An Alternative Framework for Mental Health

For many years I wanted a better framework for best practice than the current bio-medical model which pathologizes symptoms of complex trauma as a “disease” and “biological” state-without evidence! Apart from the disrespect inherent in putting labels on people who have already suffered multiple adverse experiences, it doesn’t make sense that this reductionist way of supposedly helping people is often causing more harm, leading to ongoing Royal Commissions that never seem to address the underlying structural problems in mental health care.

In Australia, the structural problems – including professional “language” and treatment approach for mental health- are driven by the DSM- the Diagnostic and Statistical Manual, revised and produced every few years by the American Psychiatric Association.  Within DSM criteria, people with complex trauma are often misdiagnosed or given labels like borderline personality disorder, Bipolar disorder, depression, generalised anxiety disorder, causing many kinds of mistreatment and mismanagement (Benjamin, 2019)

DSM started as a valiant way to understand mental health issues, developed by  Americans who didn’t like the flowery language of the existing International Classification of Diseases (ICD). However since then it has been largely taken over by white, middle-class US psychiatrists closely aligned with big Pharma. Since the eighties, Big Pharma has been gradually expanding the range of conditions classified as “disorders” in order to sell more drugs (Moynihan, 2018)

Hospital/service funding and practice now follows from these un-validated and unreliable labels, implying that one just needs to tip the right chemical into a brain to “sweeten” it. Those that can’t be “sweetened” chemically are called “outliers” by the system, or stigmatised for being “treatment resistant”, treated harshly in EDs or discharged prematurely even though very unwell or at risk. Psychotherapy is considered only as a last resort. Some of these people become the homeless that wander our street, mistrustful of the very services they have earlier turned to for help.

International trauma experts like Dr. Bessel Van Der Kolk struggle to be heard over the vested interests who find profit and convenience in the current DSM system. Multiple inquiries into mental health over decades show this system is not working. Marginalised groups such as mental health consumers seem invisible to DSM oriented practitioners. It is faster, easier and more profitable to offer drugs like “Quietipine” (to quieten the patient), than to sit beside those who are suffering or try to understand trauma systemically.

A huge shortcoming of the DSM model is that it locates the problem solely in the person, and ignores the systems and environment that created the problem in the first place. As identified by the Division of Clinical Psychology (DCP) of the British Psychological Society:

“The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a “disease” model.” (DCP, 2013, p. 1)

Indeed, the DSM system is so low in research validity and reliability that two of the largest international research funding bodies have stopped allowing DSM criteria as the basis for medical research. However organisations that promote DSM are very powerful and influential, with deep pockets and ongoing political lobbying.

The Power Threat Meaning Framework developed by members of the British Psychological Society offers a new and compelling alternative to the DSM, that appears to have a more valid and ethical way of making sense of trauma symptoms without “labelling” of symptoms including mental distress, unusual experiences and problematic behaviour. It was developed over a five year period in the UK, by researchers who looked for an evidence base for best practice in working with trauma – supported by what we know from decades of research about the causes of trauma, which are often transgenerational and systemic.

Trauma is exacerbated by disrupted early attachments and imbalances of power and the inherent inequalities that lead to abuses of power and privilege. They assert that the many symptoms of trauma are simply a survival-based adaptation to the original situation, for example hypervigilance or dissociation originating from having to survive an unpredictable or unsafe environment. This view is shared by many international trauma experts including Bessel Van Der Kolk, Janina Fisher, Pat Ogden, Lou Cozolino and Judith Hermann.

Recently the Australian Childhood Foundation sponsored the author of the new framework to speak to professionals and consumers about this model. More information about this model can be found here in power threat meaning framework intro 2018, written by the authors of the study.

The authors

Working Gently with Embodied Awareness

 Most modern trauma psychotherapy treatments aim to include the body in some way in the work of healing trauma.

Yet many patients with complex trauma conditions have an understandable phobia about noticing  their body, or are numb or dissociated from their body. Body awareness often triggers a danger response or feels unsafe in some way.

For example, health professionals may start by inviting patients to practice mindfulness, eg with the breath, only to find that simply focusing on the breath has inadvertently triggered a fight/ flight/ freeze/ dissociation or hypervigilance response. So it is essential to approach any body work with great caution, respect, gentleness and preparation!

