Updated Privacy Policy

In order to comply with the requirements of recent GDPR legislation on the collection, storage and use of client information, I have updated my privacy policy and made it available on my practice website here:
http://www.harfordtherapy.com/privacy-policy

David Harford www.harfordtherapy.com

CONTACT AFTER CONTACT: REFLECTIONS ON RESEARCH AND TREATMENT OF COMBAT-RELATED PTSD

Following completion of a quantitative and qualitative outcome analysis into the effectiveness of transactional analysis (TA) in treating combat-related PTSD (Harford & Widdowson, 2014), I have been pondering over a loose assortment of observations, inferences and unanswered questions arising from the results gathered and conclusions formed. Though there is little purpose in repeating here what can be found in considerably more depth within our research paper, instead, I would like to suggest a few interesting departure points for further discussion- and, ideally, extensive research- including an appeal for greater attention to the interplay between the therapeutic and political domains, as explored by the radical psychiatry movement and, earlier, the likes of R.D.Laing and Wilhelm Reich.

Beginning at the beginning, then, consider the prominent influence of childhood trauma as a predisposing factor in the aetiology of combat-related PTSD. Nine of the fifteen male veterans studied in our research revealed histories of abuse, neglect, or other family dysfunction prior to joining up (Harford & Widdowson, 2014, p.39); a feature highlighted by Jo Stuthridge, based on her own clinical observation that 'in every case in which posttraumatic stress symptoms escalated over time...the client revealed a history of childhood trauma' (Stuthridge, 2012, p.239) and, also, the U.S. Department of Veteran Affairs, which noted that 'increased risk of PTSD...is associated with...early conduct problems, childhood adversity (e.g. parental loss, economic deprivation) [and] family history of psychiatric disorder' (Schnurr & Friedman, 1997, p.13) before suggesting a distinct diagnostic category of “complex PTSD” to reflect this more fundamental psychopathology.

We might say, then, that these veterans, subjected to extreme, or repeated misattunement during childhood and then, later, exposed to military trauma, have doubly-dissociated, multiply-fragmented selves. They exhibit traits of personality disorders that predate their trauma symptoms, arising from an underdeveloped hippocampus, limited capacity for impulse control and affective self-regulation, the lack of a secure base (Bowlby, 1969), object constancy (Mahler, Pine & Bergman, 1975) as yet unattained and so on. As such, they are ill-equipped to withstand combat scenarios, without a fully-functioning neocortex- or Integrating Adult (Tudor, 2003), in TA parlance- to soothe limbic reactivity, render implicit memories of those trauma explicit, or autobiographical and, therefore, unable to be 'aware of and accept disowned parts (i.e. ego states)...[or] contact other people while maintaining a sense of self' (Korol, 1998, p.115).

All too often, this vulnerability to PTSD deriving from insecure attachments is exacerbated post-active service by 'poor social support' (Schnurr & Friedman, 1997, p.12) and a lack of appropriate care and reparation from the military, health authorities and governmental agencies. As one veteran reported of a protracted dispute with the UK Department of Work and Pensions, “they send you another batch [of forms], then another batch...then they say the've lost it...You go from one office to another to another...they keep on passing you- like pass the parcel” and, thus, 'the unintegrated experience of trauma is reenacted through...repetitive patterns of transference' (Stuthridge, 2006, p.275), the client's relational expectations rigidify and symptoms deteriorate. If this complex co-morbidity weren't challenging enough, therapists will often be contending with the pernicious impact of addictions and other lifestyle problems that attend veterans' understandable desire to 'disengage from [unmet relational] needs and emotions and...evade the memory and its devastating impact' (Erskine, 1993, p.184). Eight of the fifteen men examined by our study, for instance, disclosed problematic relationships with alcohol, prescribed medication and recreational drugs (Harford & Widdowson, 2014, p.38).

