Stephen Hadfield Counselling & Healthcare
PTSD – A Personal Journey Through Post Traumatic Stress Disorder
This article is a description of my own, personal journey through PTSD. Although it may differ significantly from your own, I hope that it may go some way towards helping you make sense of this condition.
Before assessing the different therapeutic approaches to PTSD, and my own experiences of what is currently on offer in the UK, it is important to briefly define what we mean by the use of the term, ‘Post Traumatic Stress Disorder.’
The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association provides common language and standardised criteria for the classification of mental disorders. DSM 5, released in 2013, moved PTSD from the class of, ‘anxiety disorders’ to a new class of ‘trauma and stressor related disorders.’ The symptoms of PTSD are set out in four ‘clusters,’ each containing a number of related markers to aid in diagnosis of the condition. (www.ptsd.va.gov) My view of this change is that it is a significant and constructive divergence from the pre-existing definition, separating and recognising PTSD as a condition with a distinct causative root rather than simply grouping it with all other ‘anxiety disorders.’ I found this particularly helpful in coming to terms with my own problems with PTSD, particularly as prior to developing PTSD symptoms, I had never before suffered with an ‘anxiety disorder’ and considered myself to have a relatively robust and resilient character.
In my own case, symptoms were particularly related to recurrent and distressing recollections of the event, intense psychological and physiological reactions and distress related to exposure to certain cues and a diminished interest in previously significant activities.
In addition to the above, I also suffered from sleep problems, a sense of a foreshortened future, irritability, difficulty concentrating, hypervigilance and an exaggerated startle response.
Prior to my PTSD ‘event’, in my case a near fatal heart attack followed by time in intensive care and two surgical procedures, I had always had a risk taking and ‘macho’ personality, enjoying adventure sports and feeling very capable of taking care of myself and my family in a physical and mentally resilient way. I essentially felt ‘robbed’ by the PTSD of what I considered to be key characteristics of what made me who I was.
As a consequence of my own experiences, I feel well placed to comment upon the questions raised within this article although, inevitably, these will be to a great extent, coloured by my own, subjective experience of the different therapies offered to me and generally, but not always, available to other patients presenting with symptoms of PTSD.
In my own case, as I physically recovered, learned to walk again and dealt with a number of surgery related health problems, I became aware that something was very wrong. I expected flashbacks and nightmares and after many years of reading medico-legal reports relating to accident victims, I knew that I had some symptoms of PTSD. I expected, however, that these would clear up with the passing of time and the gradual distancing from my period of hospitalisation.
I first sought help from my GP when I started to suffer from severe panic attacks a couple of years after the heart attack. These would wake me in terror in the middle of the night, dripping with sweat and fearful that I was going to die. At the time, the feelings of fear were so overwhelming that it was only by physically ‘running away’ and exerting myself to the point of exhaustion combined with unhealthy levels of alcohol intake in the middle of the night that I managed to stay ahead of them.
Things became so bad that I was afraid to go to bed and eventually, lack of sleep forced me to seek medical help. I am lucky to have a very good relationship with my GP and he convinced me that PTSD was the problem. His diagnosis confirmed what I already knew in my gut to be true. Looking back, I feel that I was initially resistant to seeking help because I did not want another medical label in my life and I considered the condition a weakness for which I was to blame and to which I should have been able to, ‘man up’ and resolve myself.
My GP reassured me that what I had been through was very similar to what combat veterans experience – a prolonged exposure to near death experiences and extreme stress over a long period of time. He reassured me that he had PTSD patients who had served in Afghanistan and had actually been through ostensibly less stress than I had. I think that it made me feel better when I recognised and considered that analogy as this helped me to identify with the conventionally ‘masculine’ side of my nature and showed PTSD as a result of being a survivor and fighter rather than a victim. Indeed, PTSD has long been associated with war and referred to as combat fatigue or battle fatigue. The earliest written account of what appears to be the condition is found in a report from a Roman commander, ‘fifteen guardsmen have died, apart from reservists, legionaries, the wounded and those suffering from battle fatigue.’ (Cowan 2003: 53).
I now know that I am not alone in feeling like this. The sentiments expressed in the writing of Judith Lewis-Herman expressed my feelings accurately and in a way that clearly identifies my confusion at that time, ‘….some patients resist the diagnosis of a post-traumatic disorder. They may feel stigmatised by any psychiatric diagnosis or wish to deny their condition out of a sense of pride….Admitting the need for help may also compound the survivor’s sense of defeat.’ (Lewis-Herman 2001: 158) This is certainly how I felt at the time.
