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Critical review: Dear Sword and Zimbardo, my university made me do it

Most available self-help for post-traumatic stress (PTS), or post-traumatic stress disorder (PTSD) is based on a general assumption that the problem is cognitive or perceptual, instead of situational or circumstantial (known as a fundamental attribution error). Sadly, prolonged exposure therapy (PE) is sometimes used to treat such symptoms. This document will start by defining some key terms, and then it will proceed to critically evaluate some of Sword and Zimbardo’s (2018) statements about self help and therapy for PTS as cited in The Open University (2019). Finally, it will touch on the topic of suicide in the UK, and how the rates suggest that sometimes a change in the system, rather than in the patient is needed. 

According to Ghafoori (2018, p. 124), PE involves ‘sufficient processing of the traumatic event by revisiting, repeating, recounting, and actively engaging with the trauma memory’. In other words, clients are deliberately exposed to the threatening stimuli that trigger their worst fears. This is similar to the definition posited by the Equality and Human Rights Commission (2018), which describes torture as happening ‘when someone deliberately causes very serious and cruel suffering (physical or mental) to another person. This might be to punish someone, or to intimidate or obtain information from them’. Such form of therapy can be described as the most barbaric way to treat someone with PTSD. Some might be tempted to counter-argue that PE is not done to intimidate or punish, but rather to help. Nevertheless, the evidence in neuropsychology shows that the mere perception of pain or internal discomfort can damage the nociceptor neurons (those which process pain signals); and can therefore induce, for example, hyperalgesia (an abnormal hypersensitivity to pain, or the perception of pain; Medical News Today, n.d.; Miguez et al., 2014), which is the opposite of analgesia (a reduced sensitivity to pain).  It is triggered by associative cues which produce assimilative signals that trigger psychosomatic hypervigilance, and an aversion to such cues therefore. This is why those who suffer from PTS can at times feel as though ‘they were being tortured’, and actively seek to escape or avoid such stressful stimuli. This will be explored further in the following paragraphs, especially when talking about Borderline Personality Disorder (BPD), a severe mental health illness manifesting in those who have experienced prolonged and extreme forms of trauma since childhood (NHS.UK, 2019). 

Sword and Zimbardo’s (2018) excerpt describes PTS correctly when they say that it is trauma which is carried on after an event happens, and which manifests as flashbacks, intrusive thoughts, and sleep disturbance. Moreover, they also ratify the set of symptoms as categorised by the American Psychiatric Association (2013): ‘depression, anxiety, flashbacks, avoidance, isolation, difficulty falling and/or staying asleep, difficulty concentrating, irritability, an exaggerated startle response and hypervigilance’. However, as a caveat it must be stated that ‘avoidant’ behaviour should at times be categorised as a survival skill, rather than a symptom. For instance, hyperalgesia can be induced by overwhelming the nociceptors in the brain with painful contextual cues which a person already perceives to be unpleasant, as explained by Miguez et al. (2014). This means that avoidance of painful stimuli can at times save someone from an increased sensitivity to painful situations. Moreover, Rotter’s (1966) theory of the locus of control as cited in Cherry and Barker (2015:235) would indicate that avoidance of a destructive stimulus would be in the individual’s locus of control, and this would also be supported by Rogers’ (1975) protection motivation theory as cited in Boer and Seydel (1996) which posits that fear-inducing stimuli are emotionally unpleasant, and it can therefore be expected that people will seek to avoid such stimuli. In addition, another problematic statement made by Sword and Zimbardo (2018) is that people with trauma see the world through a ‘darker lens’. Cherry and Barker’s (2015) work posited how self-help psychology at times fails to understand that it is not always the individual’s cognition that is faulty, but rather the reality around such individual (i.e. scientists can sometimes make fundamental attribution errors). A good example mentioned by Cherry and Barker (2015:244) is that of poverty, which effects on the human psyche include a lack of self-worth, a disruption of normal functioning, and feelings of marginalisation. As this is a circumstantial situation, trying to change a person’s perceptions of such real hardships might only contribute further to their symptoms. This is why it can be said that those who are seeking to profit from their work are avoiding poverty, which again is a protection-motivated behaviour, and not a symptom; therefore, challenging assumptions that avoidance is a mental health problem is crucial to improving mental health systems. Furthermore, Sword and Zimbardo (2018) also describe resentment as being a phenomenon experienced by those with PTS; however, the cluster symptomatology they list- ‘going to work, preparing meals, being interested in what they did that day—become chores’- is more consistent with the construct of anhedonia (losing pleasure in doing things that once brought a sense of comfort and satisfaction; Ritsner, 2014) than that of resentment, and this distinction is very important when trying to understand PTS; because depression-induced, affect-reactive behaviour is often mistaken with and stigmatised as narcissistic rage, or a toxic personality.  