In these potentially lethal circumstances, an effective multidisciplinary approach is indicated and, as such, consensual contact between the client, specialist health and support agencies and the therapist concerned is the only ethical way forward. Ideally, any active addictions and lifestyle problems should be addressed first. The therapist, meanwhile, focusses on co-creating a mutually trusting therapeutic relationship, strengthening the veteran's Integrating Adult (Tudor, 2003) capacity for self-regulation and self-reflection and working through any emerging transference, rather than addressing their PTSD head-on. Of course, treatment won't necessarily proceed in this tidy sequence. As one veteran recalled, “I was the teacher and you were learning from me”, or, as another commented, “It seems as though I can pick the topic; what I want to talk about, what's important to me”, and, often, it is therapeutic to follow their lead- though always mindful that the 'first goal of any trauma therapy must be helping the client to contain and reduce hyperarousal...[or] putting on the brakes' (Rothschild, 2003, p.4). Nevertheless, designing treatment in this way is consistent with established TA models, where the highest priority is 'Stabilization...establishing physical and emotional safety' (Pomeroy, 1998, p.337) and, also, psychoanalytic approaches, where, instead of self-medicating with alcohol, or drugs, clients are taught 'any of a number of deep-relaxation exercises [and] processes akin to self-hypnotic techniques that promote a form of physical and mental self-control' (Davies & Frawley, 1994, p.205-6).

The latter calls our attention to the crucial role of psychoeducation in this work. Psychoeducation strengthens the Adult ego state, the neocortex, which veterans need to quell their permanently activated fight-flight-freeze response and 'learn to reflect upon and integrate their...archaic states as well as past introjects, and to draw on them in the service of present-centred relating' (Tudor, 2003, p.202). So, why is it that I hear of veterans being prescribed breathing exercises with little explanation of their neurological affect-regulating purpose? I can understand, therefore, why some veterans are reluctant to try them. Veterans are highly-skilled and resourceful individuals, with detailed knowledge of intricate weapons systems, navigation tools and the arcane bureaucracy within the military. Further, it is not uncommon for them to be more expert in managing people- often in chaotic life-or-death situations- than the supposed experts providing their care and rehabilitation. Consequently, I believe we do them a patronising disservice if we assume that the discourse of trauma- the intertwined functions of the limbic system, hypothalamus, left-brain and right-brains, implicit, explicit and autobiographical memory, adrenaline and cortisol- are beyond their understanding. For example, one veteran remarked, “You've explained to me the processes that are taking place in the body...and [my brain and thinking] have been...defragmented like a computer...and things slowly, but surely are starting to...find their place again”. Notice, too, that five of the fifteen-veteran cohort presented with paranoid features (Harford & Widdowson, 2014, p.39) and, therefore, thorough explanation of the psychobiology behind my interventions and any associated “homework” proved essential to engendering mutual trust, openness and respect.

In particular, I have found the wealth of diagrams furnished by TA theory invaluable in strengthening veterans' neocortical capacity to bring coherent meaning to their phenomenological experiences; one individual emphasising in typical fashion the importance of, “the transactional [diagrams]...I'm a visualisation kind of person...There's your Parental [ego state], there's the Child and...you can see how it overlaps and how it all fits together”. By way of illustration, take the veterans' recurring motif of the army as a substitute parent figure- sometimes compensating for past misattunements with structure and discipline, while, at other times, compounding relational failures with bullying and abandonment. It was often helpful, here, to sketch out the Cultural Parent model (Drego, 1983) and complete the respective: 'Etiquette....the transmitted [rules] for thinking, behaving and valuing...the Technicalities, or...actual organization of the material and social life [and]...Character...socially programmed ways of feeling, handling biological needs, emotional expressions' (Drego, 1983, p.225) that captured the nature of their surrogate introject [see Figure 1].

Figure 1.