Preferably, the health professional will  undertake additional training in somatic modality  such as sensorimotor psychotherapy or somatic experiencing before attempting any such work, and will also be aware of their own transference and countertransference through their own in depth personal psychotherapy experience. I add this caution as untold harm is possible via unaware or unskilled interventions when working with the body. Please do not attempt this unless you are professionally prepared!

How do we work safely with the body? There is a four step process that can help to set this up. This week we will discuss step one, which is setting the stage properly, to create the optimal setting before beginning any body work.

According to Dr. Andy Harkin, a Sensorimotor Psychotherapist from the UK now living in Australia, we need to be clear with the patient HOW we are working with the body as well as WHY. He talks about this on youtube

So, ideally, we could start with Psychoeducation, right? Hmm, not so fast! What if the patient is not ready for this? Patients at the more complex end of the trauma spectrum will probably need preparation, prior to the apparently simple step of psychoeducation.

There is no point trying to educate if a person is in sympathetic nervous system hyperarousal. Their frontal lobes are effectively “offline” for survival reasons, so the capacity to absorb information is greatly reduced, and if they are distressed enough they will quite probably misperceive what is being said as their system is primed to detect danger to help them survive. Ideally, education is not offered until the patient is as calm and settled as possible.

So first step, ensure that you the therapist are calm and grounded, quiet and still, and let your nervous system, body and voice help the patient settle into a calmer state. Explain what you are doing simply. Your limbic system and mirror cells really can help, as calmness is contagious!

At this stage, you are not aiming for the person to be totally relaxed, nor are you beginning to talk about any trauma. Instead, you are just aiming to practice being present with the patient in a way that offers a small amount of relief from SNS symptoms if they are in hyperarousal. A calm gentle presence, some quiet reassuring words, and just sitting.

For some patients, you can invite and co-create small experiments to foster collaboration in helping the room to feel calmer, for example adjusting blinds or reducing lighting a little, adjusting the position or distance of the chairs, adjusting how you are both facing in relation to each other.

It is important to focus on CALMNESS instead of SAFETY. Saying the word “safety” can often trigger hypervigilance and hyperarousal in complex trauma patients.

Some patients feel calmer if they have something to squeeze or hold, a cushion or soft fabric. Some people need to stand up to feel calmer, this seems to be true especially where the spine is collapsed or the posture is slumped. Also, orienting to the room and then naming the date and time can help. Ask the patient to simply notice “calmer” or “less calm” inside the room. Use hand signals not words to communicate regarding this.

Avoid the impulse to DO something such as talking incessantly or writing out a prescription and instead practice just BEING with the patient in a calm and respectful manner.

Sometimes, depending on the patient and situation, being light and playful can also help. Depending on the patient, sometimes I scrunch up and toss paper balls, do side by side colouring in, roll or push large gym balls, play peekaboo, squeeze playdough, ask them to pass something in a funny voice etc.

You may spend hours, weeks or months like this with the patient, helping them to develop a felt sense of calmness and tranquillity in the room, helping them learn to soothe and settle, and gently explaining why this is the foundation for the work of healing. This is body work, as you are helping the patients body, brain and nervous system get used to the unfamiliar state of being in the window of tolerance.

As they begin to settle, you will be able to offer more in the way of psychoeducation. Although you may have very intelligent and sophisticated patients, it is important that the learning material is simplified initially. In my experience, even the word Amygdala can cause panic!

Choose your learning materials- visual, tactile, olfactory, toys and other objects- carefully and allow time and opportunity to absorb the information before you give more. Visual aids or videos are useful for this, for example the 3D Brain App. You can make your own aids or purchase from Janina Fisher and many other international sources.  For the patient with hyperarousal, slow is always better, and you must be able to hold that space and repeatedly explain to the patient why you cannot rush, especially healing!

Now you are ready to explain in detail how trauma affects the body systems and processes, in a way that is appropriate for your patient.  You can also begin to educate about the importance of learning mindfulness at this stage and perhaps now begin to notice mindfully together the experience of being calmer.

