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Introducing PTSD

PostTraumatic Stress Disorder (PTSD) can be described as normal and natural reactions to unnatural event or experiences. One clinical definition is:

The development of characteristic symptoms following a psychologically distressing event outside the range of normal human experience.

Critical Incident Stress can be brought on by any incident or experience that causes or results in extraordinary emotion which overwhelms or impairs a person's normal ability to cope. The stressful affects of a critical or traumatic incident are both immediate, in that the incident is being experienced in real time, i.e. as it happens, and short term, in that some disturbance is natural and to be expected for a period of time following an incident. Freud referred to this as objective anxiety or realistic anxiety, it being the ego's reaction in his view to danger in the external word. 

Although Freud's contribution was coined for situations when ones life was in danger, the expressions are in common use and can be used interchangeably. In any case individuals affected by PTSD have usually been involved in situations where they were in fear of their lives. As a rule of thumb if the affects associated with an incident are experienced for longer than one month after an incident then critical incident stress has become PostTraumatic Stress Disorder.

It is reasonable to assume that people who have been exposed to major traumatic events such as disasters, war, torture, kidnap, hijack, violence and rape can be expected to experience persistent psychological stress as a result. This can in turn lead to problems in readjusting to life afterwards. The nature of the stress is predictable and has been long recognised. Once known under war conditions as shell shock, battle fatigue, combat fatigue or combat neurosis, PTSD gained its current name after it appeared in many United States veterans returning from Vietnam as they tried to readjust to civilian life. It is a shocking statistic but more American servicemen's lives have been lost in the years since they returned from Vietnam than were killed during the whole course of the war. In the Vietnam War U.S. casualty's rose to a total of 57,685 killed and about 153,303 wounded.

Although the exact figures are unknown the veterans associations in America say that at least as many have since died through suicide, homicide or stress related conditions. This does not take into account the families, friends and loved ones of these causalities. Taking a conservative estimate of each death or wounding affecting at least ten other people directly, (parents and other family members, wives, children, friends etc) then these figures can be extended to include a total of 2,109,880 individuals. These figures do not include those service men that served and were fortunate enough to escape physically unscathed yet whose families and friends would none the less have experienced severe stress as a result of their serving in a war situation.

From the Vietnamese side, as a result of more than eight years of American involvement in the war, it is estimated that more than 2 million Vietnamese were killed, 3 million wounded, and hundreds of thousands of children orphaned. It has been estimated that about 12 million Indochinese people became refugees. When viewed in this context the real scope of the tragedy that was Vietnam can begin to be appreciated.

The Vietnam War also provides us with a graphic example of how a traumatic event can affect an entire people. The social conflicts within the United States that were engendered by the war led to the questioning of U.S. institutions by the American people and a sense of self-doubt that was to persist for many years afterward. This example is one of a society divided by tragedy. Many of us remember a statement made by the American president after the Gulf war to the affect that in view of their outstanding victory that the legacy of Vietnam had finally been laid to rest! More recently in the UK we have experienced two critical incidents that have served to unite society:

The Dunblane shooting led to a rapid change in the law relating to the possession of firearms by the UK government as a direct result of 

public pressure in the aftermath of the massacre.

 

The recent sudden death of Diana Princess of Wales also provided us here in the UK with an example of a society united in tragedy. We all remember the 'sea of flowers', changes in royal convention (lowering of the flag over the Palace) and the volume of people who lined the whole length of the funeral procession. Also as a secondary result newspapers have become very careful about coverage of the young princes. This may change in the future as their usual cynicism sets in again, it will be interesting to track this!

However, it was not until as late as 1980 that PTSD was accepted as a separate subcategory of the anxiety disorders in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, (DSM-III), a publication of the American Psychiatric Association. Although this was a controversial diagnosis when it first appeared it has since filled an important gap in studies of psychological health.

From a historical point it was important development when the DSM listed the cause of PTSD (the trauma) as external to the individual as opposed to being due to an inherent weakness. Such earlier historical viewpoints (lack of moral fibre) were what allowed soldiers who today would have been hospitalised to be shot for cowardice. Examples of incredibly unenlightened attitudes do still exist today however, and often in the most surprising of places. For example a Private Members Bill to clear the names of soldiers who had been shot for cowardice during the so called 'great wars' was defeated after the then Prime Minister, John Major, stated that it would be inappropriate to revise judgements in the light of modern knowledge.