What none of the ancient warriors above had access to was modern psychopharmacology. This was, perhaps understandably, the first line of treatment offered by my own doctor. I do not find this particularly surprising and given the severity of my symptoms, I would have probably felt short changed if immediate intervention based on a medical model had not been offered in the short term to help relieve my immediate problems. I note that Bergin and Garfield commented that, ‘psychotherapy and pharmacotherapy are each efficacious treatments for PTSD.’ (Bergin and Garfield 2013: 738).
I do not totally agree with this statement, however, particularly the word, ‘each’ which would imply an equality and an, ‘either or’ approach. My own opinion is that both drugs and therapy have their place but in my own experience, are most efficacious when used in tandem and with care.
Having previously trained for four years as an RMN psychiatric nurse with the NHS, I tend to be cautious whenever offered drugs, particularly when I feel that they are not being used to ‘cure’ a problem as, for example, in the case of antibiotics being used to treat an infection, but instead are being applied to mask underlying health problems and their symptoms which in my opinion, seems often to be the case with psychological and psychiatric problems. I have seen people become dependent upon prescribed drugs which have been handed out by doubtless well meaning doctors to treat anxiety and depression when in fact, the problems are ‘reactive’ as in anxiety caused by the loss of a job or depression caused by the loss of a partner. Although I feel that these are perfectly reasonable uses of such drugs in the short term to relieve the worst of the symptoms, my own life experience tells me that whatever, the problem, it will have to eventually be ‘lived through’ in the longer term by the individual involved.
At the time I initially sought help for PTSD, I was offered anti-depressants and decided, after much persuasion, that I would give them a try. After a couple of months, I reassessed the situation and realised that most of the symptoms were still there but that added to them was a sense of ‘unreality’ and detachedness in my everyday life. In essence, I never felt properly ‘awake’ and I was aware of a dulling of my senses with lack of concentration and a general lack of motivation in my day to day life. I realised that this was not something that I liked and turned to the British National Formulary to check out expected side effects. As soon as I recognised the side effects in myself, I did a quick ‘cost/benefit’ analysis and stopped taking the drug in question immediately.
Unfortunately, sleep disturbance and panic attacks continued along with the other problems set out above. I went to see my GP again and we discussed what to do. Together, we decided that sleep disturbance was the most disruptive element and I was given sleeping pills to help me at least get some rest and decrease the strain upon my heart. I also agreed to see a counsellor at the local hospital and this was arranged almost immediately. At no time, however, was the type of therapy or what I was to expect discussed and so it was that I found myself sitting one afternoon with a cognitive behavioural therapist.
At that time, I didn’t really know what to expect and thought that I would have the chance to discuss what I had been through and how this had affected me as a unique human being and what we could do together to relieve my difficulties.
While reading through the literature to write this article, I learned that, ‘Around 150,000 people in the UK survive the acute stage of a heart attack each year. Feelings of fear, anxiety and depression are common after such an event….a high proportion experience very severe distress and this has the potential to impair recovery, quality of life and threaten future health. It is therefore vital that cardiac patients are screened for psychological distress such as anxiety, depression and PTSD and are offered appropriate treatment if necessary.’ (Ayers, Copland and Dunmore 2009: 459).
I have to say that I strongly agree with this view. The trauma of such a life threatening event as I suffered also left me with a damaged heart and a number of physical problems. It seemed that no-one was prepared to offer any advice about the psychological consequences until I was seriously traumatised all over again having survived the initial physical and psychological stresses of the heart attack itself. When I left hospital, the impression given by the clinicians involved was that I was lucky to have survived and that this was down to the skill of the surgeons and that consequently, I should count my blessings and be grateful to be alive. No follow up was offered and I felt abandoned to my fate.
I felt very alone and adrift at this time in my life and hoped that some form of counselling might help me to understand the changes I was experiencing and help me cope with them in a constructive manner to enable me to get on with the rest of my life. Unfortunately, I soon found that Cognitive Behavioural Therapy – CBT, was not for me, despite apparently being the primary treatment of choice of the NHS and a variety of other agencies, apparently based upon a perception of PTSD as a ‘single’ illness rather than a complex syndrome, the characteristics of which can vary both in the symptoms involved and the severity of those symptoms from person to person.
I have to say that I could not disagree more strongly with this view as it applies to my own experience. What I experienced over the month that passed between my telephoning 999 and eventually being taken home from hospital in a wheelchair four weeks later, was a life changing event which shook me to my very core, caused me to question my belief system, my existential awareness and completely changed my day to day experiential way of life. What it was notwas some kind of computer programme error in my malfunctioning brain. In fact, it was a very real and frightening roller coaster life experience which left me a different man than I had been when I got out of bed feeling fit and well on that fateful February morning. The change in me as I was experiencing it, was valid and appropriate to my unique experience, not ‘faulty.’
