and then possibly treatment that you may go through in the aftermath of that experience or series of experiences. I’m here this evening with a colleague and friend, Andy Murphy, who was the other lay representative on the guideline development committee. Just as an aside, it was a very interesting experience for us to sit there and work with professionals on this topic.

So I’m not here to talk to you about the evidence base, that’s not my specialty. I’ve had the opportunity to hear the evidence and to understand it but I come from the other end of the experience, if you like. Stuart brought me very vividly back to the 1980s, which is when my experience originated, in 1988, with the death of my brother in the Lockerbie air disaster. And I’m sure you are familiar with the pictures from Bradford. So too are we familiar with the pictures of the nose cone of the Lockerbie plane that is trotted out on every occasion that Lockerbie gets talked about again. So that’s my own particular personal experience.

I don’t feel that I’m qualified to represent the interests of everybody who will experience trauma and develop PTSD but I’m here to give you a flavour of what it’s like to be in that position. I’m also very well aware of the fact that many of you have been in that position yourselves. You will understand it from a personal as well as professional experience and it’s not that we set ourselves apart or above anybody else; I just think it’s important to acknowledge that.

In the immediate aftermath of a trauma, I’ve thought long and hard about what it is that people might need. Looking back again at the 1980s and the development of response to trauma in the lengthy period since that time, I think there’s been an incredible cultural shift within which this guideline fits very nicely. Shifting from a perspective that was entirely paternalistic, where people were told what they should feel and what they should experience and what they should accept in the aftermath of their experience. That goes across the board, whether we’re talking about trauma or about anything else.

And I had a very strong sense of what perceived needs are and what actual needs might truly be. Now these are not definitive and they’re certainly not based on any evidence. They’re based on thoughts and sharing experience with other people who’ve gone through similar experiences to mine, not only those of major disaster but of individual trauma that the person will live with in the same way as somebody will a disaster on a greater scale.

I think the sense on the outside, if you think of how people pick up a newspaper [or] talk about counselling – and you might put inverted commas around that word – what do we all mean by that? Very many of us in this room will mean something different by it and what a person picking up a newspaper would think by it is also different. Everybody out there now thinks that if there’s a major disaster everybody will be ‘counselled’ and then they are going to be fine. Somebody to make it better, somebody to take it away. There was a very strong sense, certainly of protectionism, in that early experience in the late 80s-early 90s whereby the idea was that if you removed somebody from the reality of the experience you could then somehow erase it and make it go away – if you didn’t acknowledge it, it wasn’t there.

To go back to normal, well, I’m sure many of you will recognise the old phrase – hackneyed phrase I suppose – of the new normal; once you have a particular kind of experience in your life whether that’s major, minor, traumatic or not it will change your view, change the way you are because that’s what life experiences do to us. We do not remain the same, we are not static human beings. And when a major trauma has intruded itself into life you cannot go back and erase the experience and pretend it didn’t happen.

This is what I see as a series of pretty obvious, common sense guidelines: access to information about what’s happening in the aftermath of your particular experience, openness, honesty and sensitivity on the part of the people that are dealing with you and responding to you. Non-judgemental assistance, how fantastic that is when you can work from a base in which you’re not judging the other person but how they respond to something; that you don’t consider them inadequate if they have a particular kind of response to a traumatic event. And I would very much include the question of appropriate medical advice within that; an emotional First Aid. You’ve got to enable people to go through that experience and it’s almost like emotional sticking plasters - it’s how I see emotional First Aid.

Being offered choices; what am I going to do now? What are my options? Can I talk about it; can I not talk about it? Can I go back to the place, revisit the place? Can I go to the trial of the person who attacked me? Can I visit that person in prison and try and understand what they did? All of these things are the kinds of choices we were faced with in the aftermath of Lockerbie and after many other disasters. Or whether or not you want to understand the reality of the experience to its full degree and to its full extent? What does it mean to see a dead body in terrible circumstances? What does it mean if you’re denied access to that body? What does it mean if somebody close to you has been killed? What does it mean if they have been injured and how do I want to go forward with that experience?