DSM-III attempted for the first time to lay down criteria describing the most common effects of the onset of PTSD which in turn provided the basis for the ongoing research into PTSD. One of the most important areas of this research is the search to discover why some people were being affected in such predicable ways and whether or not it was possible to predict who was most likely to be affected.

It was quickly discovered that there was no easy way of predicting who would be affected long term after a traumatic incident, and who would recovery quickly after a period of distress or readjustment. Earlier thoughts that reactions and symptomology would be predictable in direct ratio to the nature and severity of the trauma experienced proved to be overly optimistic and have largely been abandoned. There are two main areas of research however, which buck this trend.

These are in cases involving rape and torture. In both of these cases victims nearly always show signs of long term psychological distress. In this section we will examine the situation which is summarised by what is called the rape trauma syndrome, where the long term consequences of trauma are better understood.

The rape trauma syndrome was recognised as far back as 1974 when Burgess & Holmstrom suggested a two-phase reaction. (Note: use of the word reaction is intentional, PTSD is a predicable and normal reaction to critical stress)

 

The acute phase: This involves a period of disorganisation overshadowed by constant or near constant fear. During the acute phase feelings of anger and self-blame are common as are feelings of a desire for revenge. While some women displayed their inner turmoil through crying and visible signs of tension and fear and equal number masked how they felt under a calm and subdued front. The acute phase passed, usually in about three weeks, at which time the victims moved onto the next phase.

 

The long-term reorganisation phase: This involves attempts to return to a normal lifestyle and remaking family and social contacts. A significant number of women moved house. The majority of victims never regained trust in men. The unpredictability of human behaviour seems to count against this.

The DSM-III suggested that PTSD should only be diagnosed if a number of effects or symptoms were exhibited over a period of at least one-month after an incident has occurred. In order to qualify as a causative event the incident must be 'an event outside of the range of normal human experience'. It is this distinction which differentiates PTSD from all other anxiety disorders. PTSD is the only clinically diagnosed anxiety disorder which is directly associated with a known cause. 

This is a very important point to remember and it is for that reason that it is emphasised in the text. If an individual presents with a set of PTSD like symptoms, but without evidence of a traumatic incident then PTSD can not be diagnosed. It must be borne in mind however, that whether or not an incident can be considered traumatic, is very much a matter of individual perception. Indeed, one person's trauma is another person's non-trauma. It might seem like it is stating the obvious, that PTSD can only be diagnosed in the aftermath of a traumatic incident but there are reasons for making the distinction.

For example it is perfectly possible for the significant other in a relationship with a traumatised person to themselves display all of the symptoms of PTSD after a period of time during which they were continually exposed to their partners symptoms, and to dealing with the consequences of them. Obviously the treatment strategies must differ in both cases; one will be treated for stress and the other for traumatic stress.

These criteria are briefly summarised here, but are expanded on somewhat in the next section because the criteria listed in DSM-III are limited and have been expanded upon since these were published. This list is adapted from an article on PTSD by Fred Lowe.

 

First, the person should re-experience the traumatic event persistently. This would take to form of intrusive recollections (dreams, thoughts and sudden flashbacks) which would generally prove distressing to the individual. Simultaneously with this re-experiencing the person also reports the same feelings experienced at the time of the causative incident. They also respond with the same kind of distress when confronted with reminders of the incident.

 

Second, the person persistently seeks to avoid situations associated with or which serve to act as a reminder of the original incident. This can mean trying to avoid thinking about it or to deny feelings associated with it. A person so affected would appear cut off, cold and unresponsive to the outside world.

 

Third, the person develops signs of increased arousal (sleep disturbance, irritability, difficulty concentrating and the startle response). The person would also re-experience emotions associated with the original incident when confronted with reminders of it.

Above it states: The DSM-III suggested that PTSD should only be diagnosed if a number of effects or symptoms were exhibited over a period of at least one-month after an incident has occurred.

After a traumatic incident it is perfectly normal and expected for an individual to pass through an acute phase during which they come to terms with what happened learn to assimilate it and make any adjustments that might be required. It is fair to say then that a certain period of turmoil and upset after a critical incident is natural and predictable and that this period is vital in order for healing to occur.