Cultural Parent of the British Army

(Harford, 2014- after Drego, 1983)

And what of the prevailing Cultural Parent within the health and social care services veterans encounter in the aftermath of trauma? And that of the wider civilian and political society they find themselves immersed in upon returning home? I would like to make a plea here for greater application of the social model of mental illness, whereby 'levels of mental distress among communities...[are] understood less in terms of individual pathology and more as a response to relative deprivation and social injustice, which erode the emotional, spiritual and intellectual resources essential to psychological wellbeing' (Friedli, 2009, p.III). Several veterans participating in our study were beleaguered by the debilitating side-effects of psychiatric medication- including highly addictive benzodiazepenes,which, in some cases, had been prescribed for years with scant improvement in their mental health and precious little attention to intrapsychic and interpersonal reintegration. Compounding this situation, I noticed what appeared to be 'a direct causal relationship between enforced attendance at benefits eligibility assessments and related health assessments, [including] the arrival of related written correspondence' (Harford & Widdowson, 2014, p.61) and worrying spikes in the anxiety and depression measures gathered during their therapeutic journeys.

More controversially, several veterans reported being fully aware of the dubious political motives for their presence in the second Iraq war of 2003 and, more recently, Afghanistan; of their difficulty reconciling extreme traumatic experiences with the doubtful necessity of experiencing them at all. On a personal note, I have felt increasingly uncomfortable lately with my perception of a growing fetishisation of militarism in our culture for political, or commercial ends: the red poppy infamously co-opted by the far right (Dearden, 2014), the government's programme of World War One “celebrations' and a festive television advert by a supermarket (Fogg, 2014) all leaving a bitter taste in the mouth. I wonder what this means for my ongoing work with the traumatised subjects (grammatically and constitutionally) of all this geopolitical, party political and consumerist opportunism? I am curious to know more about how the veterans themselves view their place in our current epoch. And I wonder, too, what the radical psychiatry tradition would make of it all?

Radical psychiatry posits that much psychopathology originates not in the individual's deficits and dysfunctions, but, rather, 'the mystified oppression of people who are isolated from each other' (Steiner, 1981, http://www.claudesteiner.com/rpbrief.htm). This results in alienation- or, in traumatic terms, dissociation- from their cognitive, affective and somatic selves and, also, their interpersonal capacity to enjoy mutually beneficial relationships. Steiner (1981) goes on to outline the introjective power of such internalised shame and oppression, whereby, 'When a person has incorporated in [their] own consciousness the arguments that explain and make legitimate [their] oppression, then mystification and alienation are complete. People...will blame themselves for their failure, accept it, and assume that they are the source and reason for their own unhappiness' (Steiner, 1981, http://www.claudesteiner.com/rpbrief.htm).

Reading this, a specific veteran comes to mind who astonished me by reporting that their traumatic story had been dismissed as fabrication by medical professionals on account of its disjointed and contradictory chronology. Of course, trauma impairs autobiographical memory and, with it, the ability 'to organize remote events into a verbal narrative...to form a narrative self, a “me” who persists over time...[allowing] integration of conflicting experiences' (Stuthridge, 2006, p.273). Thus, the veteran is blamed for their unconscious defensive response to the inescapable kill, or be killed dilemma, transferential expectations of misattunement are confirmed and hope for recovery retreats further from view. To borrow from a precursor to The Radical Therapist's deconstruction of the mental health industry, 'the medium is the message' (McLuhan, 1964, p.7), which, for me, underlines the necessity that we therapists, with our variously ambivalent Cultural Parents, are not complicit, unconsciously or otherwise, in our returning veterans' battles.

REFERENCES:

McLuhan, M. (1964). Understanding Media: The Extensions of Man. London: Routledge.

Bowlby, J. (1969). Attachment: Attachment and Loss (Vol. 1). New York: Basic Books.

Mahler, S, Pine, M, Bergman, A. (1973). The Psychological Birth of the Human Infant. New York: Basic Books.

