You’re polishing those nice drinking glasses your sister gave you, to make sure there are no fingerprints or smudges of lipstick, and as you finish each one you hold it up to the light and inspect it, giving it a little flick with your fingernail. Ping!
Ping! … Ping! … Ping! … Then the fifth one shatters.
Now you’re standing in broken glass. Bugger…should’ve put shoes on.
Monday’s TV documentary, The Trauma Industry, in the Panorama series on BBC 1 was about the activities of “no win, no fee” lawyers who help people to claim compensation after traumatic events. It made some good points about the system, but it got one thing completely wrong.
You can watch the documentary online for a few days:
The reporter, Allan Little, is a seasoned war correspondent who himself has experienced trauma in his work. But he went back to work, back to reporting on wars, despite suffering symptoms like nightmares and flashbacks.
His partner, journalist Sheena McDonald, was hit by a police van travelling on the wrong side of the road one wet February night in 1999, and was in a coma for 72 hours. But she recovered too. In a piece for The Observer about her experience she wrote:
So, five years on, a stranger meeting me would never guess what I’ve been through and I see no profit in mentioning it…
What is the ultimate lesson I’ve learned? That our identity relies to a great degree on other people and friends and strangers can be heroically generous. And that the only way is forward — so forward we go.
In the Panorama film, Allan Little remarks:
…for me the question is: What’s the best way to get well again? And if you choose the path of legal action for compensation for PTSD, does that help you get well again, or can it actually get in the way?
This was the core of the documentary. Some people recover after terrible things have happened to them. A few people never recover, or take a very long time. Are lawyers, the “no win, no fee” system, the ‘compensation culture’ actually damaging people’s chances of recovery?
Prof. Simon Wessely of the Institute of Psychiatry at Kings College London described the effects of the legal system like this:
What happens is people can get trapped in disability, and the worst thing about the system is it’s an adversarial system, so you know the other guys are trying to prove you are a malingerer, crook, etc. And then, you know, if you do get better you’re kind proving that you were. So you don’t. And by the time it’s all sorted out, it’s far too late. Years have gone by, and the chances then of recovery are pretty low.
When the trawler, Radiant, sank in 2002, second engineer Boguslaw Dziok drowned after his lifejacket failed. The five remaining crew were eventually rescued after spending hours in a liferaft in freezing condiotions. Only one of their lifejackets had inflated properly.
In the Panorama film some of the crew were interviewed, contrasting the story of a crewman who went straight back to work at sea with the story of the wheelman who has spent seven years suffering from PTSD and trying to get compensation through the courts.
It was when discussing PTSD (post-traumatic stress disorder) that the documentary lost its way.
The suggestion was that changes in the definition of PTSD by American psychiatrists have influenced, and will influence the number of compensation claims in UK courts, and that by implication a looser definition of PTSD will result in more people being unable to recover after trauma because the legal process is holding them back.
This is nonsense. It’s the symptoms that affect people’s lives, not the label “PTSD”. Psychiatrist Prof. Chris Brewin of University College London tried to make the point:
I think the question is: Are people genuinely suffering? Do they have real psychological symptoms as a result of their experiences?
While it’s true that the definition of PTSD will probably change in the forthcoming DSM-V, and some indications are that it might be a weaker definition, that change in labelling will not actually affect sufferers.
Prof. Brewin also made a valuable point about the underlying mechanism of PTSD:
In almost all cases if you actually examine that person’s history, you’ll find there is a previous history of traumatization. They’re someone who’s already, probably, quite vulnerable…
Like the glass that shattered, people who suffer terribly as a result of trauma have usually had invisible stresses within them as a result of previous trauma.
That glass was probably dropped. It seemed OK, but something changed in its molecular structure so that much later a little flick caused a breakdown. It can be the same with people.
This is why CBT is so effective for PTSD. CBT does not merely treat the symptoms of the most recent traumatic event, but also takes into account previous life events that could have had an influence — CBT treats whole people, not collections of symptoms.
The documentary’s faulty analysis of PTSD, imagining that the label is more significant than the actual symptoms, made it confusing and led to faulty conclusions.
Prof. Simon Wessely expressed his view of how he thinks the label “PTSD” should be used in future:
I would like to see PTSD restricted to people who have indeed been in genuinely terrifying situations where their life was in danger.
But fiddling with the label like this has little bearing on real life. Some people are very seriously affected by events that were not life-threatening, while some people face death then just move on.
Allan Little concluded:
The definition is now so loose that we’re using it to turn the ups and downs of normal life into a psychological nightmare.
Unfortunately it may be true that we are increasingly ‘medicalizing’ everyday life, influenced by drug companies and lawyers who can make bigger profits that way, but to focus on diagnostic labelling misses the big story. The real change is a change in the perception of what normal life is, not a change in labelling, and that’s a big story about how we increasingly see ourselves as victims falling short of some ideal, as opposed to victors celebrating life despite adversity.
Once it was thought that everyone has nightmares, that it’s just something that happens. In the future it might be thought that nightmares require a prescription or a lawyer. That will not happen because of a change in the definition of ‘nightmares’, but it might happen in part because when journalists try to confront issues like these they miss the big story.