Category: Theory

Scientific American has a useful piece on how the immediate treatment of psychological trauma has changed since 9/11. The issue is interesting because recent progress has turned lots of psychological concepts on their head to the point where many still can’t grasp the concepts.

The article notes that at the time of the Twin Towers disaster, the standard form of treatment was Critical Incident Stress Debriefing – also known as CISD or just ‘debriefing’ – a technique where psychologists would ask survivors, usually in groups, to describe what happened and ‘process’ all the associated emotions by talking about them.

This technique is now not recommended because we know it is at best useless and probably harmful – owing to the fact that it seems to increase trauma in the long-term.

Instead, we use an approach called psychological first aid, which, instead of encouraging people to talk about all their emotions, really just focuses on making sure people feel secure and connected.

Although the article implies that 9/11 was a major turning point for our knowledge of immediate post-trauma treatment, the story is actually far more complex.

Studies had been accumulating throughout the 90s showing that ‘debriefing’ caused harm in some, although it wasn’t until around the turn of the century that two meta-analyses sealed the deal.

Unfortunately, the practice of ‘debriefing’ by aid agencies and emergency psychologists was very hard to change for a number of interesting reasons.

A lot of aid agencies don’t deal directly with the scientific literature. Sometimes, they just don’t have the expertise but often it’s because they simply have no access to it – as most of it is locked behind paywalls.

However, probably most important was that even the possibility of ‘debriefing’ having the potential to do damage was very counter-intuitive.

The treatment was based on the then-accepted foundations of psychological theory that said that emotions always need to be expressed and can do damage if not ‘processed’.

On top of this, for the first time, many clinicians had to deal with the concept that a treatment could do damage even though the patients said it was helpful and were actually and genuinely getting better.

This is so difficult to grasp that many still continue with the old and potentially damaging practices, so here’s a quick run down of why this makes sense.

The theoretical part is a hang-over from Freudian psychology. Freud believed that neuronal energy was directly related to ‘mental energy’ and so psychology could be understood in thermodynamic terms.

Particularly important in this approach is the first law of thermodynamics that says that energy cannot be created or destroyed just turned into another form. Hence Freud’s idea that emotions need to be ‘expressed’ or ‘processed’ to transform them from a pathological form to something less harmful.

We now know this isn’t a particularly reliable guide to human psychology but it still remains hugely popular so it seemed natural that after trauma, people would need to ‘release’ their ‘pent up emotions’ by talking about them lest the ‘internal pressure’ led to damage further down the line.

And from the therapists’ point of view, the patients said the intervention was helpful and were genuinely getting better, so how could it be doing harm?

In reality, the psychologists would meet with heavily traumatised people, ‘debrief’ them, and in the following weeks and months, the survivors would improve.

But this will happen if you do absolutely nothing. Directly after a disaster or similarly horrible event people will perhaps be the most traumatised they will ever be in their life, and so will naturally move towards a less intense state.

Statistically this is known as regression to the mean and it will occur even if natural recovery is slowed by a damaging treatment that extends the risk period, which is exactly what happens with ‘debriefing’.

So while the treatment was actually impeding natural recovery you would only be able to see the effect if you compare two groups. From the perspective of the psychologists who only saw the post-trauma survivors it can look as if the treatment is ‘working’ when improvement, in reality, was being interfered with.

This effect was compounded by the fact that debriefing was single session. The psychologists didn’t even get to see the evolution of the patients afterwards to help compare with other cases from their own experience.

On top of all this, after the ‘debriefing’ sessions, patients actually reported the sessions were useful even when long-term damage was confirmed, because, to put it bluntly, patients are no better than seeing the future than professionals.

In one study, 80% of patients said the intervention was “useful” despite having more symptoms of mental illness in the long-term compared to disaster victims who had no treatment. In another, more than half said ‘debriefing’ was “definitely useful” despite having twice the rate of postraumatic stress disorder (PTSD) after a year.

Debriefing involves lots of psychological ‘techniques’, so the psychologists felt they were using their best tools, while the lack of outside perspective meant it was easy to mistake instant feedback and regression to the mean for actual benefit.

It’s worth saying that the same techniques that do damage directly after trauma are the single best psychological treatment when a powerful experience leads to chronic mental health problems. Revisiting and ‘working through’ the traumatic memories is an essential part of the treatment when PTSD has developed.

So it seemed to make sense to apply similar ideas to those in the acute stage of trauma, but probably because the chance of developing PTSD is related to the duration of arousal at the time of the event, ‘going over’ the events shortly after they’ve passed probably extends the emotional impact and the long-term risks.