That’s really my main point from this slide, you have to acknowledge and go through the experience, and nobody can take it away. And the difference between the professional who’s responding to trauma and PTSD is that you know you can’t take it away. Whereas your best friend, your neighbour across the way, they want to take it away, and consequently they are often of very little value to people who are experiencing trauma` because they want you to feel better now and they want you to go back to that person they used to know. And the fact that you can’t, almost gives you a sense that you let people down.

But how do we move in from trauma to PTSD? I’m not going to talk about what that means in any kind of scientific way at all. But where do we work from when you’ve had an experience of trauma, how do we get from there to PTSD? And how does this guideline meet people’s actual needs? How are people going to be empowered by the guideline and go forward and be able to use it in their lives to assist them? How will these needs be met and who is going to meet them? For me the overriding context for the guideline is of course the scientific evidence, the base, and it’s a real triumph to be able to say something works. And believe me, when you’ve endured a whole series of things that don’t work, it is a revelation when you understand that there is something that will; or that may.

But my context, and I think Andy’s context for this guideline is the personal testimonies that you’ll find within the guideline if you read it all. These for me are the people who have dominated my thinking all the way through this process. In the guideline you’ll find a set of testimonies from people who are direct ‘experiencers’ of particular trauma and who have developed PTSD; and also testimonies from those people who found themselves the carers of those with PTSD.

I’ve just picked out some particular phrases from a number of these different testimonies because what I want people to understand is what it’s like to be on that receiving end. What is it like to sit in the chair on the other side of the desk? What is it like to walk through the GP’s door and to begin to try and explain yourself? It’s hard enough, is it not, to go in that door and explain when you’ve got an ache in your back, it’s hard enough to explain that you just don’t feel quite right so to try and explain your psychological state is incredibly challenging. I felt I was never going to be the same. When I needed help the most I was let down.

So, I haven’t deliberately chosen negative things here but this is what it is. When you have an immediate experience, say a single trauma as opposed to a build up of trauma over many years, you feel catapulted into another world; you’re no longer the same as the other people sitting around you. And when you read about things like symptoms of avoidance and dissociation and all of those kinds of things. When you feel that you understand what it is to live through those words and what they actually mean to your social well being, it’s a very different kind of thing. ‘I just wanted to explode!’ I really like that one because there’s also a very strong sense of people wanting to explode with others, that they cannot control themselves, that you feel like you’re tipping over the edge.

Moving swiftly on to what I picked out as the things that really impacted me when I read other people’s testimonies about what their negative experiences of different kinds of treatment were, and I haven’t thought about primary or secondary care, but it was always, ‘tell me about yourself.’ I can’t tell you the number of people I saw and each time they sat down and looked at me and said, ‘Now, tell me what happened to you.’ And you just want to strangle them and say, as one or two people I know in this room know very well, ‘Read the notes!’ ‘Read the notes’ because [there] should be a history somewhere so let’s have a little continuity.’

It’s not that people don’t want to tell their story necessarily, but even when you do it’s a bit exasperating when you’re doing it in those circumstances. I feel I irritated the professionals. This really stood out for me with a man whose testimony indicates that he was untreatable because he didn’t want to be treated, he didn’t want to be any better. He saw his notes and saw, ‘Mr So-and-so is resistant.’ And you think, well, maybe he is, he could be a very difficult man for all I know but I just thought that was an interesting perspective.

You feel you’ve got to get the people to like you in order [for them] to treat you well. And then the onus is again on the person with the experience to behave appropriately. I felt I had to prove that something was wrong with me; how can I prove it to you? How will you believe me? How can I demonstrate this to you? I felt I was more use to him than he was to me. This, a little bit, harks back to the old days when many people experiencing therapy of different forms felt that they were being experimented on, just as you might experiment on a guinea pig.

So what the guideline does is to tell us that things will work. Okay, we can carry on experimenting, we’ve got to go on learning but we don’t have to start at (a) all the time. And then something that really struck me that we have to bear in mind is where professionals actually vie for the cases. You must know, in the same way that journalists vie for the story, that professionals vie for the person with the most damage. ‘Let’s try and get in there.’ This person who might be treating the family of the child who exploded yesterday in the school in America, who will be seeking to get in there and we all know, from our experience, that the people who do that don’t always do so from the best of motives.