Looked at in this way we can then expect a period of upset immediately following an incident. This is not necessarily PTSD. However, it becomes more significant if the symptoms and effects persist beyond one month after the incident, in this case PTSD can be diagnosed with much greater certainty. Unless this one-month period is respected we run the risk of over-diagnosing PTSD. 

This position however should not detract us from the need to ensure that a person exposed to a critical incident receives support and any information that might be useful to them in coming to terms with what happened. In fact it is this very early support which may serve to avoid the onset of PTSD in the first place. This is the underlying principle behind Critical Incident Stress management (CISM) of which CID plays a significant role.

As well as taking the above factors into account an understanding of PTSD would not be complete without a mention of the possibility of the destruction of our core beliefs and the debilitating effect that this can have on an individual or group.

There are as many 'core beliefs' as there are people. There are three important core beliefs that can be shattered by involvement in a traumatic incident.

 

The majority of us believe in our own invulnerability (bad things only happen to others)

 

There are reasons to live (home family work etc.)

 

Belief in ourselves and in our inherent qualities (we usually see ourselves as basically good, competent people able to cope with life’s trials and tribulations).

These core beliefs can be left in tatters as a result of a major trauma, whether perceived or otherwise. This can eventually lead to a personality breakdown. In this section we will be concentrating on two which are of particular interest to those involved in the study of PTSD and which authors writing on the subject generally always mention. Note that the core beliefs do not occur in isolation and damage to one will have knock on effects on others as they find that they have to be revised to fit the new reality.

The first core belief is a belief in ones own invulnerability. This belief, that nothing bad is going to happen to us, is necessary in order that we do not become preoccupied with risks and prevents us from becoming paralysed with fear. Imagine the results if every time we tried to cross the road we became afraid of becoming another accident statistic, or that we could be hit by a meteorite at any time! These are exaggerated examples used solely to illustrate the point. Under normal circumstances we are not overly concerned with possible dangers and risks that surround us, and we believe that we are protected by and large by society and its systems and conventions.

However, when a violent assault, rape or other traumatic incident strikes this belief that we are protected within society disappears, and the victim can become dominated by fears. In fact 'Anxiety Neuroses' the fear that something bad is about to happen is quite common among those affected by PTSD. This is what leads them to double, triple and quadruple check locks, lock car doors and windows while driving, check the pilot light on the gas boiler to make sure it is still lit, look over their shoulders to make sure that they are not being followed and even to ring home during the day to hear their answering machine message to reassure themselves that someone has not broken into their home and stolen it. In one case a young man used to go from room to room to listen to his wife and children breathing, just to make sure that they were not dead.

Although many of us are more enlightened these days there still exists a prevalent belief that people get what is coming to them. This leads to a situation where victims are blamed for what happened to them. How many times have we heard people say that a rape victim was 'asking for it'? At least one judge gave some credence to this point of view having famously accused a rape victim of 'Contributory Negligence'. Expressions such as date rape are also in common use and this also leads people to believe that 'Contributory Negligence' plays a part and that victims should somehow have been more careful. Attitudes like this after an event such as a rape can often cause as much if not more damage than the original incident. This is termed secondary injury and is covered below after compensation neuroses.

The second core belief that can be destroyed after exposure to a trauma is that we are capable, brave and able to handle anything and so on. Traumatic incidents are by their nature incidents which almost anyone would find distressing. They generally generate fear and horror and often overwhelm a persons abilities to cope, nothing in their past having prepared them for what has happened. Prior to an incident occurring most people would be able to tell you exactly how they would respond when faced with a particular incident. In reality these assumptions are based on totally unrealistic expectations about what is possible in any given situation. For example a person might say that if they were confronted in the street by a gang of three muggers asking for their money that they would fight them off and give them a good beating. In reality the first a mugging victims knows about an attack is when it is all over, their bag has gone and they are left with a broken or bruised arm or wrist in the case of female victims or in the case of male victims they have been violently kicked and punched to the ground without a word being spoken or no other warning received that they were about to be robbed. 

In any case, speaking as a former Special Forces soldier, if three muggers actually asking for my money confronted me, they can have it. In my case the sense of injustice is tempered by actual knowledge of what is involved in a serious fight, and believe me, its not worth it unless you really have no other choice. Money can be replaced, your life and health can not.