But while the comparative studies should have put an end to the practice, it wasn’t until the World Health Organisation specifically recommended that ‘debriefing’ not be used in response to the 2004 tsunami [pdf] that many agencies actually changed how they went about managing disaster victims.

As well as turning disaster psychology on its head, this experience has dispelled the stereotype that ‘everyone needs to talk’ after difficult events and, in response, the new approach of psychological first aid was created.

Psychological first aid is actually remarkable for the fact that it contains so little psychology, as you can see from the just released psychological first aid manual from the World Health Organisation.

You don’t need to be a mental health professional to use the techniques and they largely consist of looking after the practical needs of the person plus working toward making them feel safe and comfortable.

No processing of emotions, no ‘disaster narratives’, no fancy psychology – really just being practical, gentle and kind.

We don’t actually know if psychological first aid makes people less likely to experience trauma, as it hasn’t been directly tested, although it is based on the best available evidence to avoid harm and stabilise extreme stress.

So while 9/11 certainly focussed people’s minds on psychological trauma and its treatment (especially in the USA which is a world leader in the field) it was really just another bitter waymarker in a series of world tragedies that has shaped disaster response psychology.

So unusually for a psychologist, I’ll be hoping we’ll have the chance to do less research in this particular area and have a more peaceful coming decade.
 

Link to SciAm piece on psychology and the aftermath of 9/11.

Mother Board has a completely fascinating article on the current ongoing trial testing whether MDMA or ‘ecstasy’ could be useful in treatment combat trauma.

The piece is interesting as much for what it doesn’t say, as for what it does, and for how it ties into the history of psychological treatments for posttraumatic stress disorder or PTSD.

The trial is testing whether MDMA can assist in psychological treatment for the condition, in which a traumatic event leads to a sense of current threat and intrusive sensory impressions that are maintained by a pattern of avoiding reminders.

The most effective tried-and-tested treatments for the condition are types of therapy that are ‘trauma-focused’ that involve, among other things, a mental revisiting of the traumatic memories to ‘take the sting out of their tail’.

But this is exactly what most people who arrive in psychologists’ offices don’t want to do. This makes sense from the perspective of someone who is troubled by these memories and wants to stop thinking about them, but the avoidance actually helps maintain the problem.

This is, in part, because the person never learns to adjust to the anxiety (they don’t habituate in technical terms) and the memories remain as fragmented impressions that don’t fit into a coherent narrative, making them more likely to intrude into the conscious mind.

In other words, most people with PTSD initially arrive for treatment wanting a better form of avoidance because their current methods simply aren’t working. The mental health professional has the unenviable task of explaining that treatment involves exactly the opposite and reliving the event and experiencing the anxiety will be key.

It is so key, in fact, that anti-anxiety drugs like benzodiazapines (e.g. vallium) may reduce the effectiveness of treatment because they dull the experience of stress that the person needs to adjust to.

The MDMA trial is interesting in this regard, because ecstasy is, for many, a remarkably effective anti-anxiety drug.

So how does the drug facilitate the psychotherapy? Here’s the description from the article:

MDMA’s effects typically manifest themselves 30-45 minutes after ingestion, so it doesn’t take long for rhythms to develop in Charleston. Sessions at the clinic oscillate between stretches of silent, inward focus, where the patient is left alone to process his trauma, and unfiltered dialogue with the co-therapists. “It’s a very non-directed approach,” Michael Mithoefer told me. This allows subjects to help steer the flow of their trip. They are as much the pilots of this therapy as their overseers. “Once they get the hang of it,” Mithoefer explained, “sometimes people will talk to us for a while and then say, ‘OK, time to go back inside. I’ll come report when I’m ready.’”

That said, patients understand that if no traumas emerge, the Mithoefer’s must coax them out. But they’ve never had to. The traumas always emerge, and by now there have been over 60 sessions between an initial, smaller Phase 2 study and the present trials. Horrors are bubbling up naturally, patient after patient.

This harks back to a more psychoanalytic or Freudian-inspired idea of trauma and treatment. The goal of the therapy is to understand the inner self while the drug is intended to help us overcome psychological defences that prevent us from seeing things as they really are. In fact, this is a central assumption of the therapy.

This approach is not new. ‘Narcoanalysis’ was used widely in mid-20th Century where a range of drugs, from ether to sodium pentathal, were applied to patients with ‘war neurosis’ for exactly this purpose. Unfortunately, it was unsuccessful and abandoned.

