A client recently came to see me for counselling in private practice. She was feeling despondent and disappointed, as a result of the treatment she has received from her local health centre. She told me, ‘I went to my GP because I was depressed. She gave me fluoxetine tablets, and I had a short course of CBT, but they haven’t really worked.’ She added, ‘I’m not sleeping very well and I’m on edge all the time.’
I learnt that the PHQ91 and GAD72 screening tools administered in primary care had shown moderate scores for both depression and anxiety, and this had led to her referral for CBT. I have no argument with the observation of the client’s depression and anxiety; the other symptoms she described were also consistent with those diagnoses. However, I was interested that she had been unable to benefit from the combination of CBT and antidepressants – or perhaps had been unable to engage with it for reasons as yet not understood – although it was in line with the National Institute for Health and Care Excellence (NICE) guidelines3 for those diagnosed with mild to moderate depression.
In subsequent work with this client, I encouraged her to tell stories of her life; these stories indicated that her current symptoms had a traumatic origin. I was then able to adopt a strategy to help her to make causal links between her current symptoms and the underlying trauma. Understanding links between ‘then’ and ‘now’ proved helpful, and gave her an ongoing strategy for interrogating her symptoms as to their meaning.
CBT has good empirical evidence for effectiveness in cases of mild to moderate depression and anxiety,4 but counsellors often see clients like this one, who have experienced a disappointing outcome after undertaking short-term CBT. In such cases, it may be that we are mistaking depression and anxiety as diagnoses, rather than as symptoms of something else, such as trauma. It is vital to ensure that previously traumatised clients do not fall through the net of clinical services because their trauma might not have been recognised. This article makes a case for taking causality more seriously than is sometimes the case.
Depression and anxiety as diagnoses
Undoubtedly, debilitating depression and crippling anxiety can be regarded as clinical entities in their own right, and the diagnostic criteria for a number of forms of each are clearly laid out in the DSM-55 and ICD-10.6 Where risk assessment shows significant suicidal ideation, appropriate measures should be put in place, as proactive treatment of depression should be prioritised.3 Some patients, happily, recover well and do not relapse. However, others, while able to return to an acceptable level of functioning, are still troubled by chronic low mood or other symptoms. Medication may continue on repeat prescription, or may be deemed unnecessary, but in either case, further contact with medical professionals is likely to be minimal. Any underlying causes of depression or anxiety are, therefore, not addressed.
In part, some of the trouble may lie in the UK Government’s focus on NHS funding being targeted at restoring patients’ functionality. If someone with a diagnosis of depression or anxiety is well enough to return to work, that is considered as ‘job done’ – a good outcome. Overworked GPs, even if they have an interest in mental health, seldom have the time to probe more deeply into patients’ back stories, which are often hazy and complicated, and resistant to the pattern formation required for a clear diagnosis; as a result, symptoms can sometimes become diagnoses. So chronic depression might be treated with long-term medication for want of something else (with a justification such as, ‘Well, counselling didn’t work, and the patient didn’t like it anyway’) and the patient somehow just learns to live with it, albeit going through life without many of the joys and achievements that they might otherwise have had. But this level of amelioration of symptoms is often a long way from a wider sense of wellbeing, which may only be achieved through a deeper exploration of causality than is possible in basic six-session or computerised CBT.
I suspect that this approach may also be the result of the prevalence of current discourses on evidence-based practice, which have perhaps overridden the real interests of the patient, with too much weight being placed on the screening results. Medical education and NICE are still dominated by empirical positivist assumptions, whereas less easily quantified, but good quality, qualitative research struggles for recognition by clinical commissioning groups, who frequently stick with the ‘safe’ option of considering NICE guidelines as rules rather than guidance.
Some years ago, Totton7 described two ways of being helpful. The first is to provide ‘maximum amelioration of distress in minimum time’. According to Totton, this approach avoids detours and distractions, and privileges symptom removal over the uncovering of meaning. The second way of helping leans more towards encouraging self-knowledge and psychological exploration. Both approaches are valid.