At the time, however, I was at a very low ebb and ill equipped to discuss the merits of different types of psychotherapy even if I had known what I was talking about – which I didn’t! Consequently, I duly turned up for my slot and was surprised that the woman I met had no interest in what I had been through and simply wanted me to fill out a variety of questionnaires. I felt deflated, betrayed and confused when I left and decided to buy myself a cheap, ‘self help’ book on the subject to see if I could understand what was being offered. I quickly understood the basic concepts and realised why the therapist was not interested in my experience – it was because in her view, the problem lay not with my experience but with my way of thinking. To quote from the little book I bought, I should have been asking myself, ‘how helpful has my thinking been today? ‘ and, ‘how helpful has my behaviour been today?’ (Sinclair and Hollingworth 2012: 175). In essence, I began to feel that the problem was all my fault!
I would not seek to belittle the benefits of cognitive behavioural therapy in some circumstances and I should make it clear that I respect it as a serious and effective discipline having since read and studied widely in the subject. My problem with the application of it to my own difficulties is that I felt, and still feel, that it was simply not appropriate as an effective tool for the multitude of both physical and psychological problems I was encountering at stage of my recovery.
To clarify, I felt that CBT may have been effective in helping me think differently and change negative behaviours if these related to, say, depression following surgery or anxiety about a further heart attack. The problem, however, was that from my point of view, what I really needed at that stage of my recovery was to ‘debrief’ and to tell someone all of the awful things that had happened to me. As I tried to explain to my wife, although she visited me for an hour each day in the intensive coronary care unit, it was what was happening to me and what I had experienced during the other 23 hours that I needed to tell someone about
I instinctively knew that what was being offered was wrong for me. I should clarify that I do not mean to say that CBT is in itself the wrong choice for all PTSD clients, but rather that the way that the particular practitioner with whom I was in contact was approaching my problems felt to me as if it was doing more harm than good, particularly when I was invited to re-live my trauma. As I tried to explain to her, I was not talking about a single incident such as a car accident but about a multitude of incidents spread over a number of weeks when on some days I lay helpless watching my wife being told to ‘prepare for the worst’ and on other days, helplessly pressed a button for help as the alarm bleeped at 3am on the intra-aortic heart pump keeping me alive and no-one could be found to identify the problem. Thinking of one incident in therapy only served to remind me of all the others and made me feel as if I was dying all over again. This was a very upsetting process and all I really wanted to do was tell someone about it all and have my fears understood and validated.
I remain of the view that CBT when applied to PTSD appears to follow a set pattern of treatment which at one stage, ‘…tends to consist of exposure and modification of maladaptive beliefs about events, behaviours and symptoms,’ but that the therapy as a whole is intended to be, ‘a collaborative enterprise designed to uncover mental patterns, assumptions and secrets, not as a tool for browbeating patients who appear to hold irrational beliefs.’ (Brewin 2003: 194-197). I agree strongly with this statement and would agree that this is the way that CBT should be most effectively used to treat PTSD. In my own case, however, I felt that my beliefs were being undervalued and treated as irrational. As I tried to explain to my CBT therapist, I am at 5 times the risk of having another stroke or heart attack because of other medical conditions – there is nothing irrational in my fears. If I have learned nothing else from my heart attack, it is to trust my own instincts and intuition about my health.
Whatever my subjective experiences, however, I do feel that that CBT is a useful therapy when targeted at a specific problem. I often use it myself with my own clients but In my opinion, the fact that it offers the advantages of a generally shorter duration of therapy and the use of ‘self help’ exercises and ‘homework’ is what makes this form of therapy is so prevalent at this time, as it allows a GP diagnosis of a psychological problem to be specifically targeted, often by minimally qualified counsellors. In the case of PTSD, however, where different problems can exist in tandem, I am of the view that its use needs to be more carefully considered and weighed against other therapies.