So this is why the MDMA treatment is a gamble. All known effective psychological treatments for PTSD involve not only confronting the memories of what happened to make sense of them, but also re-experiencing the associated anxiety. A treatment with a drug that removes anxiety will, by current predictions, have limited effectiveness.

But this is also why the approach is interesting, because if it is shown to be genuinely effective, we might have to rethink our ideas about PTSD and its treatment.
 

Link to Mother Board article on the MDMA PTSD trial.

In the coming weeks we can expect to see politicians and pundits lining up to give us their smash-and-grab clichés for the recent urban riots in the UK.

They’ll undoubtedly give a warm welcome to our old friends economic decay, disengaged youth and opportunistic crime, and those of a more psychological persuasion might name-drop ‘deindividuation’ – the process where we supposedly lose self-awareness and responsibility in large crowds.

This belies the fact that crowd behaviour is a complex area that is surprisingly poorly researched.

But what we do know about is the interaction between large crowds and the police and you could do much worse than check out the work of psychologist Clifford Stott who researches how crowds react to policing and what triggers violence.

In his 2009 report on the scientific evidence behind ‘Crowd Psychology and Public Order Policing,’ commissioned by the UK constabulary, he summarises what we know about public disorder and how the authorities can best manage it (you can download it as a pdf).

He notes that the old ideas about the ‘mob mentality’, deindividuation and the loss of individual responsibility are still popular, but completely unsupported by what we know about how crowds react.

People don’t become irrational and they do keep thinking for themselves, but that doesn’t mean that the influence of the crowd has no effect.

In terms of policing, one of the clearest effects to emerge from studies of riots and crowd control is that an indiscriminate kicking from riot police can massively increase the number of people in the crowd who become violent.

This is probably because the social identity of people in a group is fluid and changes according to the relationship with other groups.

For those into academic jargon, this is known as the Elaborated Social Identity Model of crowd behaviour – a well-supported theory with an overly complicated name but which is surprisingly easy to understand.

Imagine you’ve just got on a bus. It’s full of people and you have to jam into an uncomfortable seat at the back. There are people going to work, some vacant students heading home after a night on the beers, some annoying teenagers playing dance music through their tinny mobile phone speakers and some old folks heading off to buy their groceries.

You’re late and you missed your train. You feel nothing in common with anyone on the bus and, to be honest, those teenagers are really pissing you off.

Suddenly, two of the windows smash and you realise that a group of people are attacking the bus and trying to steal bags through the broken windows.

Equally as quickly, you begin to feel like one of a group. A make-shift social identity is formed (‘the passengers’) and you all begin to work together to fend off the thieves and keep each other safe.

You didn’t lose your identity, you gained a new one in reaction to a threat.

The problem police face is that in most large threatening crowds only a minority of people are engaging in anti-social acts. Lots of people ‘go along for the ride’ but aren’t the hardcore that kick-off without provocation.

If the police wade in with batons indiscriminately, lots of these riot wannabes suddenly start to feel like they’re part of the bigger group and feel justified in ripping the place apart, mostly to throw at the coppers.

Suddenly, it’s ‘them’ against ‘us’ and a small policing problem just got much much bigger – like attacking a beehive because you just got stung.

The trick for the police is to make sure they’re perceived as a legitimate force. When they have to charge in, they’re doing so for a reason – to target specific criminals. The ‘them and us’ feeling doesn’t kick in because most individuals don’t feel that the police are targeting them. It’s the other idiots the police are after.

And herein lies the problem. The psychology of crowd control is largely based on the policing of demonstrations and sports events where the majority of people will give the police the benefit of the doubt and assume their status as a legitimate force.

Clifford Stott’s report has lots of advice for forces who want to establish and maintain this impression. The cops should start out in standard uniforms, should be scattered around the crowd and should make an effort to interact. If trouble looks like it’s brewing, non-violent folks should be allowed to leave and the police ‘have a word’ with the specific people involved. Force is only ramped up in proportion to the threat.

I’m no expert and I’ve been watching the UK riots from 5,000 miles away from the safety of Colombia (a sentence I never thought I’d write) but it strikes me that most of the rioters probably never thought of the police as a legitimate force to begin with.

This goes beyond establishing police legitimacy on the day and means many of the standard assumptions of behind crowd control probably don’t work as well.

But the fact that thousands of young people across the country don’t have faith in police is a much deeper social problem that can’t be solved through street tactics.

I have no easy answers and I suspect they don’t exist. Politicians, start your clichés.
 

Link to homepage of psychologist Clifford Stott.
pdf of ‘Crowd Psychology and Public Order Policing’.