While the first type of helping is provided well by current IAPT services,8 many clients seem to find that there is still something missing and opt, in time, to engage in some of the psychological exploration of which Totton writes. Not infrequently, such exploration uncovers a history of trauma, somewhere in the spectrum between developmental trauma and single-event trauma.9 DSM-5 and ICD-10 list numerous symptoms which can be experienced by trauma sufferers, as does Herman’s description of complex trauma.10 Depression and anxiety both feature in these lists.
I have recently carried out a phenomenological study11 of seven survivors of childhood trauma. The study consisted of ‘experience near’12 semi-structured interviews in which the participants explored features of their developmental trauma, experiences of personal therapy, career choices, and meaning-making from their life experiences. All participants were experienced counsellors or psychotherapists themselves and had, over the years, reflected in depth on the effects – positive and negative – of their early traumas. The study confirmed the symptomatic diversity of trauma in adults who had experienced childhood trauma. Symptoms, even in this sample, included: depression, generalised anxiety, irritability, anger, numbing, decreased concentration, insomnia, emotional flooding, hopelessness, shame, suicidal ideation, worthlessness, few or no memories, flashbacks, hypervigilance, feeling unreal, and loss of sense of self. Some of these symptoms feature in both trauma and depression, but identifying those much more indicative of trauma can help to clarify a diagnosis.
I was particularly interested to discover that none of the participants had initially sought counselling with an understanding that they were traumatised. Instead, each participant had first presented for counselling because they were depressed or anxious, to a greater or lesser extent. Perhaps they, like many clients we see, thought of trauma in terms of what one of these interviewees described as ‘big T’ trauma – the fire, the car crash or the assault. Because children have extraordinary ways of surviving, many adults who have suffered adversity in childhood do not recognise that their situations were traumatic, even when looking back at them. There are, of course, exceptions – chief among them, childhood sexual abuse – but there are other less clear-cut traumas, which can also cause much distress in later life.
This was the experience of the seven participants, whose individual traumas had resulted in different effects and different ways of coping. Two had no personal memory of their trauma and had either learned of it from others, or had returned to it in the form of what one participant described as ‘bizarre perceptual experiences’ and ‘confusing memories’ relating to a time ‘way, way back’. Ogden and Fisher13 point out that the survival strategies adopted by children in adverse circumstances can be carried through to later life, where those strategies work less well. Dissociation played a major part for these two participants. One believed, from what he later learned of his experiences, that the ability to dissociate saved his sanity, but left a legacy of confusion as a teenager. He suffered low mood, which was inexplicable to him, and he described repeatedly hitting rock bottom. Unfortunately, referral by his GP to a counsellor did not go well, with the client feeling unable to communicate his problems or to believe that anyone could understand him when he could not understand himself. Lack of connection, or – as we might say – a good therapeutic alliance, led to the client giving up on counselling until very much later, preferring to try to work it out for himself through reading. The other participant, sadly, had a major breakdown as a young adult and required hospitalisation. After discharging herself and undergoing years of counselling, she recovered and trained as a therapist.
The five other participants did have clear memories of their childhood circumstances. One of them had lived in a household where long-standing domestic abuse was present, two had been in families where parents were chronically ill, either mentally or physically, one had been neglected by parents, and one had been hospitalised for lengthy periods as a young child.
One of these participants grew up with one parent who suffered from a serious long-term physical illness, and was barely able to communicate, while the other parent was focused on being a carer, even though mentally unwell. This participant had grown up in constant fear that the world was not a safe place, and that death, disease and pestilence were lurking around every corner. Her survival strategy was to become her parents’ advocate and carer, and a de facto counsellor, even before she was a teenager. Her natural progression was to enter a medical profession, but she soon found that working with sick people was something she did not want to do, and she moved sideways into counselling. Her fear of imminent catastrophe dogged her, though, and threatened to bar her from a satisfying family life.