Steiner, C. (1981). In Corsini, R (Ed.). Handbook of Innovative Psychotherapies. New York: John Wiley & Sons. Retrieved from http://www.claudesteiner.com/rpbrief.htm

Davies J. & Frawley, M. (1994). Treating the Adult Survivor of Childhood Sexual Abuse: A Psychoanalytic Perspective. New York: Basic Books.

Rothschild, B. (2003). The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD. New York: W.W. Norton.

Schnurr, P. & Friedman, M. (1997). An Overview of Research Findings on the Nature of Posttraumatic Stress Disorder. In Session: Psychotherapy in Practice, 3(4)

Drego, P. (1983). The Cultural Parent. Transactional Analysis Journal, 13(4)

Erskine, R. (1993). Inquiry, Attunement, and Involvement in the Psychotherapy of Dissociation. Transactional Analysis Journal, 23(4)

Korol, J. (1998). Confluence, Isolation, and Contact in Psychotherapy with Clients Who Dissociate. Transactional Analysis Journal, 28(2)

Pomeroy, W. (1998). Trauma, Regression, and Recovery. Transactional Analysis Journal, 28(4)

Tudor, K. (2003). The Neopsyche: The Integrating Adult Ego State. In Sills, C. & Hargaden, H. (Eds.), Ego States. London: Worth Publishing.

Stuthridge, J. (2006). Inside Out: A Transactional Analysis Model of Trauma. Transactional Analysis Journal, 36(4)

Friedli L (2009). Mental health, resilience and inequalities. Copenhagen: World

Health Organization Regional Office for Europe.

Stuthridge, J. (2012). Traversing the Fault Lines: Trauma and Enactment. Transactional Analysis Journal, 42(4)

Harford, D. & Widdowson, M. (2014). Quantitative and Qualitative Outcomes of Transactional Analysis Psychotherapy with Male Armed Forces Veterans in the UK presenting with Post-Traumatic Stress Disorder. International Journal of TA Research, 5(2)

Dearden, L. (2014). Britain First accused of 'hijacking' the poppy ahead of Remembrance Day.

http://www.independent.co.uk/news/uk/home-news/britain-first-accused-of-hijacking-the-poppy-ahead-of-remembrance-day-9841107.html

Fogg, A. (2014). Sainsbury's Christmas ad is a dangerous and disrespectful masterpiece.

http://www.theguardian.com/commentisfree/2014/nov/13/sainsburys-christmas-ad-first-world-war

Interview: Transactional Analysis Psychotherapy as a Treatment for Combat-Related PTSD

For those interested in my ongoing clinical work and research into the treatment of combat-related PTSD, please find below a link to a brief interview conducted in April 2014 at the UK transactional analysis conference in Blackpool:

https://www.youtube.com/watch?v=IZIIvmYynXM

In due course, I will be posting a link to a much more extensive interview I undertook on the same subject earlier this month, together with an article exploring various ideas emerging from my research which is to be published during Spring in 'Counselling In Scotland'- the journal of Counselling and Psychotherapy in Scotland (COSCA).

I hope you find this first instalment of interest.

David Harford www.harfordtherapy.com

New Research on the Effectiveness of Transactional Analysis Psychotherapy in Treating PTSD

For those interested in counselling and psychotherapy and, in particular, my work with armed forces veterans experiencing posttraumatic stress disorder (PTSD), please click on the following link to access my research paper in the International Journal of Transactional Analysis Research on the effectiveness of transactional analysis (TA) psychotherapy as a treatment for the profound and enduring psychological impact of combat-related trauma:

http://www.ijtar.org/article/view/13801

This and the preceding pilot study can also be found at the foot of the following page:

http://www.harfordtherapy.com/aboutme.htm

Scottish Transactional Analysis Conference 2014

Just a brief update to announce that tickets for the 2014 STAA Conference, which is to be held on Saturday 25th October in central Edinburgh, are now available from the STAA website. As usual, there is a discounted fee for STAA members (in addition to free admission to our forthcoming Summer Event).

