10 years of the Crisis, Disaster and Trauma Section

The conference began with two talks on Post-Traumatic Stress Disorder (PTSD) – Professor of Mental Health Thanos Karatzias (Edinburgh Napier University) was first, with an exploration of what we know about complex PTSD (CPTSD). A new diagnosis in the ICD-11, CPTSD describes symptoms beyond the three symptom clusters of PTSD – re-experiencing a traumatic event, avoidance, and a sense of threat – and includes three further aspects – affect dysregulation, negative self-concept, and disturbed relationships.

Karatzias explained that the apparent overlap between CPTSD and borderline personality disorder has been controversial, with some clinicians believing they are one and the same. However, Karatzias said several studies have suggested they are distinct conditions. His own research has found that CPTSD is much more common than PTSD, and those with CPTSD are more likely to have other conditions including depression, dissociation, and borderline personality disorder, and use services to a greater degree than those with PTSD.

Last year Clinical Psychologists Dr Hannah Murray (Oxford Centre for Anxiety Disorders and Trauma; OxCADAT) and Dr Sharif El-Leithy released their book Working with Complexity in PTSD: A Cognitive Therapy Approach. Murray explained that complexity in PTSD can encompass numerous factors including barriers to entering treatment, physical health problems and ongoing risks, all of which can affect how clinicians approach treatment.

However, Murray explained that although clients with CPTSD begin their treatment with more severe levels of trauma compared to those with PTSD, and end treatment with higher levels than people with PTSD, their symptoms do still decrease at the same rate as those with PTSD. Murray pointed to the OxCADAT website which includes training resources, videos, and publications for therapists to help them deliver cognitive therapy to those with PTSD and social anxiety disorder.

A betrayal of what's right

The concept of moral injury, or the negative impact of witnessing or carrying out behaviour which goes against one's own beliefs or values, has entered the mainstream since the Covid-19 pandemic. Dr Deborah Morris, Director of the Centre for Developmental and Complex Trauma (St Andrews Healthcare) has been exploring this among workers in mental healthcare.

Morris said that when we thought about occupational distress in the past we largely used the frameworks of burnout and secondary trauma. However, some recent reviews have suggested that interventions based on those frameworks have a limited impact on wellbeing. 'There is a mismatch between our intuitive understanding, interventions, and wellbeing'.

Given the ethical and moral dilemmas to which healthcare professionals are often exposed, moral injury has been posited as a potential cause of occupational distress. This concept was originally brought together in Jonathan Shay's book Achilles in Vietnam where he described moral injury as coming from 'a betrayal of what's right, by someone who holds legitimate authority, in a high stakes situation'.

Now there are around 16 definitions of moral injury, and studies have found that it is associated with poorer therapy outcomes and suicide. However, questions have been raised over the usefulness of the concept given the lack of an agreed definition – some have asked whether it adds anything new. Morris explained that moral injury existed before the pandemic but we were not paying attention to it. Since the pandemic moral injury research has explored aspects including the availability of resources, and decisions over who gets care.

Morris said healthcare professionals, including those working in secure mental health settings, have largely been missed by the literature – even though such contexts could be a breeding ground for moral injury. There has also been little exploration of intersectional aspects: we do not have a good understanding of its relationship with other pathologies, including whether it may be a facet of burnout, depression and PTSD.

In her own research, Morris wanted to address some key questions – is moral injury prevalent, does it impact on functioning, and does it contribute to our understanding of occupational distress? This work is in the data collection stage, with an aim to develop an integrated occupational distress questionnaire. Morris is also working with a research group in China to eventually replicate the work.

The data she has collected so far, through an online survey, included around 330 mental healthcare professionals. Nurses, allied professionals, healthcare assistants and non-clinicians were asked about depression, anxiety, secondary trauma, moral injury, and how all those aspects related to their own functioning. Moral injury was endorsed by clinicians and non-clinicians alike and was associated with other psychological conditions, physical health problems and reduced functioning. Morris said the work so far – which also found around one-quarter of those surveyed had little to no social support – suggested that we need to consider workers' broader needs and better ways to support them.

Shame and compassion

Two talks in the afternoon explored compassion in working with both trauma and staff support including one from Consultant Clinical Psychologist Dr Deborah Lee (Berkshire Healthcare Foundation NHS Trust).

She opened her talk with thanks to two professors who influenced her career journey – Professor William Yule (see box), her supervisor during her clinical training, and the founder of Compassion-Focused Therapy Professor Paul Gilbert. 'When I listened to Paul Gilbert I realised I hadn't understood shame: it's a social state of threat which emerges in interpersonal trauma.'

Lee said that complex PTSD was a helpful new diagnosis and its three symptom clusters which are distinct from PTSD all have shame in common. She explained that the human brain has two conflicting drives – one where we feel a need to compete to find safety, and another where we seek connectedness and safeness. Developing a compassionate, self-soothing mind, she said, can help people to develop the capacity to feel safe in their own minds, as well as fostering connections and safe relationships. Lee explained she has been developing a compassionate resilience group programme for 25 years which has helped people to reduce their CPTSD symptoms.

Senior Fellow of the Emergency Planning College and author of When the Dust Settles; Stories of love, loss, and hope from an expert in disaster, Professor Lucy Easthope (University of Durham), has spent more than two decades planning for and responding to disasters. She said there were themes from her book which seemed to have hit home with readers – one of those was that the hardest part of working in disasters was going home, and another was the difficult honesty needed in disasters. 'In disaster, we have to have difficult conversations all the time… there is a lot of breaking of news, a lot of shattering of hope.'

Easthope touched on the importance of personal effects following disasters – an area she is particularly proud to be involved with. While the general approach is to dispose of these items, she said in mass fatality incidents where there is no body personal effects can become like a surrogate body for families. 'Without a body, you often see challenges with ambiguous loss. Protecting personal effects at a scene can start a process within a family to give an indication the person was there.'

A short history of the Crisis, Disaster and Trauma Section

• Emeritus Professor of Applied Psychology Professor William (Bill) Yule was the driving force behind the creation of the section and worked for seven years to put the case to the BPS for a Section.
• In 2010 Yule put a formal proposal into the BPS to create a Section, supported by then-president Dr Carole Allan and Dr Liz Campbell – with support from Susan Eppel. 
• The Section had its first meeting in October 2013 with 17 attendees. Yule was its first chair with Dr Peter Eachus working as Treasurer and Dr Anne Douglas as secretary.
• The current chair is Dr Siobhan Currie – a Senior Educational Psychologist.
• The Section now has more than 1,100 members.

Crisis, Disaster and Trauma Section 

June conference 

On Friday 16 June, the Crisis, Disaster and Trauma section is hosting a one-day conference in Nottingham which will bring together themes of trauma and justice. Featuring talks from psychologists and legal experts, the talks will explore the latest evidence and knowledge on the relationship between trauma recovery and justice, redress, access to formal and informal support and recognition in the aftermath.

Associate Professor Dr Blerina Kellezi (Nottingham Trent University) has organised the conference and will also speak at the event. She said the conference talks would help to demonstrate that trauma happens within a wider social context. 'Whether people have access to support or access to rights and justice has an impact on whether they are targets of traumatic events or whether they can overcome challenges. For some populations, there are more risks and we need to think more systemically and more broadly in terms of the risks they face, but also how we can think about prevention rather than just trying to fix things. Trauma will be at the centre of the conference but also perspectives of justice –from the legal perspective, from a social perspective, and from the political perspective.' 

To register, visit Trauma and Justice. An interdisciplinary approach.