But the positives: how do people walk away from their experiences thinking, ‘I can live my life better now? I’ve been given the tools to help myself, to understand what I’m thinking, what I’m going through. ‘People gave me back a life I think is worth living.’ The central part of that quote actually said, ‘saved my life’ as well. And, ‘we had a rapport.’ What’s the trust? How can you trust this person that’s sitting there with you?

‘It was hard work.’ I kind of like this idea because a lot of it seems a bit airy-fairy, floating around and you think, ‘Mm, I’m going to sit around and talk about my experience, how’s that going to help me?’ But having a structure and understanding that there might be an end goal, can be very helpful to people. As one person put it, ‘it was a revelation. It opened a door to a new life.’ I put in brackets that that was CBT. These are individual anecdotes that have nothing to do with the evidence base but I just thought you might like to have a look at it.

A lot of my experience is of groups of people coming together to share their experience. A very close friend of ours was killed some years after Lockerbie, in a light aircraft accident and once I heard that he had been killed – he was a man who had been very close to my brother and he was very helpful after the death of my brother and really shored up a lot of the family - I couldn’t believe that he too had died in this way. But when I put the phone down from hearing that news, I don’t go to my neighbour, I don’t ring my best friend. I ring my friend whose brother was also killed in a bombing in an aircraft the year after my brother was killed and he can ask me, ‘what happened? Have they found the body? Where is he? Who’s helping his wife? Where are his children? Do they know what caused it?’ Because he knows I want to talk about the nasty stuff and that’s fine. Whereas the nice people are trying to make you feel better by not talking about the nasty stuff. So at the launch this morning, Bill, in some discussions, used the word nasty and I really like that because it is nasty and there’s no getting away from it.

So that’s what really helped me in those circumstances, not people trying to make me feel better – [but] people with the same experience. Well, there’s an awful lot of challenge in being with people with the same experience. It’s very challenging, it’s sometimes very difficult in itself but it’s incredibly rewarding and if you feel at three o’clock in the morning that you have to talk about this right now, you know the people who won’t be bored, who won’t be embarrassed and who won’t be hurt by what you want to say. That’s a fantastically rewarding thing.

Accept the new you. I think nothing could be better than that statement, really, because there is a new you and you can help control who this new you is and learn how to control it. But that’s the point, you don’t erase it, you go forward with it. We’ve all heard those phrases that people use when a person in their family dies - a child [perhaps]. I’ve had a father who numerous times has used this expression: ‘we learn to go forward but it’s like losing a leg. You limp forever.’ But you go forward into the future in a very positive way if you can.

Best of all possible worlds? Let’s understand what the problems are, accept that the problem exists and that we can do something about it. Support those who have it and indeed those who are offering the support as wel, and let’s get access. That’s my hobbyhorse, if you like; definitely, access. But I’d like to leave you with the words of one particular survivor who talked about the physical impact of her very worthwhile treatment, which is that she could freely breathe again. And yet at the same time, PTSD will always walk beside her. It’s not gone and it’s there. It’s acknowledged [and] it’s accepted; let’s try and go through it and take it with us without destroying our lives.

So for me this guideline hopefully will help all those who have yet to experience the trauma [and] will offer them something very different from what we could offer people in the past. Thank you.

Mark Brayne:

Thank you all three of you for putting several critical issues out on to the table. For those of you who have not yet read the personal testimonies in the guidelines - the full guidelines are pretty thick, they’re rather thicker than the small pamphlet that’s at the back there - the personal testimonies are pretty powerful indeed and are really worth reading; especially for the journalists among you.

I’d just really like to put it out to the floor. One of the questions I ask myself about this is how will this be reported? How will these guidelines enhance an understanding of trauma and a more intelligent reporting of trauma on the part of journalists who report the trauma? And what implications do these guidelines have for the narrative of trauma in the coverage – in the journalism? So if we can bring the discussion also round to the journalism to link it in with the clinical and the treatment response. Who’d like to start, with questions or observations?

