21
Reflecting formally on the need to provide stepped care for
individuals who have experienced traumatic events.
This account will explore the need to be able to impact more usefully on the
symptoms of mental distress stemming from individuals exposure to traumatic
incidents or events. There are a number of locations across Britain where
specialist trauma teams are in place but on the whole trauma care is reliant on
stepped primary and secondary care provision. The account will detail and
analyse issues around demographics and adherence to diagnostic criteria.
The piece will illustrate the need for stepped care practitioners to develop their
skills of recognition and assessment in order to take on a preventative role
with those affected by trauma. It will be argued that the present care system
currently fails to deliver a service that promptly meets the needs of people
experiencing debilitating symptoms that can have devastating effects on the
individual themselves and their families. Treatment options and need for
training and education will be discussed. The process of working with primary
and secondary care to develop a clinical network aimed at improving trauma
care and supporting those working with trauma will be discussed.
The process of reflection often used by experienced nurses is ‘reflection in
action’ (Schon 1992). In the past few years I have become used to examining
my responses to clinical situations whilst engaged in them and then if
appropriate modifying my care. It is a real sense of disconcertion regarding
the perceived inadequacies of the care options available for what is a growing
problem in the UK that is driving this account
The issue of adherence to strict diagnostic criteria (Table 1) can actually mask
the level of the problem. Literature describes PTSD as being 'a common
anxiety disorder with a lifetime prevalence of about 8%' Kessler et al (1995).
This medicalised description typifies the objections that proponents of the
recovery movement feel about the whole issue of diagnosis (Ralph, Lambert,
and Kidder 2002). It would appear more useful to aim to provide care and
support for people experiencing distress caused by psychological trauma.
22
Table 1: THE CLINICAL PRESENTATION OF POST TRAUMATIC STRESS
DISORDER (PTSD)
1. PTSD usually develops within 6 months of the traumatic event and
includes the following symptoms.
2. Images dreams or flashbacks of the traumatic event.
3. Avoidance of cues which act as reminders of the traumatic event.
4. Difficulty recalling important aspects of the traumatic event.
5. Increased arousal and anxiety when exposed to trauma cues.
6. Depressed or irritable mood.
7. Withdrawal socially.
8. Difficulty concentrating.
9. The presence of nightmares leading to disturbed sleep.
10. The individual is easily startled.
Compiled from ICD- Classification (1992)
On formal reflection Boud (1985) it seems the case that all too frequently
traumatised individuals whose presentation of psychological distress fails to
fully meet diagnostic criteria can sometimes struggle to get prompt trauma
focused specialist care. This may be due to a number of reasons including
the paucity of CBT oriented care (Lovell and Richards 2003) and the fact that
individuals often present with a collection of symptoms that warrant a
diagnosis of depression rather than PTSD (McQuaid et al 2001). In terms of
the individuals subjective views of their problems it is likely, given the intrusive
nature of trauma symptoms that interventions aimed at lessening the impact
of flashbacks, nightmares and feelings of loss of control will be welcomed.
These interventions are also likely to be important factors in treating the comorbid symptoms of anxiety and depression. The successful treatment of the
symptoms of trauma is likely to include an emphasis on improving unhelpful
thinking, (NICE 2005) addressing sleep disturbance and making lifestyle
changes including encouraging exercise (Mental Health Foundation 2005). All
these interventions are also known to be useful for depression and anxiety
(NICE 2009).
In many areas of Britain practitioners are now coming across traumatised
individuals from countries where war and torture have been common place.