The participant who had mentally ill parents used avoidance and distraction as her main survival strategies. She borrowed her school-friends’ parents as significant nurturers, spending time in their houses and going on holidays with them. She was a bright pupil and put energy into her academic work, though overdoing it left a legacy of anxiety and insomnia in early adulthood.
The participant who was hospitalised for long periods as a child had survived by steering a path between pleasing those who could meet her needs and rebelling against those who made ‘unreasonable’ demands on her. Because it seemed too risky to express anger outwardly, her adult self turned it inwards, leading to depression and self-doubt. This inner pressure cooker would occasionally express itself in unpleasant dissociative experiences of derealisation, or out-of- body sensations.14
Another participant was also rebellious. She had experienced significant neglect and long separations from her parents, but in her case it was because of parental life choices, not illness. She rebelled against teachers and carers until something ‘had to be done’, and (failed) attempts were made to bring the family together again in her teens. Her chosen profession was one which replicated the institutionalisation that had been a feature of her childhood, and she gladly abandoned it after starting a family of her own. However, all was not well, because as a child she had become adept at compliance as well as rebellion. She would uncritically trust people whom she perceived as being able to make up some of the care deficit in her life. In adult life, this had appallingly led to shockingly emotionally abusive ‘treatment’ by an untrained, unsupervised, self-styled counsellor.
Anger was the predominant feature in the adult life of the final participant. As a child, she had been witness to long-term domestic abuse and alcoholism in the family, and learned quickly that her father was terrifyingly angry. It was far too dangerous for her to express her own anger at home, so she rebelled at school instead. Being one of the ‘difficult’ pupils, she was not believed when she reported being sexually abused by one of the staff, something which only fuelled her anger and took her on to a longer path of destructive behaviour, seeking out, as a young adult, relationships with angry men with whom she could justify being angry. She also tried ‘less legal ways of coping’ at that time.
This study demonstrates that it is vital to ascertain any traumatic origins which underlie, contribute to, or exacerbate the client’s diverse experiences of current distress, including depression and anxiety. Each participant had a history of adversity in childhood, but none had made the connection, prior to counselling, between their adolescent or adult symptoms and earlier trauma. Yet, not far beneath the surface, lurked other typical trauma symptoms: fear, anger, hypervigilance, dissociative amnesia, derealisation, flashbacks, insomnia, shame, mistrust and catastrophising. All of these would give good cause to explore the clients’ histories more deeply. Without considering the varied roots of current distress, even in a very gentle way, it seems unlikely that a relevant stance in therapy can be found.
Symptomatic treatment of depression and anxiety will, of course have benefits for the client, and may well be what is called for where trauma is not an underlying cause. However, where it could be, are we not at risk of selling our clients short by failing to recognise it? Such failures, do, in my opinion, reveal a weakness, not in individual counsellors, but in the IAPT stepped system and NICE guidelines themselves. Many counsellors who have a particular interest in trauma report seeing clients who display symptoms of anxiety or depression that have a traumatic aetiology, which had previously been missed in primary care, where counsellors are constrained by pragmatic protocols. How sad that only a minority of clients are able to access therapies like dynamic interpersonal therapy,15 which might be more likely to be able to detect and treat past trauma. We come back again, of course, to pragmatic constraints of budgets and personnel, but that is material for a different article.
The importance of allowing clients to tell their story cannot be overestimated. Rather than rigidly assessing and treating patients with a present focus, even one initial session in which serious attention is paid to past events and circumstances, could give an invaluable opportunity to pick up those clues to trauma, which would allow faster onward referral where this is available. Even if we cannot address trauma issues adequately in six sessions, we can at least be honest with clients about that, and indicate that further work will probably be needed at some point. In the meantime, some of the pressure of the untold trauma story can be reduced, and the symptoms given some meaning.
Pat Bond, PhD, MBACP (Accred), is a counsellor and supervisor in private practice in North Tyneside.
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