Stephen Pilling:

I’m the co-Director of the National Collaborating Centre of Mental Health, which sponsored for NICE the production of this guideline. I can’t resist just using this opportunity to again say thank you to John, Stuart, Bill, Andy and Pam who are here today and the other people who produced the guideline.

For me the question, to try and bring it back to what Mark was saying, is that I think we have a product in the NICE guideline that stands the sort of scrutiny against the best that anybody has produced anywhere in the world. And I think we’ve done that consistently for NICE over a number of years now and the PTSD guideline is absolutely no exception. However, we have a real challenge in terms of its implementation, and in my intellectual arrogance I used to think that a headline on the front of the Guardian or the Independent was where we ought to be because then people would realise what a wonderful document we’d got. I’ve now rather switched my view to thinking that a headline on the front of the Sun, Daily Mirror or, God forbid, the Daily Mail, would be something that would have more impact.

I think there is a real issue about what role the press play in promoting implementation because one of the most powerful forces for implementation of this guideline are going to be people who’ve had the experience of Pam, Andy and others going along to the GP, going along to health professionals and saying, ‘this is what I want.’ And if we simply leave it to NICE or to the NHS to get that information over to people, it won’t happen. So I’d be interested in people’s thoughts and comments on that.

Hilde Rapp:

I work across many sectors so I haven’t got a real label. I’ve been a journalist and I’ve also been involved in what I think is relevant here, in the implementation of the National Service framework for mental health where obviously implementation was the real, real challenge. It meant really translating any guideline - developing any guidelines locally was part of that project - into a language that was accessible and meaningful to all stakeholders. To people who have themselves experienced the difficulties and whether they call themselves survivors or whether they call themselves service users or whether they call themselves people, makes a big difference I think, to how people will receive what one says to them. But there’s a message for clinicians that will be different to service managers, to journalists, to everyone. And between us we could probably work very hard together to find ways to creating a strap-line that really targets a particular audience that needs to be on board with this.

Mark Brayne:

Would any of the journalists like to comment on what they’ve heard and how this might be conveyed in a way that will make a difference to people’s understanding of trauma? David Loyn.

David Loyn:

I’m a reporter with the BBC. There is always a problem in reporting these things - well, problem - it’s a fact now that it counts as part of the emergency response to incidents and we expect them to be there. I think as Sarah said there’s always this journalistic line [that] along with the police, fire and ambulance, there are trained counsellors; as if you might send untrained counsellors! I think there’s a real danger with that and potentially there’s a real danger in understanding these guidelines - that there’s a sort of ‘one size fits all’ quite unsophisticated response to what’s happening.

If you look at the Paddington train crash, you’ve got the bereaved and survivors. The two groups don’t talk to each other, they have totally different needs. You have police, fire and ambulance who attend the incidents with completely different kinds of expectations – and journalists – who all have different psychological needs afterwards. I think in a sense, ours are the simplest because we volunteered and because temperamentally we’re quite aggressive people who seek what we need afterwards and are willing to talk very openly about the incident.

[For example] the worst thing that ever happened to me in my life - after it happened I was interviewed by a group of journalists, I wrote two thousand words to the Observer. I wrote to From Our Own Correspondent, I spent the night with the wife of someone we had to leave behind telling her the whole story and why we’d left him behind and so by the time I … three days later I’d told the story twenty or thirty times to a variety of different people; and by the time I sought help it wasn’t a very complicated issue to get myself out of.

So I think, temperamentally, journalists are very simple in all this but I just wonder whether there’s a ‘one size fits all’ group of counsellors, coming in after an incident, which the NICE guidelines fit [into] that stereotype in a way, that it’s eight or twelve sessions - which sounds like jobs for the boys to me - sixty to ninety minutes each in a particular ‘now approved’ kind of way. This, in a sense, could be moving backwards from a number of journalists believing that these things are very sophisticated; people are of different temperaments and require different kinds of intervention.