In brief then, people's self-image and faith in themselves can be totally destroyed after an incident because their assumptions about what they were capable of and expectations were unrealistic to begin with.

Having core beliefs challenged is not always to the long-term detriment of the trauma victim. There is some welcome good news:

As a direct result of their experiences many people emerge stronger, more emotionally stable and with a more realistic worldview than prior to their trauma. People tend to appreciate life more, worry less and to be more proactive. With recovery, self-confidence, once shattered, can climb to new heights.

A compensation neurosis is a genuine psychological phenomenon, which has become misunderstood through misuse by the uninformed. We often hear PTSD described a form of compensation sickness with comments like "I've just been traumatised and I can feel compensation setting in", bandied about in the popular press. This is perhaps understandable because it is certain that some people do 'play the game' and play up or invent injuries of various kinds in order to achieve financial compensation. On the other hand, since leaving the military in 1989 and going on to work with many traumatised individuals the only victims that I have come into contact with who have applied for any form of compensation have been victims of crime entitled to claim through the Criminal Injuries Compensation Board (CICB). Awards through the CICB are awarded to all qualifying victims of crime and are not generally very generous.

True compensation neuroses on the other hand occurs when the mind blocks any attempt at healing or recovery until such a time as the victim is compensated for the injury received. This needs clarification. During the visit to the UK of the Japanese Emperor in 1998 many former prisoners of Japanese prisoner of war camps came out in force to protest the lack of a formal Japanese apology for the treatment that they suffered in these camps during their internment.

I personally would be willing to bet that if such an apology were forthcoming that many of these Veterans would lose at least some of the anger that has fuelled their campaign through the years. This would be because they would have been 'compensated' for their suffering. If any of you had harsh and unsympathetic words to say about these protesters, many of whom turned their back on the emperor during a televised parade, you might like to revise your judgement in the light of new knowledge. 

True compensation in this case means the feeling of seeing the right thing being done, a sense of natural justice if you will. This situation does not of course only apply to the group mentioned. Compensatory actions or whatever of this nature can never right the original wrong but they could go a long way in helping survivors to put things behind them.

As a point of interest, support groups, including the Royal British Legion all report an upsurge in calls from distressed veterans at times of anniversaries of major events associated with the last war. Prime examples were the recent bicentennial anniversary of D-Day and the release of a major motion picture.

Secondary injury occurs in many ways in the aftermath of a critical incident. One example is that of a rape victim who visited a therapist was asked to be honest with herself and to admit what she had done to attract her attacker. 

Although taking personal responsibility for certain aspects of ones life and ones action is commendable under many circumstances, this is not one of them. A victim is by definition completely innocent of any wrongdoing, and they certainly do not deserve what happens to them. This level of insensitivity found in a female therapist in this case led to a complete nervous breakdown and a suicide attempt on the client's part.

To date being female and in the wrong place at the wrong time does not yet constitute a crime in this country. The blinkers worn by some people are such a permanent part of them that they perhaps no longer realise that they are there. They at least have the virtue of being easily recognisable; they say things like 'she was asking for it.' Perhaps societies attitude to rape can fairly be described as very hypocritical.

Most rape victims are attacked by people known to them, the same is true of most violent crime, but this can never be used as an excuse to tone down our response to it. Consider what happened when a man was raped on a train a few years back. The same service which had failed to act decisively when female passengers had been subjected to attack suddenly found the resources to put in place the kind of safeguards that safety campaigners had already been asking for with little result. What is the difference you may ask? Cases such as this make it fair to ask if is it societies attitude toward rape that needs changing or just men's?

Further examples of serious secondary injury in the case of rape might be the discovery by the victim that they have been made pregnant, have contracted a venereal disease or being stigmatised by their family or social group.

Secondary injury does not of course only happen in the case of rape victims. 

Soldiers being injured in War situations having to fight for compensation, families of people who died in tragedies are frequent victims of secondary injury when they discover how little consideration they merit from the authorities when conducting their investigation and so on. In the latter case there is some evidence that attitudes are changing, but the indications are that they will take years to filter through.

In some cases trauma victims are handled very sensitively and with great consideration, however there will be times when you discover that the official response to victims of trauma has left a lot a lot to be desired. Documented examples of the types of things that can cause secondary injury are:

The social worker who said, "I understand what you are going through" to a parent whose child had been murdered.

