Although many medical schools now include psychology in the curriculum,
students do not accord the subject the same importance as subjects seen
as more relevant to medical practice, for example, anatomy or pharmacy.
And until recently, psychology was not taught at all in medical schools,
with the result that most doctors in practice currently have no training
in common psychological disorder. This is clearly not reflective of the
large number of visits to GPs which are ‘psychological’ in nature. The consequence
of this huge gap in training is that most of what practitioners know about
psychological stress is learnt ‘on the job’, through experience with patients.

This method of learning is fraught with problems: in any trade, it produces
biased perceptions (because of cognitive errors of judgment). In medicine
specifically, ‘rules of thumb’ for diagnosis or treatment tend to develop
and these may be inaccurate or incorrect.

With psychologically distressed patients, medical practitioners are
even more likely to have biased perceptions. Psychological problems are
‘invisible’ and so their severity is hard to calibrate. This leads to a
suspicion that there are pre-existing vulnerabilities: the person is ‘weak’
or ‘just neurotic’, or is a ‘poor coper’ or has a pre-morbid personality
problem. Particular demographic groups may also be seen as more or less
vulnerable to psychological distress. This is a model of ‘social weakness’
and substantially it is based on lay beliefs and biases obtained through
clinical experience. Such beliefs may well lead the doctor, perhaps inadvertently,
to underestimate the distress the patient is experiencing.

Very occasionally, general practitioners are faced with widespread psychological
disorder in the community they serve. After the Lockerbie disaster, for
instance, hundreds of local residents experienced – and continue to experience
– emotional damage. Disasters on the scale of Lockerbie, although thankfully
rare, provide what amounts to a large-scale in-service training programme,
one which challenges preconceptions and ‘rules of thumb’ about vulnerability
and social weakness. Indeed, the local doctors acknowledge that at the outset
they didn’t truly recognise or understand that they were seeing classic
symptoms of post-traumatic stress disorder. And they also expected the ‘strong’
in the community to withstand psychological distress while the ‘weak’ succumbed.

What happened, however, was that the doctors were struck by the degree
to which people from all walks of life and of all ‘types’ were emotionally
and psychologically affected. It was a surprise that working males who,
as a demographic group, are considered more resilient and good at coping
were also emotionally traumatised. Eventually as more residents of Lockerbie
came forward, the striking feature for the general practitioners was that
it was not the weak, or those who had had previous psychological problems,
or other ‘subsections’ of the population who were affected, but everyone,
to one degree or another. There were apparently no groups or types of people
who were immune and, because of this, their models of social weakness had
to be questioned and abandoned. Lockerbie was an exceptional experience,
and a regrettable but valuable clinical lesson.

Lockerbie’s doctors are not the only people whose understanding of psychological
distress has increased. People in the community are generally more aware
of the influence of psychological factors in physical illness; and they
feel more comfortable about discussing such issues with the family doctor.
This is true even for people for whom psychological disturbance (in others)
was almost a joke.

So not only in this extreme situation, but every day, doctors are expected
to possess the same knowledge as a specialist in the area – a psychologist.
They can, however, refer the patient on for psychological treatment, though
this does not always happen: there are lengthy delays in obtaining an appointment,
and many patients are unwilling to be sent elsewhere to see a ‘shrink’.
This may encourage general practitioners to continue to treat disturbed
patients on their own – possibly using sympathy and psy-chotropic medication.
Common sense may also enter the consultation, but unfortunately common sense
tends to be idiosyncratic. Sympathy and appropriate medication to control
the symptoms are often helpful but it is rare for general practitioners
to have time to deal with patients with potentially complex psychological
problems. And some doctors may not really believe in the ‘legitimacy’ of
psychological disorder, and accordingly may fail to treat their patients
appropriately.

One solution would be to give medical students much more training in
psychology. Hand in hand with this would be a recognition that more time
is needed for each consultation – something that is unlikely in the current
political urge to rationalise and reduce services.

An alternative solution undoubtedly also runs counter to what the government
sees as necessary cost-cutting in health care, that of having a psychologist
as an integral staff member in a general practice. This step would have
a number of benefits. Doctors would have something more substantial to rely
on than their own individual inclinations, interests and common sense.

Many patients are resistant to the idea that their illness is ‘psychological’
rather than ‘physical’, and suffer in isolated silence. An immediate referral
within the practice would give the common psychological disorders a face
which is somehow more ‘acceptable’ to the patients, making it part of what
patients might see as ‘real medicine’ rather than making them think that
they are going mad. Treatment for psychological disorder could be dealt
with quickly and avoid the entrenchment of problems brought about by delays
in getting appropriate help.

General practitioners are not psychologists, and rare epidemiological
lessons are not sufficient insurance that patients, generally, are being
dealt with in an informed and unbiased way.