To strengthen the patient’s commitment to the work of healing, it makes sense that you practice what you are teaching including developing capacity for interoception, awareness of subtle changes in your own body, and being able to develop a wide vocabulary for describing what you notice. The therapist’s capacity to be embodied greatly enhances the possibility that the patient will eventually learn something more about embodiment.

Next, and before approaching any work with the body, it is important to negotiate conscious permission giving from the person to do the work of healing. This will require negotiation with all the parts if structural dissociation or DID are present. Respect for the patient and their parts is critical at this point. Do not start any body work without permission being established. Do not ignore parts who are undecided. Do not rush this step! We will discuss the art and science embedded in the process of permission giving as part of the forthcoming trainings to be offered next year for health professionals.

The above approach is based on the work of prominent trauma leaders as described elsewhere on this site, and my own experiences as a practitioner working with complex trauma, dissociation and DID. Your views and comments about this post are welcome.

 

 

 

 

 

 

 

 

 

DIY Healing Trauma

Settling skills

There are many ways to begin to heal trauma. Before we contact any aspect of trauma, we start by learning how to manage uncomfortable emotions. Safety and stabilization, the ability to tolerate distress and to return also from a state of numbness or dissociation, are all important foundational skills to begin the process of healing trauma.

Attached is a handout I sometimes use with some basic tools and skills. I would be interested in your feedback

How the Health System Harms Trauma Patients

Trauma treatment is a field which has evolved perhaps more radically than any other field of medicine in the last 20 years, but is still harming patients.

Driven by many breakthroughs in neuroscience we have a better understanding of how the brain as a whole works, including the effects of long term trauma and mis-attunement on the brain and nervous system, the discovery of mirror cells, the importance of nervous system and emotional regulation to prevent re-traumatisation during therapy, the significance of the therapeutic alliance, and the astonishing range of survival strategies and structural dissociations which allow humans to survive otherwise impossible ordeals. All this on top of the incredible discovery of neuroplasticity which now offers the potential for a cure to what were previously believed untreatable trauma symptoms.

New knowledge however, takes a long time to spread. For example, some health professionals  still prescribe Betadine for wounds, even though we have known since the eighties that it actually irritates skin tissue and impairs healing!

Likewise, I’ve noticed that a good number of health professionals seem almost entirely ignorant of these last two decades of scientific advances in understanding trauma, still working conceptually within the old, “biological” model. The biological model, favoured by drug companies, is where one simply tips in some chemical to “sweeten” a brain that seems a little sour after trauma. Drugs, drugs, drugs. Take some more drugs, please.

This seems to be the default position today. If, after many months of trialling drugs you say don’t want more drugs, and you want to try and learn to manage the emotional distress yourself, you are somehow being a difficult patient! In fact, one of the primary drugs used for trauma patients, Seroquel, was originally marketed as Quietipine- the drug to quieten troublesome patients! So patients are apparently supposed to shut up and take their medicine.

This despite the fact that international expert bodies such as ISSTD do not recommend drugs as first line treatment for complex trauma and dissociation.

“By the way, we are going to treat you like a wilful, wayward child, not like an adult who suffers from long term serious symptoms of trauma. “Putting in boundaries” becomes an excuse to adopt a punishing stance which blames you for your trauma symptoms.” Many studies now show that the very places that people go to for help often retraumatise them or leave them feeling belittled and ashamed. 

I suspect that for evidence-based practice to be possible, there has to be an open mind, space for new learning. In a way, we have to be innocent and adopt what the Buddhists call “beginners mind”. When any health professional holds the position of being “expert”, it is so much harder to learn, let alone take in the huge amount of new scientific knowledge that allows us to treat trauma safely and effectively.

As the ASCA guidelines for trauma sensitive service delivery (2012) explain, it is clear that many times, the patient, who goes to hospital or other health services for help, is actually further traumatised and re-traumatised by the very system that should be helping. I believe that unless health professionals inform themselves and adopt more evidence based practice, this will never change.

Since I wrote this blog in 2014, ASCA, now called the Blue Knot Foundation, has published another comprehensive update on best practice in the treatment of  complex trauma, in 2019 (Kezelman & Stavropolous ). In June 2020 as I review this blog, I believe that today even more than before it is an ethical imperative for all health professionals to be trauma informed, especially with the world in the crisis state it is now in.