 

The detail of the evidence presented at a murder trial removes any thoughts that the victim might not have suffered. The effect that listening to this kind of harrowing detail might have on the family and friends in the public gallery in a courtroom can only be guessed at.

 

The emphasis being placed on the offender and his right to a fair trial.

 

Procedures surrounding the identification of dead bodies at the morgue. The worst affected parents or stepparents were those who saw clear evidence of violence when they were identifying a body. In one case a bereaved parent said' "Her face was showing with her mouth wide open and a ligature round her neck." Many people get their ideas about how bodies are identified from television; the reality is often completely different.

Unfortunately there is not always a happy ending to every story.

Simply put it is the result of a traumatic event in a persons life which causes intrusive thoughts and/or unwanted reactions and feelings which serve to render the person experiencing them less than "fully functional." These thoughts, reactions and feelings are natural and predictable reactions to unnatural events. Characteristic symptoms of PTS involve a re-experiencing of the event and a strong desire to avoid any stimuli associated with it. This can also include a "shutting off" process and withdrawal or an increase in general responsiveness and arousal. Reactions can include memories, distress, numbing (reduced interest in previously significant activities and people), arousal leading to irritability and tension, avoidance, feeling a loss of control, anger, guilt, shame, sadness and a sense of loss.

All of the above are common for anyone who has been through any traumatic experience though the intensity will vary from person to person. If the situation is not relieved and becomes long term then complications may arise. These can take the form of anxiety and depression, emotional apathy (the 'I couldn’t care less attitude') and may eventually lead to the development of stress related physical symptoms. Although avoidance symptoms are normally present throughout the re-experiencing of trauma may be a delayed reaction. The good news is that many people report becoming more confident, stronger and more capable as a result of having overcome a significant incident such as PTS. As a first step to overcoming PTS or for coming to terms with a Traumatic Incident a Critical Incident Debriefing is suggested.

 

The person has been exposed to a traumatic incident in which both of the following were present:

 

1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or the threat to the physical integrity of self or others

2. The persons response involved intense fear, helplessness or horror

1. Recurrent and intrusive recollections of the event causing distress

2. Recurrent dreams

3. Acting or feeling as if the incident were recurring

4. Intense psychological distress and/or (5) Physiological reactivity at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event

1. Efforts to avoid thoughts, feelings or conversations associated with the trauma

2. Efforts to avoid activities, places or people that arouse recollections

3. Inability to recall an important aspect of the trauma

4. Markedly diminished interest or participation in significant activities

5. Feelings of detachment or estrangement from others

6. Restricted range of affect (i.e. unable to have loving feelings, show sympathy etc.)

7. Sense of foreshortened future (i.e., does not expect to have a career, marriage, children or a normal life span)

1. Difficulty falling asleep or staying asleep

2. Irritability or outbursts of anger

3. Difficulty concentrating

4. Hypervigilance

5. Exaggerated startle response

The above clinical criteria offered by the American Psychiatric Association can be expanded on and the remainder of this section contains information gleaned from too many sources over a number of years to list. The points, which are repeated, are important ones, and the repetition is intentional to reinforce their importance:

PTSD is a unique condition, in that its onset is linked directly to a known cause.

PTSD is best looked upon as a normal reaction to an event rather than attempting to define or look upon it as any form of disorder in the genuine sense of the word. The kinds of events that can lead to the development of 

PTSD are those likely to cause severe distress to most people.

Stress following a traumatic incident can have far reaching consequences, affecting more than those directly involved, such as relatives, rescuers, witnesses, colleagues, and support staff. All of these can be and are affected in various ways.

For the individual trauma victim this can mean problems with relationships, difficulties at work, ill health and, unless assistance is forthcoming, a developing sense of isolation. In extreme cases severe and disturbing symptoms can develop. The symptoms of PTSD can develop weeks, months and sometimes even years after the causal event.

Characteristic behaviours associated with PTSD

In all cases involving PTSD we would expect to observe some evidence of avoidant behaviour, even in cases where classic symptoms have not manifested, although the existence of such behaviour of itself is not always an indication that PTSD will develop. Those affected might seek, whether consciously or unconsciously, to avoid contact with anything, anyone or anyplace associated with the original incident. People might also seek to avoid talking about major incident, which is a complicating factor where intervention or treatment is concerned.