Margaret Mitchell teaches psychology at the Queen’s College, Glasgow.

The scale of the Lockerbie disaster and the numbers involved presented
a major challenge to psychology: how do emergency workers respond to trauma?
Research to answer this question has led to conclusions that run counter
to two prevailing assumptions based on common sense. The first finding is
that training and on-the-job experience do not prepare emergency workers
for these quite extraordinary duties. The second is that what actually upsets
these workers about their duties is not necessarily what we would expect.

Anachronistic, not to say wrong, ideas about coping are reflected in
the ways emergency workers have traditionally been advised (and expected)
to cope: keep your feelings to yourself, put it out of your mind, have a
drink. These are what cognitive psychologists would call avoidance or denial
strategies. They are supposed to reflect toughness. And they are quite possibly
the worst ways of dealing with demanding duties.

My research backs up the view that these strategies are associated with
an increase in psychological symptoms. They also have the quite opposite
effect to that intended: most of us are familiar with the odd circularity
of trying not to think about something, and so thinking about it more.

Why are these coping strategies perpetuated when the users themselves
must find them no good? The answer is based on confusion about stress, psychological
debility, and a fear that if these things are mentioned, everyone will want
a nervous breakdown.

In the emergency services, overt toughness is required and signs of
stress are very bad for a career. Most workers will deny that they have
any problems, hence the apparent effectiveness of the strategy itself. This
veil of silence leads to all sorts of misconceptions – for example, that
the main problems with the work are the traumatic and horrifying sights
involved. This view fits neatly into the weak/strong dichotomy: either you
can take it or you can’t – which isn’t a very useful insight.

But what else is stressful about the work? Is there another, more useful
way of thinking about it that would put the straight horror of the work
into context? What aspects of the work, for example, at Lockerbie, were
still going around the workers’ minds several months later?

Certainly, many of the emergency workers could not get rid of particularly
jarring images, and these intruded and became the focus of obsessive thinking.
But many expressed great difficulty in coming to terms with what could be
called the ‘meaning’ of the event – it was too big, too cruel, there was
too much devastation, they had had no sense of an overall strategy or what
progress was being made.

Perhaps most importantly, they had no sense of their own contribution
– feelings of uselessness and of not having done enough are extremely common
after disaster work. It seems that people need to impose some sort of coherence
or personal meaning on novel and chaotic experiences.

Sometimes attributing a cause to an event such as a disaster helps people
to understand it. An earthquake has a natural cause, and the Clapham rail
crash was principally explained by mechanical failure. Even though the cause
of the Lockerbie disaster was identified as a terrorist bomb, the nature
of the disaster was so far from experience or expectation that rescue workers
found it particularly hard to take.

The aspects of the work with which the workers seemed to have most difficulty
coming to terms were the horrifying and unusual circumstances of the victims’
deaths, the scale of the physical destruction, the intrusion of Middle East
terrorism into our culture, and the enormous loss of innocent lives at Christmas.

It was these aspects that made it hard to find a ‘slot’ for the experience
– like unfinished cognitive business – and they led to intrusive thoughts
and rumination.

So there were these other ‘structural’ aspects to the disaster – worries
and even some quite factual questions which still bothered them many months
later. It seems there was little communication, no one talked about it in
an informed or structured way. But talking is very important, and could
quite easily have put many issues to rest. Research has found that there
is an inverse relationship between confronting an upsetting experience by
talking about it, and the tendency to obsessively think about it.

Disclosing with others like this depends on who it is with: it is important
that they share mutual experience, which suggests that properly trained
peers or supervisors would be good. Talking about something can also force
possibly idosyncratic perceptions and feelings into words, taking them out
of introspection and diminishing the opportunity for myth-making and rumination.

Rather than being ‘soft’, as distinct from ‘tough’, this approach treats
disaster workers like adults who can deal with information, and who need
this information to make sense of their work. It is essential for psychological
health.

Physical health is also at stake. Introspection and rumination tire
the body and lead to psychological vulnerability. Not only that, but stress-related
illness such as high blood pressure and ulcers can develop, and the body
becomes more vulnerable to disease. And a preoccupied mind leads to accidents.
In the year following their duty at Lockerbie, a sample of police officers
who worked in the mortuary took over 30 per cent more sick leave, compared
with only 4 per cent more for the rest of the force.

The old ways of denying problems are not the best, nor are the new ways
of providing counselling which miss the mark by focusing only on the emotional
reponse to trauma. The cognitive approach suggests psychological support
that is specific to the experiences of disaster and emergency workers and
which will foster in them real toughness and real resilience, in a way that
denial never, ever could.

Margaret Mitchell worked with David McLay, Chief Medical Officer at
Strathclyde Police, in research on the effects on police officers of their
duty at Lockerbie.