Millions of people from across the globe are fleeing from wars where it is
known that more than 80% of casualties are civilians (Elbert and Schauer
2002). Many of them are severely affected by the psychological
consequences of traumatic stress. In fact the nature of the trauma is
significant. This is particularly the case if it has been an assaultive event, as it
is known that this can lead to a more intense trauma reaction McQuaid et al
(2001). We are also beginning to see professional soldiers and journalists
(Feinstein and Nicolson 2005) who have been working in Iraq and
Afghanistan presenting at primary care practices with PTSD, partial PTSD,
and/ or trauma driven depression and anxiety. The suggestion that the armed
forces will recognise traumatised personnel and offer prompt responsive
23
treatment is not always accurate. In fact (Gabriel and Neal 2002) suggest a
number of rationales for this including the propensity for individuals in the
midst of a macho culture to resist being perceived as weak or as mentally ill. It
is important that stepped care practitioners are vigilant when confronted with
patients both civilian and military who have been involved in combat
experience and that they are able to utilise tools to aid the process of
recognising trauma symptoms. Practitioners can be helped in this process by
utilising the Impact of Events Scale (Horowitz et al 1979)) or by the use of
mnemonics that can aid practitioners to identify clusters of trauma symptoms
some of which are shared with other common mental health problems
(Khouzam 2001).
TRAUMA =

A Traumatic event occurred in which the person experienced,
witnessed, or was confronted by actual or threatened serious injury,
death, or threat to the physical integrity of self or other and, as a
response to such trauma, the person experienced intense
helplessness, fear, and horror

The person Reexperiences such traumatic events by intrusive
thoughts, nightmares, flashbacks, or recollection of traumatic memories
and images.

Avoidance and emotional numbing emerge, expressed as detachment
from others; flattening of affect; loss of interest; lack of motivation; and
persistent avoidance of activity, places, persons, or events associated
with the traumatic experience

Symptoms are distressing and cause significant impairment in social,
occupational, and interpersonal functioning (patients are Unable to
function)

These symptoms last more than 1 Month

The person has increased Arousal, usually manifested by startle
reaction, poor concentration, irritable mood, insomnia, and
hypervigilance
The use of tools can prevent a tendency to make value judgements about
what constitutes a traumatic event. Clinicians should bear in mind that it is the
response to trauma that is important and should not make judgements on the
severity of the index event. It is crucial that stepped care practitioners use
outcome measure tools such as the IAPT minimum data set and the REF tool
(Crisp 2008) which measure outcomes of treatment from a patient's
perspective of their mental health oriented problems. It is likely that within
many primary care settings that a stepped care approach to treatment will be
utilised (Bower and Gilbody 2005). As such structured evaluation can ensure
that patients not responding to treatment can be helped to access a more
24
intensive therapy perhaps delivered by a specialised clinician. Within a
stepped care approach clinical supervision should be linked to ongoing
evaluations of treatment progress thus ensuring that clinicians are able to
discuss and advise where treatment is failing to achieve objective progress.
Goldberg and Huxley (1992) describe a filtering process that takes place in
primary care, which entails practitioners actually being the first point of contact
for people experiencing mental distress. The fact is that primary care staffs
and stepped teams with short waiting times are likely to be the only health
professionals to confront patients who have very recently experienced
potentially traumatic events. Acute Stress Reaction (ASR) is transient in
nature, and develops following a traumatic event. Symptoms begin within
minutes of the traumatic event and should dissipate within hours ,days or a
few weeks. (Table 2).
Table 2. ACUTE STRESS REACTION
Symptomology
 Patient appears dazed
 Consciousness levels are reduced
 The patient presents as being overactive and agitated
 The patient becomes withdrawn
 Autonomic anxiety symptoms are present
 Temporary amnesia is common
 Patient appears disorientated and depressed.
Compiled from ICD- Classification (1992)
The types of traumatic events leading to an acute stress reaction are similar
to those associated with PTSD. It is known that although ASR is a very
different, less severe disorder than PTSD its very presence is known to be a
precursor of the more severe disorder. It is also known that should an acute
stress reaction become prolonged then the application of a brief cognitive
approach can prevent the onset of PTSD (Bryant et al 1999 and Foa (1995).
Cognitive restructuring input when applied in this situation, is a preventative
intervention aimed at helping the individual to cope better with intrusive
usually critical thoughts whilst awaiting therapy. Primary care clinicians
require training to equip them with the skills and knowledge needed to identify
whether or not following the individuals traumatic experience he or she has
developed negative thoughts about him/herself. It is very often the persons
perceived failure to manage or control the situation, which results in the
distorted thought processes. Should the assessment identify the presence of
unhelpful thoughts the practitioner can help the distressed individual to
challenge these thoughts in a structured manner. Research suggests that this
approach can go on to reduce the prevalence of future PTSD (Bryant et al
1999, Foa 1995). As such it is crucial that primary care staff are able to both
25
recognise acute stress reaction and PTSD symptoms and contribute to their
management.