So what else can offer relief to the client with PTSD? Again, I have to consider my own, subjective experience of the problem and I note Professor Stephen Joseph’s view that, ‘There are no “right” or “wrong” ways to react to adversity. Different people exposed to the same type of trauma may respond in quite different ways. Everyone’s reactions will be individual. And not everybody will have all of the problems (described below) or experience them to the same degree.’ (Joseph 2011). It was at this stage, following my disillusionment with CBT that I had a brief flirtation with Eye Movement Desensitisation and Reprocessing Therapy (EMDR) on the recommendation of a psychiatrist friend whom I used to instruct in medical negligence cases. The treatment wasn’t cheap and was relatively novel, only having been around since its development by Dr Francine Shapiro in 1989. I did a little reading, however, and was encouraged by the fact that it had been recommended for the treatment of PTSD by the American Psychiatric Association since 2004 and by the US Department of Veteran Affairs and the US Department of Defence since 2010. I only attended for a couple of sessions before realising that, in my experiencing of the procedures as used on me , the therapy was based upon the idea of desensitisation to painful memories and the reprocessing of negative thoughts – essentially CBT with added eye movements. In particular, shared elements with the CBT I had already experienced were the asking of me to recall the ‘trauma’ and monitor my physiological responses to the memory. As I am at high risk of a further cardiac event, I found the stress caused by this very frightening and not at all beneficial. Once again, I felt as if I was being treated as a malfunctioning piece of computer software and not a unique human being.
As part of the research for this article, I looked a little more closely into EMDR and found glowing reports on its efficacy (in other people!). In particular, I noted, ‘Significant treatment effects were obtained based upon self-reporting, psychometric testing of subjects and standardised interview measures…’ (Carlson. J.G, Chemtob. C.M, Rusnak. K, Hedland. N.L, Murnoka M.Y. (1998) I am not able to comment upon this research in depth within the confines of this article but having often used psychometric testing via an employment agency I am not entirely convinced of its appropriateness in this setting without examining the research in much further detail. Similarly, I wonder at the efficacy of ‘self-reporting’ in this context and what format this took. I have noted, however, on a general basis from my own reading, that a recurring criticism of EMDR coincides with my own reaction – that the eye movement is irrelevant and that the beneficial effects arise solely from the attributes it shares with CBT.
These similarities were discussed at length by Watts in 2013 (Watts. B.V, Schurr. P.P, Mayo. L, Young. Xu, Weeks. W.B, Friedman. M.J, 2013). Nevertheless, the World Health Organisation (WHO) does not share this view and in 2013, drew clear contrasts between the two therapies, particularly because EMDR, unlike CBT, does not challenge beliefs or involve detailed descriptions of the event, extended exposure or homework. (WHO 2013).
Having tried pharmacology, CBT and EMDR, I was beginning to believe that I was right in my thinking that the best way to deal with PTSD was with the use of my own resources – in other words, toughen up and shut up. I come from a military family and the discussion of feelings was not a major feature of my life until recently. Indeed, my grandfather served in the jungles of Burma in WW2 for six years and told many gory tales. My uncle was a Gurkha officer and similarly did not seem worried about his combat experiences. The more I thought about their lives, however, the more I realised that they had strong regimental ties and friendships which had lasted for years and that they had been able to ‘talk out’ their shared and common experiences with their compatriots. I also realised that they both had their own hobbies and interests in which they took solace alone and away from their families. I slowly began to understand that what I needed to do was devote more time to myself and not expect someone else to solve my problems.
In my own case, I have found that writing and painting has helped me greatly and I would recommend creative activities as a way of breaking negative thought patterns. I was not surprised to find that others have also found writing a help. As well as writing out a narrative of what happened to me as a way of making sense of it all and organising my thoughts, the narrative form has allowed me to tell my story at my own pace and in my own way. I note that the US Army, as part of a programme called, ‘Operation Homecoming’ operates a creative writing scheme for veterans whereby they are encouraged to try to express their emotions and make sense of their experiences through this medium. (www.vietnow.com). I was interested to read a Guardian article on this subject where a researcher at King’s College commented that, ‘I couldn’t trust a therapist like I could trust a piece of paper. Once you’ve said something, you can’t unsay it, but with a page of writing you can…proponents of therapeutic writing argue that while the processing may bring up difficult issues, the writer is always in control of them which is not always the case with talking therapies.’ (Pollard. J. 2002). This certainly ties in with my own experiences.
Similarly, drawing and painting has been useful to me during panic attacks where I found he diversionary aspect of this creativity useful in calming symptoms. To this end, I strongly agree with one of the early proponents of art therapy, Adrian Hill who wrote that the value of art therapy lay in, ‘…completely engrossing the mind…releasing the creative energy of the frequently inhibited patient.’ (Hill. A, 1945). From my own experience, I have found art very useful in moving my mind away from panic and recollection of unpleasant events. I note that this causes me to strongly agree with the British Association of Art Therapists’ own stated view that art can be used, ‘… not as a diagnostic tool but as a medium to address emotional issues which may be confusing or distressing.’ (www.baat.org/About).
The one area of therapy that I think offered most to me, however, has been the person centred approach although I also accept that this is not for everyone and I can think of a number of my friends who would much rather use the pragmatic, problem solving approach of CBT than talk about their feelings and experiences.