Looking forward to seeing you there!

http://www.scottishta.org.uk/staaconferences.htm

David Harford www.harfordtherapy.com

Pilot Study on the Treatment of PTSD with Transactional Analysis Psychotherapy

Having recently watched the harrowing 'Broken by Battle' edition of Panorama following the plight of several army veterans living with post-traumatic stress disorder (PTSD), I was moved to compose a few thoughts in response to the programme- and, also, to highlight the research I'm presently conducting into the effectiveness of transactional analysis psychotherapy for the treatment of PTSD.

Sadly, I have to report that many of the trenchant criticisms levelled at the authorities by the veterans and their families mirror similar observations made by the individuals I work with. Hopefully, though, the mass exposure to these issues afforded by this compelling programme will serve to focus minds in the Ministry of Defence and relevant health and social care services with a view to dramatically improving the care and treatment of those who have risked everything at the behest of our political and military leadership.

Among the most pressing concerns raised by my work is the apparent irony that, too often, the care and treatment of veterans is brief, intermittent and fragmentary and, as such, only serves to reinforce the fragmentation of self and experience brought about by the experience of trauma. Individuals tend to be seen by different practitioners at successive appointments, or receive a confusing plethora of short-term treatments using different approaches. Consequently, progress is limited and, crucially, the veterans are unable to build a mutually trusting therapeutic relationship and can find themselves re-traumatised by having to recount their history over and over again.

I have heard, too, of individuals being disbelieved and accused of lying, or exaggerating their experiences, because their stories are conflicted, or lack a coherent time line. This, despite the fact that conflated, or contradictory narratives are a common symptom of the traumatised brain, where memories are laid down as dissociated fragments in haphazard fashion under the auspices of the limbic system's 'fight-flight-freeze' response, rather than the orderly, complete and easily retrievable explicit memories stored when a person is calm and the neocortex is in control.

Veterans also spoke of breathing exercises being prescribed without any explanation as to the neurological purpose of these simple, yet effective techniques- which shift executive control of the brain back from the limbic system to the neocortex and, thereby, allow an individual to treat their own panic and anxiety symptoms. Simply put, why would anyone stick to an exercise they are advised to carry out when nobody fully explains what it's for and how it works? What is needed here is clear and concise, non-patronising information. Indeed, the very act of giving a patient a way of understanding the impact of trauma on their mind and body through a mixture of spoken and written language and simple diagrams in itself stimulates the neocortex and helps them acquire the sense of autonomy and efficacy they need to regain control over their fight-flight-freeze mechanisms.

For many individuals- based on both my clinical experiences and the testimony of several clients- it is the safety, consistency and affective containment provided by one-to-one, long-term psychotherapy that is most effective in the effective treatment of PTSD- especially when backed up by carefully-monitored psychiatric medication and person-centred social care. Furthermore, all such treatment should be provided with the informed consent of the patient concerned, obtained in advance, so as to maintain confidentiality and fully include them in their treatment.

It is with the intention of finding solid evidence for these initial observations that I have embarked on an extensive programme of research into the effectiveness of TA psychotherapy, in particular, for the treatment of PTSD; commencing with a pilot study based on a sample of six clients. This brief survey can be read and/or downloaded by clicking on the following link and registering free of charge for online access to the International Journal of Transactional Analysis Research (IJTAR):

TA Psychotherapy for Armed Forces Veterans Presenting with PTSD - David Harford 2013

As alluded to in the pilot, a full-scale study is presently nearing completion employing a larger sample of clients and a wider range of quantitative and qualitative outcome measures, which, all being well, will provide strong corroboration for my working hypothesis that 'transactional analysis psychotherapy is an effective treatment for post-traumatic stress disorder (PTSD)'.

