Psycosocial lead GRAHAM FAWCETT talks about his past experiences, cross-culture and his transdiagnostics approach in mental health.
How does the work you’ve recently done as a Consultant Clinical Psychologist in the East End of London translate into the work you will be doing for Thrive?
As part of the work I did with the victims of the London 7/7 bombings, I was involved in developing screen and treat protocols for people who suffered a traumatic event.
The first three months after a traumatic event are critical. We developed checkpoints to track people over this time to measure how they were doing. People initially received a ten item Traumatic Stress Questionnaire which they filled out 24 hours after the traumatic event. People who scored above the threshold were reinterviewed after one month and if they still scored high, they were re-interviewed at three months. They were only treated for PTSD If their score was still high at the end of three months.
This same approach can be used for missions and humanitarian workers who have experienced similar traumas. TRIM and Psychological first aid also take this approach.
Finally, we discovered that some people may need extra support. These include people who have been traumatized before (e.g. sexual or physical abuse in childhood), or who have already had underlying medical or physical conditions before the event. This is something we also need to keep in mind when working with mission and humanitarian workers.
How has the work you’ve done during your time in the NHS informed the innovative cross-cultural approach you’re bringing to Thrive?
Many of my patients were either refugees or asylum seekers. Because I had previously worked in many of the countries from which they came, I was able to understand and empathize with their background and with the circumstances that brought them to the UK. This gave me the credibility.
It also gave me a deep appreciation of the difficulty in translating and making sense of mental health issues in different languages and cultures. For example in Silheti, a Bangladeshi language, there is only one word for emotion so it’s difficult to get to which emotion they are describing.
Similarly, this is a challenge for us in the cross-cultural work we do in Thrive. Treating local staff is difficult because the approaches routinely used do not translate easily into the languages and cultures of our clients.
Also, current approaches to mental health are individualistic. To counteract this we ran more community oriented approaches and groups. Similarly, in Thrive we will need to adopt more community/family based approaches when working with people from cultures which are community based.
Finally, I discovered how important it is to do talking therapy in the ‘heart language’ of the patient or in the actual language in which a particular trauma occurred. For example, I had a Czech woman tell her story to me in Czech, a language I don’t speak. The therapeutic impact was the same as if she’d worked through an interpreter. I anticipate this will have applications for Thrive.
What cutting edge approaches are you currently using with your patients?
I no longer look at and treat discrete disorders. Just as transdiagnostic theory has revolutionised cancer treatment, it is revolutionising the diagnosis and treatment of different mental illnesses.
For example, cancers are no longer defined by their geographical location in the body. Rather cancer is thought of in terms of its genetic makeup. A particular location in the body may potentially be a host to many kinds of genetically discrete cancers (over 25 in the case of ‘breast cancer’) each requiring a specific treatment. Equally a tumour with a particular genetic makeup may occur in multiple areas of the body. Therefore, in order to treat it effectively, it is more important to understand the genetic makeup of the cancer rather than its location.
Similarly, in mental health, a person can suffer from a mental health problem such as depression, anxiety or eating disorders. However, these are symptoms, not the underlying cause of the problem. This is something quite different and can be expressed as a ‘transdiagnosis’.
With trauma, crucial questions include why do some people become traumatised and need psychological help after a traumatic event and why do others get better on their own? Why are some people are resilient whilst others are not? The underpinning issue is what is it that keeps the memory live and traumatic in some cases and not in others?
Whether or not people develop a psychosis or become traumatized, is often based on whether or not they ruminate. Rumination is one of the underlying causes of mental illnesses, which then manifests as different symptoms—e.g. trauma, depression, or obsessive compulsive disorder (OCD).
“….A person can suffer from a mental health problem such as depression, anxiety or eating disorders. However, these are symptoms, not the underlying cause of the problem…”
People who ruminate ask the the same questions over and over like, ‘Why me? If only I hadn’t gone there that day or said this or done that. then it wouldn’t have happened.’ They keep reliving traumatic events in their minds which keeps the trauma fresh. In a different example, if a person ruminates about sad events they can become depressed. Instead of treating the person for depression, it is then important to treat the underlying rumination.
I suspect that rumination and other transdiagnostics are universal and that they transcend cultures. One of my goals for Thrive will be to collect data cross-culturally to see if transdiagnostic theory bridges the cultural difficulties we currently face in treating mental illness. It is at the forefront of mental health research today and provides an exciting model for the future treatment and diagnosis of stress in the future.
What do you see as the biggest issues regarding staff care facing the humanitarian/mission sector?
One of the biggest issues is that care hasn’t kept pace with science. It is hard to conduct research in the humanitarian space around trauma and staff care because most humanitarian and mission workers are sane! In a large-scale study conducted by a humanitarian agency, 2001-2002, 100% of the workers interviewed used adaptive strategies to cope with stress whereas in the ‘normal’ population we would expect to find a large proportion using avoidant strategies.
Also, there is not much funding currently available for this research. If we are to make progress, we must make it a priority and find new ways of funding it
Briefing and debriefing is useful. Research has shown that people benefit from structured reflection, especially pre, mid and post deployment. Unfortunately these terms have become toxic because of their association with a particular approach to trauma and organisations have become guarded about them.
Finally, there needs to be a greater focus on care for national staff who are working in their own country or abroad. Transdiagnostics may provide the means to overcome the cross-cultural challenges involved and is where Thrive can bring innovation.
Graham is also a consultant psychologist for East London NHS Foundation Trust in England where he has worked for the past 12 years. Prior to that he served in Youth With a Mission for 16 years where one of his roles was the provision of staff care. During this time he also was also a consultant to World Vision where he was involved in designing and implementing an organizational stress management research project with colleagues to build World Vision staff resilience in the Middle East, Eastern Europe and the Caucuses.
Graham’s specialisms include trauma, psychosis, complex trauma and transdiagnostic theoretical approach to treating mental health conditions. His work has always involved applying cutting edge theory in practical clinical situations and then using the data and knowledge gained by extensive clinical application to advance scientific theory and research in mental health.