The subject of this post is a paper I just read online published in the American Journal of Psychiatry. I usually only glance at the subject lines of articles and dismiss them, because they are usually about psycho-active drugs. This time the title focused on the roots of mental illness. The link included an interview by Stephen M. Strakowski, MD. with the authors of the paper entitled:
The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders
For the DID community, and for society in general, this is a critically important topic. The title of the paper speaks for itself. I have been fighting for years to elicit recognition of this. As of the date of my reading, there were 52 comments at the end of the article, representing a fair cross-section of psychiatrists today.
As noted in my previous post regarding progress in the DID community, and the (mostly) lack of progress in the therapeutic community treating DID, it is of grave concern to me. I wanted to know if psychiatrists of this generation have moved on. Or, are they still dismissing the serious consequence of early childhood trauma and neglect like my contemporaries. Because I have been retired for more than a decade, I try to follow this issue in journals.
I remain disappointed. While the article, interview and research are spot on – highlighting the deep and ongoing impact of trauma, many readers of the article are still harbouring, defending and promoting their old ignorance. They remain committed to their mis-understanding of psychological trauma, about the nature of traumatic memory, and fail to see the presence and impact of trauma in their daily clinical work. I have addressed the common questions, listed in quotations below, that readers of the article raised.
[1] “Most importantly, just how accurate are these reports? What are the biases present? Considerable research has shown that human memory is notoriously faulty.”
In assessing traumatic memory, we are concerned with the effect of the trauma on the patient’s current functioning. The fact that exact details are not accessible precisely is of no significance. If a child has been raped, I don’t care if her recall is not precisely accurate. The inability to accurately identify the culprit’s height and weight, or the crime scene’s exact detail. This is the nature of traumatic memory.
In my book series Engaging Multiple Personalities, I wrote, “It is dangerous to use our own ability to access non-traumatic memories as a standard against which we judge a trauma victim’s response.” Clinicians should not be bogged down worrying about individual minor details of the event, but instead should focus on the clarity of the emotional memory. Otherwise, they will continue to ignore the effect of the past trauma on their patient’s present functioning.
[2] “Do those answering questionnaires often do so subconsciously wanting to please or support the expert asking the question? Are those suffering in other ways predisposed to emphasize past negative experiences?”
There is this persistent charge that we help create false memories in our patients. It is no doubt left over from the 1980s which saw a sudden rise court cases of victims accusing their parents or care takers of sexual abuse. The pendulum does swing well over the median in any social phenomenon when it first arises, but that simply means we should examine our own biases as well as the statistical likelihood of abuse. We must maintain an appropriate index of suspicion – particularly when encountering depression that is drug resistant.
[3] “How often are accounts independently verified?”
This fails to acknowledge that most abuse occurs behind closed doors where the only witnesses are the abuser(s) and the abused. The demand for independent verification ignores the fact that the trauma can be identified enough to know that something bad happened by its impact on a patient’s current presentation.
[4] “As the preceding comments show, there is always an abundance of anecdotes. What is needed is hard questioning scientific work and evidence closely scrutinized.”
It is common in challenging psychiatrists by dismissing what they do when they report on a single case. They call it anecdotal rather than “scientific” evidence. Anecdotal simply means that it is based on personal experience rather than formal research. Formal research is fine, just as the article that provoked these responses was based on a large study. Nevertheless, there is so much anecdotal evidence that psychiatrists should not wait to adjust their index of suspicion when encountering patients who likely have trauma in their background. If a patient experiences multiple treatment failure by psychiatrists who only used pharmacological agents, and showed recovery or significant improvement following psychotherapy, surely any inquiring mind would seek to find out the reason. Common sense, empathy and compassion suggests that therapists should at the very least start questioning the lack of humanistic aspect in merely prescribing psycho-active medication as the sum total of the therapeutic engagement.
We must reconsider the error of seeing all mental illness as a brain disease. In medical training, we all were taught that when considering a diagnostic formulation, we take into account, biological, psychological, social and noetic elements. It is amazing that today, in the name of “science”, psychiatrists have mostly turned into mechanistic pill pushers. This is science as defined by the pharmaceutical industry that has its own profit driven agenda – hence all the “off-label” recommendations they promote in Continuing Medical Education conferences. They infer that psychiatrists should feel proud that their work is “scientifically based” because they are prescribing pills to correct a “chemical imbalance.” This logic allows them to ignore social, psychological or spiritual factors in a patient’s life milieu. In fact, it is like prescribing insulin to pre-diabetic patients without asking whether or not they eat sugar saturated meals every day. There is only symptom management as the underlying cause is not being addressed. As a result, healing is not possible.