Furthermore, not only can PE induce hyperalgesia, but it can also create more repressed forms of trauma, and people can end up getting worse. Since pain-avoidant behaviour is not irrational when thinking about the way in which human neurons’ function and how these react to overwhelming amounts of discomfort, why is such inhumane treatment so often justified? Indeed, exposure to stressor cues which produce psychological discomfort can physically damage nociceptors, and this might explain why BPD with comorbid PTS patients, for example, are seen as ‘difficult to work with’ (Harvard, 2006) due to their exhibited hypersensitivity and hypervigilance (Palmer and Unruh, 2018). This type of systemic prejudice is based on a presumption of cognitive and behavioural guilt; especially if such expectations and attitudes are perceived as torturous by the client.  No wonder many BPD clients develop an aversion to health-care, and no wonder Cherry and Barker’s (2015) chapter on self-help highlighted some of the paradoxical reactions that can happen when people are given the wrong type of help, or the wrong set of coping techniques. For example, some expectations when it comes to treating traumatised individuals are unrealistic and can make some individuals feel worse. Some of these errors include expecting someone to only think optimistically, or to ignore the circumstantial stressors they experience.  Furthermore, Eysenck (1998) posited that when the nervous system is overwhelmed by external stressors, this causes an increase of the release of corticosteroids (stress hormones) and when too many corticosteroids are released, the immune, endocrine, and circulatory systems can malfunction. So the awareness of the potential repercussions of prolonged psychological torture, or PE is not new, and many of those who engage in such activities know that what they are doing is perceived as harmful by others (actus reus) and if they continue doing it nevertheless, then there might also be a guilty intent behind such decisions (mens rea; Palmer, 2018). 

It is dangerously equivocal on one hand to call avoidance of suffering a problem, and on the other hand wonder why people are self-harming. For example, Wager (2015) explained that only 1 in 800 cases of child sexual abuse make it to child protection services, which means that most of the victims of such henious acts grow with the trauma they experienced, and recreating their sexual abuse not only would be illegal, but it would only make things worse for them. This is why PE can have disastrous consequences for those who are severely traumatised. Moreover, expecting someone who has endured sexual abuse to stop avoiding their worst fears would be irrational; and such confusion could potentially lead the individual into further traumatic circumstances and relationships, or to suicide, which is not that uncommon in the UK nowadays. For instance, according to Samaritans (2019) there were 6,859 suicides in the UK in 2018. This was a ‘significant’, and tragic increase in rates from previous years. The cruel nature of everyday mental health misconceptions might have contributed towards such results (Kinderman, 2015). The ambiguous messages sent by certain frameworks can leave people feeling hopeless, confused and neglected, a prerequisite for suicidal ideation. Compassion, however, could save lives (Kinderman, 2015:291). So in the case of BPD with comorbid PTS, a treatment going wrong is often blamed on the patient rather than on the health system. It is a paradox because the mere action of the patient complaining is categorised as a symptom, rather than as a rational response to a painful, unfair, and/or stressful trigger.  This is why taking into account socio-environmental stressors should not be an exclusively academic matter, but rather a general rule for the prevention of inhumane and degrading treatment. Nevertheless, it is good that Sword and Zimbardo (2018) display a well-intentioned contribution to the development of more effective mental health apps, a topic that is beyond the scope and capacity of this document. 

To summarise, Sword and Zimbardo’s (2018) work as cited in the Open University (2019) mentions PE as one of the traditional forms of therapy used to treat PTS; nevertheless, they seem to attribute most problems to human cognition, rather than to situational factors. Furthermore, they seem to be deleteriously equivocal when they use the criteria for anhedonia to describe resentment, without providing satisfactory evidence to support their claims. Finally, they describe avoidant responses as a symptom, rather than as an everyday behaviour. However, research has shown that avoiding certain situations is rational, and mental health frameworks should take this into consideration when treating severely traumatised individuals, instead of speculating and risking someone’s physical integrity to death. 