Stuart Turner:

I think we should have more controversy in this, as well. One of the things that I tried to say at the very beginning was [that] this was a guideline about PTSD; it’s not a guideline about people. I think that’s a problem. I’ve seen probably forty or fifty survivors of the Paddington train crash and you’re right. They’re all different and they all have different needs and for some of them it was very helpful to have the opportunity to talk. Some very mixed feelings come through in my recollections [as] to how they feel about the media interviews they had. Some seemed to have got very caught up in it in an almost obsessional way and it hasn’t been very helpful; others sat at home. That’s my experience; someone’s reacting to that but that’s my experience, that they got too involved in it somehow - in what was happening in the media and it wasn’t helpful they would say, to their long-term reaction.

[For] others it was probably helpful to be able to talk straightaway and to do those sorts of things. For most people, after a disaster you’re not going to get PTSD. For most people after a disaster what you need probably is the support of your friends. What you need is somewhere to be living; you need somewhere where you can eat. You need the basic essentials and you need a lot of support. Those human things are really important. Now, they’re not PTSD. Some people will go on to get PTSD. This guideline is about PTSD and it’s picking out one aspect of the way that some people respond to that sort of incident and I think that’s the difficulty. It’s hard to get to marry the scientific and the human. The human is there because it’s what we do all the time but the science is what we’re trying to get across and that’s difficult.

Mark Brayne:

I think I’d just add that my reading of the guidelines is that quite specifically they are advising against bringing in the counsellors and ‘one size fits all.’ My fear, with you David, is that the media – the Daily Mail has been mentioned in this context – might misunderstand either through ignorance or naivety or through wilful misrepresentation what these guidelines are about but they’re actually a very sophisticated set of instructions about what works and what doesn’t work.

Kate Nowlan:

[I’m a therapist from Counselling in Companies]. Well, I really agree with this ‘one size fits all’ bit. But from a clinician’s point of view, I find it quite terrifying because it seems to me that when one works with trauma, one is working as a clinician with intuition and with respect and with trust and with story telling and all sorts of things, which are not about an imposed model. And what alarms me as a clinician is that some of us who work maybe in different ways, maybe sometimes using EMDR, sometimes using cognitive but sometimes using quite other ways of working, that we are going to be marginalized and all the NHS funds are going to be put into this particular way of working. I think it’s actually quite alarming.

Jane Gilbert:

Independent psychologist, having worked in the Health Service in adult Mental Health for nearly twenty years with all kinds of difficulties. I wondered if the panel could comment on some of the ethical issues involved in randomised controlled trials for anything to do with psychological therapy? This is ground that has been well trodden before in the sense of when they did that big study on sorting out what therapies are suitable for use in the NHS. They did a whole series of studies on psychotherapy, and again they came up with CBT, and one of the things is that that’s often what receives the funding in universities. And I don’t think journalists are fully aware of the ethical implications of RCT when people are in psychological distress. I just wondered if someone would like to comment perhaps, on that as an additional point?

John Durkin:

[From Fire Stress Solutions]. I’m an ex fire-fighter. My career ended when I was injured and suffered post traumatic stress disorder and then went through the trauma of a lot of what you referred to Pam, as, if you like, an establishment control of my particular symptoms. As a result of my disillusionment and the loss of my career I undertook a psychology degree. Within weeks, I claim, my recovery was all but complete simply because I understood what had happened to me.

[I] became convinced that fire-fighter colleagues of mine could do a lot more for themselves than they were actually given credit for and maybe this is true for many people who work on the front line in whatever occupation you find yourself; that the experts have more to learn from you than you from them. That’s a personal opinion.

But in terms of journalism and reporting, one concern that I do have, and I’m going to quote this because it seems to surprise most people that I read it to. This is from the last page of the Cochrane Review: that of the eleven trials, three studies associated intervention with a positive outcome – this is the debriefing review – six studies demonstrated no difference on outcome and two showed negative outcomes in the intervention group. The two, presumably, are your study, Jonathan and another study relating to road traffic accident victims.

So if this was a boxing match, the debriefers would have won by one round and it concerns me that in reporting and interpreting just two of those studies, we have a quite unbalanced view of what is actually possible. I use the term debriefing to avoid further dispute over what that actually means. But I’m concerned that this is actually in the public domain and only one aspect of it. The critical aspect of it has been discussed.

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.