[5] “Maybe the most distressing aspect of some of this is the arrogance of those who purport to know what really happened… and the judgments laid on many families just trying to do their best.”
This is not about corporal punishment by an overworked house wife or an over-strict father, following the Biblical admonishment of “Spare the rod and spoil the child.” This is about someone, not necessarily a parent, engaging in sexual molestation, physical abuse, neglect, and betrayal trauma. It is about abuse, not about “spoiling” a child.
With respect to corporal punishment used by parents to discourage certain unwanted behaviors, one should consider whether or not the child automatically learns a different lesson, that one should use force if someone disagrees with you.
The significant factor in analyzing corporal punishment that may actually be abuse is whether that harsh physical punishment is given in the absence of love. In the absence of other supportive and loving people in the environment, corporal punishment will leave a permanent injury to the victim. Alice Miller has written amply on effect of early child abuse and trauma. Her books are thoughtful and practical.
[6] “There are millions of traumas a year, including those to children. Trauma is the common cold of psychiatry. Around 90% of people feel bad for a week, then forget about the trauma. This is analogous to having a cold.”
This reader should go back to the definition of psychological trauma, which means stress that overwhelms the system, leaving behind a gaping wound that refuses to heal by itself. The common cold does not devastate the patient. It is healed by one’s own healthy immune system. And yes, it is usually forgotten a few weeks later because its impact ends when your body finishes the healing process. The effects of child abuse and neglect last a life time. Even if it is not accessible to one’s declarative memory at any given time, the body keeps the score because the damage has not been healed. It often emerges in the form of symptoms like depression, rage, or self-harm rather than an accessible declarative memory.
[7] “Those who are affected by trauma have pre-existing conditions or genetic vulnerabilities to it.”
This reminds me of what happens when patients are labeled as suffering from a personality disorder. This unfortunate and common practice implies that the patient has to live with the dysfunction or disability because of constitutional factors. Effectively, is it saying: “You are born with an inability to handle distress. You may as well learn to live with it. Just get over it.”
Finding a pre-existing condition to explain a patient’s vulnerabilities does not help. The main problem in understanding and accepting the connection of early abuse and neglect to their consequence of dysfunction in later life is the difficulty in finding a concise, easy to apply treatment – such as a medication. But, there are no medications that heal early childhood trauma. Psychiatrists perhaps feel threatened and insecure when we face a case for which we have to employ full empathy, exercise compassion and be fully genuine when facing another human being who is experiencing this level of psychological pain. Pharmaceutical companies and their affiliated conferences/training programs promote simple clear cut mechanistic approaches, as if the human mind is like fixing car or draining of an abscess.
Psychiatry is, or used to be, predicated on a deep understanding of the need to engage with empathy, a positive regard, and a genuine openness on the part of the therapist. Carl Rogers named the three essential attitudes necessary for a therapist to be of benefit: congruence (genuineness), unconditioned positive regard, and empathy. This comes with deep listening. It is far from a mechanistic cold surgical procedure or prescription pad.
I believe this view is much more important than EMDR (eye movement desensitization and reprocessing,) or CBT (cognitive behavior therapy), which are listed as the recognized treatment procedure for trauma based PTSD, for different kinds of dissociative disorder, and disabling emotion of depression, anxiety, panic disorder. In and of themselves, no doubt they are helpful for some patients, and more helpful in the hands of well trained and empathetic therapists. But, we should understand that EMDR and CBT are just tools. They are like scalpels: It is only in the hands of a skillful surgeon that a scalpel becomes a truly useful tool.
The real problem is the difficulty to finding therapists who understand the need to be grounded in empathy. Less important is the number of years of training or how many diplomas are in the office walls. Not enough attention is paid to the humanistic issues.
In medical schools we were all taught that when considering a clinical problem, we need to consider the biological, psychological, social and noetic roots. This has not changed and will not change in all worthwhile medical institutions wherever they are found. It is unfortunate that for many psychiatrists once graduated and licensed to practice, these consideration are soon forgotten. When such simple rules are forgotten, it is easy for a materialistic philosophy to take over. Financial consideration takes precedence and, as a result, one become more easily swayed by pharmaceutical company marketing.
Just consider a hypothetical child who is inattentive in school and gets a quick diagnosis of ADHD. If no one is interested in identifying his concern that his parents are fighting every night to the point of violence, is the critical diagnosis of ADHD all you need to come to?
We must do better than this. Real advances in psychiatry will require getting back to its roots of empathy and compassion. Let us all push ahead step-by-step in the right direction.