The obvious danger within this approach is that a great many individuals
experiencing trauma will recover without intervention and as such clinicians
should ensure that they assess carefully and avoid pathologising simple
distress. Of course should the individual present with persistent symptoms of
PTSD the stepped care practitioner should augment their care with an early
referral for trauma focused therapy delivered by a specialist.
Reflective process is often driven by feelings of perplexity (Boud 1985). In this
case there is a need to reflect mainly in order to achieve a sense of catharsis.
Kennedy-Moore & Watson (1999) suggest that expressing emotion reduces
negative emotional experience and psychological arousal. The beneficial
effects can be immediate and are the direct result of expression rather than
operating in a cognitive or interpersonal level. I have recently been working
with patients who have experienced horrific events associated with war and
conflict in their countries of origin. Their stories impact on my emotional well being in a new and disturbing manner. It seems that males commit many of
the atrocities and it is this dynamic that can instil not only a sense of vicarious
sadness but also of vicarious shame). It is recognised that vicarious affect can
stem from trauma work (Figley, C 1995) and as such it is important that
practitioners (of both sexes) are able to utilise strategies to supplement
supervision which may not be available closely after the clinician has been
exposed to the patients stories. Butterworth et al (1998) suggests that
reflective practice can enable clinicians to express emotion in a helpful
manner.
Fortunately reflective practice also facilitates learning and progression. Given
the need for stepped care to be able to impact more effectively on what is
palpably a growing problem in the UK it is important that practitioners are able
to provide a range of interventions aimed at meeting the diverse trauma
needs presenting in primary care.
NICE guidance for PTSD (NICE 2005) recommends that people with severe
PTSD symptoms in the first month after the traumatic event should be offered
CBT trauma focused therapy and all people with PTSD should be offered
either CBT or Eye Movement desensitisation and reprocessing (EMDR).
Again the over emphasis on strict diagnostic criteria can mean that many
individuals experiencing debilitating trauma symptoms that do not meet full
diagnostic criteria have no guidelines or standards to guide treatment that is
so badly required. The usefulness of the NICE guidelines for primary care can
be questioned. The recommendation that all individuals be offered therapies
that are not readily available can lead to long waiting times for treatment
(Thomson and Freer 2005 p1) and present a range of challenges to stepped
care teams who inevitably 'hold' patients whilst they await specialist treatment.
Given the levels of distress and social ramifications of living with trauma
symptoms it is important that these services recognise their capacity to
provide care, support and interventions.
26
NICE guidance (2005) makes it clear that debriefing should not be routine
practice. Wesselly et al (2000) actually states that 'Debriefing may
paradoxically induce that distress in those who would otherwise not have
developed it'. This requires careful consideration. A primary care patient
feeling confused, angry and isolated may need to be listened to and to be
reassured. They may need to tell their story. This is not debriefing. This is
natural empathic caring and is an important function of primary care. In these
days of protocol driven oriented care it is worth perhaps reflecting on the
therapeutic value of just, listening (Cox et al 1987) re-framing and
normalising.
CBT based self- help books should be offered by practitioners via a library
loan and this can be seen as a means of offering a CBT approach that is
effective for a number of literate and motivated individuals and is easily
resourced (Lewis et al 2003). It is known that bibliotherapy approaches can be
useful for anxiety disorders in general (Gould and Clum 1993) and although
cognitive therapy was found to be superior to self-help in Ehlers et al 's 2003
study it did prove useful to a proportion of patients. Purely in terms of
empowering individuals to understand their condition, bibliotherapy can be
very useful to traumatised individuals. More significantly patients using selfhelp literature may gain from a sense of recognition of self and identifying with
emotions and experiences that can be inherent in the content of the book
Cohen (1994).