However, this more substantial body of research may also need to give consideration to the impact of ATOS benefits assessments on veterans presenting with PTSD, as my initial results seem to suggest that the government's publicly-stated drive to reduce the number of benefit claimants using a private company and, by all accounts, poorly-trained, or unduly-influenced assessors, is extremely damaging to the health and welfare of this very vulnerable group of people.

On this last point- and by way of echoing the core message of 'Broken by Battle'- these remarkable men and women have risked their lives and experienced appalling horrors in the course of their duties; often, with terrible consequences for their physical and mental health and well-being. You would think, therefore, that they would receive the very best of ongoing care and support from those who sent them into danger. In reality, the picture is decidedly mixed and, sometimes, shockingly neglectful.

David Harford www.harfordtherapy.com

MY TOP 40 ALBUMS OF 2013

Following the precedent set by last year's festive post, here are my 'ALBUMS OF THE YEAR 2013'. They're ranked according to a nebulous system balanced somewhere between how many times I've listened to them and my personal and, perhaps, eccentric assessment of their quality....

1. The Besnard Lakes – Until In Excess, Imperceptible UFO
2. Darkside – Psychic
3. James Blake – Overgrown
4. Julia Holter – Loud City Song
5. Jon Hopkins – Immunity
6. My Bloody Valentine – m b v
7. Factory Floor – Factory Floor
8. John Wizards – John Wizards
9. The Haxan Cloak – Excavation
10. Dean Blunt – The Redeemer

11. Foxygen – We Are The 21st Century Ambassadors Of Peace & Magic
12. The Knife – Shaking The Habitual
13. Egyptrixx – A/B Til Infinity
14. Holden – The Inheritors
15. Mount Kimbie – Cold Spring Fault Less Youth
16. White Denim – Corsicana Lemonade
17. Fuck Buttons – Slow Focus
18. Machinedrum – Vapor City
19. Nosaj Thing – Home
20. Gold Panda – Half Of Where You Live

21. Zomby – With Love
22. Deerhunter – Monomania
23. Forest Swords – Engravings
24. Young Echo – Nexus
25. Maxmillion Dunbar – House Of Woo
26. Daniel Avery – Drone Logic
27. Tropic Of Cancer – Restless Idylls
28. Pissed Jeans – Honeys
29. Solar Bears – Supermigration
30. Arcade Fire- Reflektor

31. Pantha Du Prince & The Bell Laboratory – Elements Of Light
32. Four Tet – Beautiful Rewind
33. Savages – Silence Yourself
34. Hyetal – Modern Worship
35. Neon Neon – Praxis Makes Perfect
36. Toro Y Moi – Anything In Return
37. Icarus Line – Slave Vows
38. Vatican Shadow – Remember Your Black Day
39. Youth Lagoon – Wondrous Bughouse
40. Atoms For Peace – Amok

Then we come to my "COMPILATIONS OF THE YEAR 2013", which are ranked along similar lines...

1. Mutazione: Italian Electronic & New Wave Underground 1980 – 1988
2. Metal Dance 2: Industrial, New Wave, EBM Classics & Rareties 79-88
3. Deutsche Elektronische Musik 2: Experimental German Rock and Electronic Musik 1971-83
4. Cosmic Machine: A Voyage Across French Cosmic & Electronic Avantgarde (1970-1980)
5. After Dark II – Italians Do It Better
6. John Talabot – DJ Kicks Mix

And, finally, a number of "HONOURABLE MENTIONS 2013", which all had their merits, but didn't quite cut the 'Top 40' mustard...

Blondes – Swisher
!!! (Chk Chk Chk) – Thriller
Darkstar – News From Nowhere
Washed Out – Paracosm
oOooO – Without Your Love
Moderat – II
Daft Punk – Random Access Memories
The National – Trouble Will Find Me
Umberto – Confrontations
Low – The Invisible Way
Sally Shapiro – Somewhere Else
Laurel Halo – Chance Of Rain

I hope you enjoy sifting through my selections.

David Harford www.harfordtherapy.com