I was interested to note that, ‘International guidelines now recommend that cardiac rehabilitation programmes include health education and psychological counselling’ to ‘reduce mortality and morbidity….and improve quality of life and psychological well being.’ (Dalal et al 2015: 351). My own experience tells me that this makes perfect sense. We often talk of being, ‘heartbroken’ and of ‘heartfelt’ feelings and of ‘speaking from the heart.’ It is clear that our culture has always held the heart as a mystical centre of our feelings and emotions and a physical assault on the same, first by an illness and then by a stranger with a scalpel, is, in my firm opinion, having experienced both, also an assault on our emotions and sense of self. Although I continue to suffer from physical pain, I always have strong painkillers at my disposal for when I need them. I do not, however, have a therapist on hand 24 hours a day to talk through the psychological sequelae of what happened to me when I am in emotional pain.
Professor Stephen Joseph who, although more concerned with ‘post traumatic growth,’ comments on Carl Rogers’ theories in this regard that they, ‘provide the conceptual underpinnings to the client centred and experiential ways of working with traumatised people. Furthermore, Rogers’ theory provides an understanding of post-traumatic growth processes and encourages therapists to adopt a more positive psychological perspective to their understanding of how people adjust to traumatic events.’ (Joseph 2004: 101-119).
Unfortunately, we live in a society which often seems, from my own half century plus of life experience, to be increasingly driven by economic concerns which, in my experience, appears to have led to CBT being the ‘market leader’ in the treatment of PTSD at this time. Whether this will change with more research into the efficacy of other therapies remains to be seen and it is interesting to note that, ‘broadly based reviews (Wampold 2001, Roth and Fonagy 2004), have concluded that bona fide therapies that have been actively researched tend to be similarly effective,’ but that, ‘,,,despite such findings, the predominance of published research on CBT has given CBT a greater credibility than other approaches.’ (Stiles et al 2008: 677-688). I have found this to be true in my own experience of library based and internet research where there does appear to be a more extensive body of research in the CBT field compared to other ‘talking therapies.
My own views, which result from both my own experience as someone instructing psychiatrists and clinical psychologists in my work to someone being on the ‘receiving end’ of NHS funded therapy, have led me to agree strongly with the following statement, ‘In North America and Europe, economic pressures on mental health services and scientific political trends towards treatment standardisation have led to the development of guidelines calling for certain psychological treatments to be officially recognised as effective – reimbursed by insurance and actively promoted in training courses at the expense of other treatments.’ (Gatz et al 2007: 496-497).
My own experience of PTSD and its emotional effects upon my thinking process is at one with the description provided by Quinn who notes that PTSD, ‘…reorganises individuals’ perceptions of the world (tending) to reduce their tolerance for facades and false intentions. (Quinn 2008: 458-476). Accordingly, I have found that Person Centred Therapy has been useful to me, based as it is on ‘authenticity’ and the building of a congruent and empathic relationship between patient/client and therapist.
If I was asked to pinpoint why I have found PCT the most helpful intervemntion in my own case, I would probably have to say that it is because I was able to feel ‘heard’ and my experiences were validated in a non-judgmental way by my counsellors. I personally found this much more beneficial than a ‘problem solving’ approach offered by some other therapies that in my experience, often told me what I already knew and offered little in the way of empathy or the space to explore my feelings by simply recounting at length the things I had been through, many of which were buried deep in my psyche.
I hope that my experience of the PCT approach can develop into something positive, and that in Quinn’s words, the combination of therapy and the experience itself will, ‘help to create the whole person who can say, “I am as good enough now as I was earlier and will be in the future; there is no happy ending or cathartic, life changing moment.’ (Quinn 2008: 464)
In conclusion, I would mention that as I have always suspected, PTSD does not, in my experience, ‘go away’ and that one can only hope that with time and treatment, its worst manifestations will dissipate. I do not expect a cure, only help with management of the symptoms by being able to recount my experiences. Despite the condition being relatively new from the evidence driven viewpoint of modern psychology, it has been with us since ancient times as mentioned above. David Foy wrote in 1992 that, ‘only slightly over ten years ago, the majority of psychopathologists doubted that such a disorder existed,’ before going on to note that, ‘interviews with older veterans – for example, those who were prisoners of the Japanese during WW2 – demonstrate that this alternating pattern of remission interspersed with symptomatic periods can continue for 50 years, well into the seventh decade of life.’ (Foy 1992: 11-19).
Stephen Hadfield is clinical director of ‘Stephen Hadfield Counselling & Healthcare’ to learn more, search online or go to www.medicolegalcounselling.co.uk
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