Patients whilst awaiting specialist care may be helped by medication. It is
known that both Mirtazapine and Paroxetine can be useful agents in
alleviating some of the trauma symptoms (NICE 2005) they can both also be
responsible for side effects. Primary care practitioners can support patients by
ensuring that they are aware of these adverse affects and are able to develop
strategies to mediate them.
Stepped care practitioners are becoming increasingly aware of the importance
of exercise as a strategy for reducing symptoms of anxiety (Mental Health
Foundation 2005). Many Primary Care Trusts are now able to prescribe
exercise. The psychological impact of being able to have some control over
symptoms by partaking in a normalising activity should not be
underestimated. Similarly patients can be enabled to gain a modicum of
control over anxiety symptoms by being taught a relaxation technique at an
early stage of the trauma- induced condition (Vaughn et al 1994).
It is apparent then that stepped care practitioners with training and support
can intervene more confidently to alleviate some of the symptoms of trauma
related distress. They can also offer structured support and enable the
individual to achieve a sense of being back in control over their well being.
Stepped care services are equipped with a workforce who with training from
specialists in trauma work could offer those interventions recommended by
NICE (2005).
It seems then that despite the fact that the number of people experiencing
distress from psychological trauma living in the UK is likely to continue to
27
grow, service provision as it exists, will struggle to manage this distress.
There are options including the commissioning of specialist teams but a more
cost -effective approach may be to explore the treatment options. Eye
Movement Desensitisation and Reprocessing (EMDR) has been recognised
by NICE (2005) as an effective evidence based treatment. In terms of
enhancing the capacity to treat, EMDR has certain advantages over other
equally effective treatment approaches.
1. Mental health professionals can be trained to practice over an intensive
staggered 6 day training course.
2. EMDR tends to result in patients experiencing psychological relief in a
short span of time (Silver et al 2005)
3. The therapy has real usefulness in both the early and later stages of a
traumatic illness (Silver et al 2005)
4. EMDR is known to be a very acceptable treatment with low drop out rates
(Lamprecht et al 1999).
Unfortunately in order to increase the accessibility of EMDR more therapists
are required and the training can currently only be delivered by a small
number of EMDR specialists. Although registered trainers may argue that this
ensures the quality of the training, a well regulated 'train the trainers' scheme
would ensure that more patients had access to the treatment. On reflection
EMDR has not always been regarded as a bona fide treatment option. When I
first trained in 2000 many colleagues were sceptical and questioned the
quality and validity of the approach. This is certainly the case with a very
promising treatment approach. The rewind technique has evolved from the
work of Richard Bandler (1979) one of the co-founders of Neuro-linguistic
programming. The process was originally entitled the VK dissociation
technique. The approach has been refined by Griffin and Tyrrell (2001) and
seems to help by allowing traumatised individuals to use deep relaxation
techniques and to then reprocess the traumatic memory so that it becomes
stored as low impact memory rather than one that initiates a terror response.
This is achieved by enabling the traumatic memory to be moved within the
brain from the amygdala to the neocortex. At present there is limited evidence
to support wide spread acceptance of the technique (Muss 1991, Guy and
Guy 2003 and Hossack and Bentall 1996) but it should be remembered that
this was also the case with EMDR. Indeed when one examines Marks (2002)
criteria for the maturity of a therapeutic science few accepted therapeutic
approaches including medication can survive all 4 of the criteria.
Criterion 1: a given treatment must improve a particular problem (a) reliably,
(b) enduringly and (c) cost-effectively and (d) must be acceptable to patients.
Criterion 2: only specified components of the treatment should produce the
improvement.
Criterion 3: the mechanisms by which therapy components yield improvement
can be delineated.
28
Criterion 4: why therapy components help only some sufferers and not others
with the same problem can be pinpointed.
As this piece has illustrated the role of supporting and treating traumatised
individuals in primary care is likely to continue to expand. An argument has
been made that recommends that both stepped care teams and secondary
care have clear roles and when trauma symptoms are severe and cases
complex, specialist care is required. In terms of meeting the needs there is a
requirement to build on the capacity of health professionals to deliver existing,
effective treatment modalities within a stepped care system.
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