As well as physical avoidance we also observe evidence of attempts to avoid thoughts and emotions associated with the traumatic incident. This can lead to problems concentrating, skills deterioration, difficulties in expressing emotion, the development of a very pessimistic outlook, and sometimes no feelings of hope for the future, a "what’s the point?" mentality.

Physiological and psychological arousal is also very common. This is most noticeable in the ‘startle response’ where, for example, a person over-reacts to a sudden noise or flash of light. There is a general increased sensitivity to noise and an affected person’s general stress levels can be quite high. This can lead to physical symptoms as well as irritability, outbursts of temper, frustration and even violence. A person affected in this way may well experience difficulty in accepting the status quo, may feel unsettled at home and work, and may feel that they have nothing in common with anyone anymore. Hyper-vigilance is also common, leading to sleeplessness and the feeling of being constantly drained and exhausted. The person experiencing physiological and psychological arousal is constantly waiting ‘for the other shoe to drop’, in that they live in the constant expectation and fear that something bad is about to happen.

Re-experiencing: Reactions and emotions associated with an incident can be re-experienced days, months or years later. A person involved in an assault can feel the fear again, as if the incident were happening all over. These experiences can occur as the result of direct association or can apparently come out of nowhere as the result of subconscious associations.

Direct association means that something experienced or seen is reminding the victim of the original trauma. These reminders are not always obvious, covering as they do the entire range of sense, sight, sound, smell, taste and touch.

Sight: Newspaper and television reports, people, places, objects or pictures.

Sound: Emergency sirens, alarms, voices, loud or sudden noises or bangs.

Smell: Fuel (petrol etc.), ‘Hospital smells’.

Taste: Food, drink, sweat, dry mouth, body odours.

Touch: An associated object such as a steering wheel, metal, weapons or tools.

These "out of nowhere" (subconscious) reactions can happen at anytime and anywhere. And it is because they are so unexpected that they can be very frightening, even terrifying for the victim and for those around them.

Of the three characteristic behaviours this re-experiencing is probably the one most commonly associated with the condition PTSD. Most of us have heard of the flashback, where intrusive images of a traumatic event suddenly occur. This becomes even more distressing when accompanied by ‘acting out’ where the person reacts as if they were in the middle of the traumatic incident once more.

Denial is quite common, particularly amongst men. This complicates intervention and treatment options considerably as it may take either a mental or physical breakdown of some sort before the affected individual accepts that there is a problem which needs addressing. In denial, a person refuses to accept that a problem exists and will quite strongly resist and ignore any evidence to the contrary.

Characteristic symptoms associated with PTSD

There are three main areas of the human response to consider – emotions/feelings, behaviour and physical symptoms. Those presented here are fairly predictable in response to a traumatic incident. It is, however, the type of person involved and how that person perceived the incident which will determine more than anything else how he or she reacts.

Some people discover that their entire outlook on life is changed as a result of a traumatic incident. Some people, for example, turn to religion, others reject their previous beliefs. Often those affected reappraise their personal values, beliefs, priorities and relationships. This can be positive, though more often though it can be entirely negative. People affected by trauma tend to think subjectively (emotionally), and as a result do not generally benefit from an overview, focused as they are only on certain aspects of the trauma and its results.

There is some good news among all of this doom and gloom. Precisely because the emergence of PTSD is associated with a known cause we know a lot more about it than many other conditions. Prevention strategies have been developed as well as intervention strategies to minimise its likelihood in the event of a major incident occurring. Treatment options are well documented. Carers have a lot of information and research at their disposal in order to assist them in their efforts.

Michael O'Sullivan

Michael began to specialise in the study and treatment of posttraumatic stress disorder while serving in the military. During his military service, 5 years with a Special Forces unit, he experienced first hand the affects and some of the causes of PTSD. He was also able to experience and observe first hand the affects of long term exposure to highly stressful situations. Clinical hypnosis was quickly identified as a valuable method of assistance for former colleagues experiencing these problems and it was this fact that led to Michael’s interest in the subject. Today he provides critical incident debriefing services, and combines clinical hypnosis, precision therapy techniques and cognitive therapy in order to assist people who have been exposed to trauma. A former charity director, Michael maintains his interest in the voluntary sector.

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