The NICE Guidelines

Britain's National Institute of Clinical Excellence (NICE) recently published the most comprehensive guidelines compiled to date on effective treatments for post-traumatic stress (PSTD).

Based on detailed evidence and research, the NICE guidelines are expected to have a profound impact, both in the UK and internationally, on how organisations and healthcare professionals respond to psychological trauma in the future.

On the evening of the March 22 launch of the guidelines, the Dart Centre organised an open-forum discussion at the Frontline Club in London to consider the implications for journalists in their reporting of and response to trauma.

The panel included NICE advisors: Dr Stuart Turner, psychiatrist and founder of the Trauma Clinic in London; Dr Jonathan Bisson, psychiatrist and community trauma response specialist in Cardiff, and Pamela Dix of Disaster Action.

Dr Turner opened the discussion by relating a personal history of the evolution of trauma response and research in the UK, dating back to the 1980s, including the Harrod's bomb in London ; the Bradford football Stadium fire, and the King's Cross fire.

What has changed since the 80s, Dr Turner asked. He noted that some of the tools used in the 80s are still valid, for example, using therapy that focuses on the traumatic experience; ensuring that people have enough time to deal with their experiences, and the use of anti-depressant medications.

However, since then there had been landmark changes, he said, such as the increase in scientific evidence using the Randomised Control Trial (RCT); the Meta-Analysis, which involves pooling evidence from several trials; as well as the licensing of certain drugs for the treatment of PSTD.

As a member of the guideline development group, Dr Turner emphasised that the focus of the NICE consultation was not just on results being statistically significant but also clinically meaningful. "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," he said.

Outlining NICE's main conclusions, Dr Turner recognised the limitations of the guidelines and how they focus specifically on PSTD, and on interventions which had been subjected to randomised trial.

The new guidelines show for example that debriefing in the form of brief, individual, and routine single-session interventions should not be routine practice.

"The guideline says, importantly, that everyone without exception with PTSD should be offered the opportunity of active treatment," Dr Turner told the audience. "The guideline recommends two [treatments] on the basis of evidence: one is trauma-focused CBT (Cognitive-Behavioural therapy) and the other one Eye-Movement Desensitisation and Reprocessing—EMDR."

According to Dr Turner, drug treatments were disappointing. "This means," he added, "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 for the NHS." However, patient choice is important, and for those who prefer not to engage in trauma-focused psychological treatment, drug treatments should be considered, he said.

Jonathan Bisson focused primarily on psychological treatments for established PTSD, which can include one-on-one trauma-focused therapies such as CBT, EMDR; or individual non-trauma focused therapy such as stress management and relaxation, and psychodynamic therapy.

"At the first line are the trauma-focused therapies," Bisson told the audience. The NICE guidelines recommend trauma focused therapies (CBT and EMDR) over 8-12 sessions with 60-90 minutes for each session. However, non-trauma focused treatments should not routinely be offered, the guidelines advised.

Pam Dix, who began working with trauma survivors after the death of her brother in the 1988 bombing of a PanAm airliner over Lockerbie in Scotland, moved on from the evidence base and talked about the perspective of the PTSD sufferer, making a distinction between perceived and actual needs.

"I think there's been an incredible cultural shift within which this guideline fits very nicely," she said. "In the late 80s/early 90s the idea was that if you removed somebody from the reality of the experience, you could somehow erase it and make it go away—if you didn't acknowledge it, it wasn't there."

The idea that someone could 'make things better'; trying to protect someone from the reality of what happened or trying to make them go back to 'normal' are all perceived needs, according to Dix.

She praised the value of non-judgemental assistance, or "emotional first aid". The actual needs of the trauma sufferer, she said, bring together access to information; openness, honesty and sensitivity; being offered choices, and understanding that one needs to go through the experience.

The context of the guidelines for Dix lay in the personal testimonies they included from people who are direct 'experiencers' of trauma", going on to develop PTSD, as well as testimonies from the carers of those with PTSD.

"Accept the new you," was one of the personal testimonies that strongly resonated with Dix 's own experience. "There is a new you and you can help control who this new you is. That's the point, you don't erase it, you go forward with it."

Focusing on the journalism of covering trauma, Mark Brayne, director of the Dart Centre in Europe, opened up the discussion with a question on the implications the guidelines have for the narrative of trauma in the journalism.

Stephen Pilling, co-Director of the National Collaborating Centre of Mental Health, said that "there is a real issue about what role the press play in promoting implementation. If we simply leave it to NICE or the NHS to get that information over to people, it won't happen."

David Loyn, BBC Developing World Correspondent, expressed anxiety about the implementation of the NICE guidelines. "The real danger in these guidelines," he said, "is that there's a sort of 'one size fits all' quite unsophisticated response to what's happening."

Noting Loyn's concern, Brayne said the guidelines in fact represented a valuable step forward, in their emphasis on psychological talking treatments and "watchful waiting" rather than hasty treatment with drugs. But there was indeed a danger that the "the media might misunderstand, either through ignorance or naivety or through wilful misrepresentation what these guidelines are about."

Kate Nowlan, a therapist from the Employee Assistance provider Counselling in Companies, was alarmed by how the guidelines might be mis-read.

"Some of us who work in different ways, sometimes using EMDR, sometimes using cognitive, but sometimes using quite other ways of working, [are concerned] that we are going to be marginalized, and that all the NHS funds are going to be put into this particular way of working," she said.

Pam Dix, responding to the anxieties in the audience, said that "the guideline is not intended to be a substitute for clinical judgement or flexibility in relation to the individual. Every traumatic experience is different. And that will partly dictate the way in which the treatment is delivered. Treatment options that are being recommended are no substitute for clinical judgement. That's what it says on Page One."

Mike Jempson, from the media pressure group Mediawise, drew attention to the way in which a document such as the NICE guidelines can be publicised by the press, possibly as "an explosion of PTSD—a drain on resources—and probably an attack on the television for retraumatising people by presenting images of awful events," when really, very few people go on to develop PTSD.

From a journalistic point of view, Jempson thought it might be more helpful to use personal testimonies to explain the different kinds of treatments and what works and what does not. He also raised the point about the effect of media coverage on those who have been traumatised.

Dix, taking Jempson's point about humanising the experience and making it more accessible to the public, raised concerns about the possible manipulation of personal testimony by journalists and editors.

"Use of personal testimony is a bit tricky," she said, "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."

Mejinderpal Kaur, who works with a human development organisation in the tsunami affected area of Sri Lanka, suggested that if journalists are to report better on trauma that they should be "given the opportunity to do frontline training-by-being, where the psychological counselling is taking place."

Noreen Tehrani, a London-based therapist who has recently published a book entitled Workplace Trauma, suggested that journalists who are looking for case studies should "be looking at a full range of different ways of looking at effectiveness," and not just the trials on which the guidelines are based.

Brian Kelly, freelance cameraman, shared his testimony from within the journalistic experience, reflecting on his experience of covering war zones and undergoing EMDR therapy, which he found "fantastic". EMDR, he said, worked very well in getting him through a traumatic experience. However, he pointed out, that as a tool on its own it would have been ineffective.

On that note, Dr Turner ended by saying that "there isn't a blanket ban on other treatments. Getting [the best ones] into the GP surgery, getting it implemented, these are huge tasks. I just feel so passionate, and I see people day in 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. If these guidelines are a step forward, then I think that's a useful thing."