References

American Psychiatric Association (2013a) ‘Posttraumatic stress disorder, in Diagnostic Statistical Manual of Mental Disorders, 5th ed, Arlington, pp. 271-280.

Boer, H. and Seydel, E. R. (1996) ‘Protection motivation theory’, Conner, M. and Norman, P. (eds), Predicting Health Behaviour, Buckingham, Open University Press, pp. 95-120. 

Cherry, S. and Barker, M. J. (2015) ‘Self-help: changing people’s understandings to change their experience’, in Turner, J. and Barker, M. J. (eds), Living Psychology: From the Everyday to the Extraordinary, Milton Keynes, The Open University, pp. 227-259. 

Equality and Human Rights Commission (2018) ‘Article 3: Freedom from torture and inhuman or degrading treatment’, 15 November [Online]. Available at https://www.equalityhumanrights.com/en/human-rights-act/article-3-freedom-torture-and-inhuman-or-degrading-treatment (Accessed 26 April 2020).  

Eysenck, M. (1998) ‘Biological bases of behaviour’, in Eysenck, M. (ed), Psychology: an integrated approach, Essex, Addison Wesley Longman Limited, pp. 23-67. 

Ghafoori, B. (2018) ‘Prolonged exposure therapy for experiential avoidance: a case-series study’, SAGE, pp. 122-135 [Online]. Available at https://pmt-eu.hosted.exlibrisgroup.com/permalink/f/gvehrt/TN_sage_s10_1177_1534650118766660  (Accessed 26 April 2020). 

Harvard (2006) ‘Borderline personality disorder: treatment’, in Harvard Mental Health Letter, 1 July [Online]. Available at https://pmt-eu.hosted.exlibrisgroup.com/permalink/f/gvehrt/TN_medline16862705 (Accessed 26 April 2020). 

Kinderman, P. (2015) ‘Beyond disorder: a psychological model of mental health’, in Crighton D. A. and Towl, G. J. (eds), Forensic Psychology, 2nd edn, West Sussex, John Wiley and Sons, The British Psychological Society, pp. 291-300.

Medical News Today (n.d.) ‘Hyperalgesia: What you need to know’ [Online]. Available at https://www.medicalnewstoday.com/articles/318791 (Accessed 26 April 2020). 

Miguez, G., Laborda, M. A. and Miller, R. R. (2014) ‘Classical conditioning and pain: conditioned analgesia and hyperalgesia’, Acta Psychologica, Elsevier, pp. 10-20. 

NHS.UK (2019) ‘Borderline personality disorder’, 17 July [Online]. Available at https://www.nhs.uk/conditions/borderline-personality-disorder/ (Accessed 1 May, 2020). 

Palmer, B. and Unruh, B. (2018) Borderline Personality Disorder : A Case-Based Approach, 1st ed, Belmont, Harvard Medical School [Online]. Available at https://pmt-eu.hosted.exlibrisgroup.com/permalink/f/h21g24/44OPN_ALMA_DS51130622870002316 (Accessed 27 April 2020). 

Palmer, E. J. (2018) ‘Psychological approaches to understanding crime’, in Davies, G. M. and Beech, A. R. (eds), Forensic Psychology: Crime, Justice, Law, Interventions, 3rd ed, West Sussex, The British Psychological Society/John Wiley & Sons, pp. 27-47.

Ritsner, M. S. (2014) Anhedonia: A Comprehensive Handbook Volume I : Conceptual Issues And Neurobiological Advances, 1st ed, London, Springer [Online]. Available at https://pmt-eu.hosted.exlibrisgroup.com/permalink/f/13ueeno/44OPN_ALMA_DS5176564010002316 (Accessed 27 April 2020).  

Samaritans (2019) ‘Suicide Statistics Report’, December [Online]. Available at https://media.samaritans.org/documents/SamaritansSuicideStatsReport_2019_Full_report.pdf (Accessed 26 April 2020). 

The Open University (2019) ‘Excerpt 2’, DD210-19J Study Guide: Week 27: TMA 05 [Online]. Available at https://learn2.open.ac.uk/mod/oucontent/view.php?id=1467741&section=1.2 (Accessed 26 April 2020). 

Wager, N. M. (2015) ‘The psychology of extreme circumstances’, in Turner, J. and Barker, M. J. (eds), Living Psychology: From the Everyday to the Extraordinary, Milton Keynes, The Open University, pp. 139-178. 

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