Toward Better Care in Mental Health

Patients who have experienced complex (childhood) trauma or C-PTSD are frequently stigmatized by healthcare institutions, and ignored, misdiagnosed or worse if they attend clinics or hospitals (Benjamin, 2019). The very services they turn to for help often to treat them with disregard, disrespect, or contempt, especially if there are self-harm or suicidal symptoms, potentially re-enacting or repeating the original trauma which was relational. Often, patients report being treated like wayward adolescents, ignored, disrespected or at worst rendered powerless. Like a client of mine who felt suicidal and sought admission to protect herself from her own impulses, but then was discharged from hospital abruptly when she attempted suicide on the ward, with no clear safety plan.

Patients are effectively silenced with strong medications, ECT or other treatments which lack substantive evidence base, such as admission to hospital for long periods of time which has been shown to decrease positive outcomes in complex trauma( Fisher et al, 2015). While working as a nurse in the past I have observed many patients arriving at the hospital with large plastic bags filled with medication on admission. Instead of asking “what happened to you” as we should, many health professionals only ask ” do you have any risks?” or “do you want some seroquel?” There is little understanding of the long term impact of adverse childhood experiences(ACEs), the effectiveness or ineffectiveness of medications, the importance of a collaborative approach, or even the neuroscience of trauma and attachment despite decades of research. 

There is even less recognition of the various dissociative conditions that accompany complex trauma, ranging from “structural dissociation” (Steele et al) to depersonalisation, derealization or DID. ( Kezelman & Stavropoulos, 2019)

Why is this? Well, one of the reasons is that the practice of medicine is supposed to be evidence based- that is- relying on scientific studies that are well designed and free from bias, to inform best practice. This means that as the science evolves, ways of treating conditions should evolve too. However, in Australia the Diagnostic and Statistical Manual (DSM) is a widely relied upon taxonomy of mental health conditions with descriptions. In the medical world, there is growing concern about DSM, and both national and international research funding bodies are no longer supporting research proposals linked to DSM criteria as they are not valid or reliable(Benjamin, 2019).

DSM categories and descriptions are simply based on the opinions of psychiatrists in the US, who do not always listen to the opinion of subject matter experts.  Concerningly, it has been reported in the BMJ and by many others that up to 75% of these contributors to the DSM are funded directly or indirectly by drug companies (Moynihan, 2015).  Further, the drug companies have a publication bias which ignores drug trials which don’t further their marketing of drugs! (Wampold et. al, 2013) Drugs may also be declared safe for long term use after a trial of only six weeks. The editor of the British Medical Journal resigned in protest at this publication bias some years ago, but as yet no government will curtail Big Pharma as they risk losing their substantial political donations. Moynihan points out that in 2015, drug companies sponsored 30,000 “education events”, and his research shows that drug companies are ever lowering thresholds for the definition of many diseases to sell more product, for example ADHD medication.

DSM classifications are widely used by government, health insurance funds, and health professionals to communicate information about patients. This framework favours medication as the promary and often only treatment recommended for many conditions that are in fact the sequelae of complex trauma.

Patients are stigmatised by labels like Borderline Personality Disorder, and this contributes to the problem of creating a health care system with appropriate care and treatment for people with complex trauma symptoms. The labels imply that the problem is caused by or located purely in the patient, instead of co-locating the problem within the family and societal system. Many concerned doctors such as Bessel Van Der Kolk have written about this distortion of the therapeutic lens, and Bessel has tried strenuously to influence the medical DSM panels in their description and understanding of trauma. However, the panels have so far rejected the evidence and maintain DSM categories which are pejorative and unhelpful for best practice in treatment of complex trauma.

Very few organisations have properly or even partially implemented the Guidelines for Trauma Sensitive and Trauma Informed Service Delivery published in 2012 by the Blue Knot Foundation ( Formerly ASCA ), and revised in 2019.

Also using drugs as first line treatment means that patients are never taught the skills and attitudes necessary to manage uncomfortable emotions like anxiety and depression, to manage flashbacks or panic attacks, or to deal with the shame, fragmentation and loneliness of their condition. Over time, they may become more dependent on medication and less self- trusting and self-resourcing.

Yet due to funding costs in hospitals and lack of real support for staff, many clinicians are under so much pressure that they can scarcely listen to, let alone respond to in a thoughtful, respectful and collaborative way, to the patients who are presenting for help. Literally, their stress levels are so high their brains are “off line” a lot of the time. This often creates a massive over-response to and focus on “risk” or “safety” rather than care, choice and collaboration.

To be fair, clinicians are generally taught little about complex trauma during their training, but there is such a negative response to symptoms such as self harm that much leadership, reform and education will be needed before mainstream services change (Benjamin, 2019). We also need to be aware of ethical boundaries that prescribe how organisations, governments and individual clinicians should best respond to outside attempts to influence, including gifts, overseas travel, education, wine, food, gratuities and other incentives from drug companies, and seek greater transparency in research on drugs with supposed efficacy. Some work has been done on this in Australia but not enough in my opinion.

In the meantime, those of us who work closely with individuals with complex trauma must do what we can to educate and inspire change, where possible in our professional networks or groups, in addition to educating our clients. This website is part of my desire to support change!

In the next blog, I will turn to what Clinicians can do to work more effectively with patients suffering from complex trauma.

 

Clinician guidelines for working with complex trauma

Clinician Guidelines for Working with Complex Trauma

Part 1 

To work effectively with complex trauma, we must challenge habitual ways of doing therapy, unlearning old habits and making room for new ones. In this three part blog I explore why treatments and approaches have changed, some system problems that prevent effective treatment, suggest some ways in which working with trauma is different from traditional therapy and invite the clinician to cultivate the attitudes and qualities which are most helpful, and reflect current best practice in the field. I mention a number of world leaders in the field for those who wish to know more. 

What is Complex Trauma? 

The term complex trauma or C-PTSD has come to mean the type of trauma which is not a one-off event, and is relational. Complex trauma can include mental, physical or emotional cruelty or abuse, witnessing abuse done to others, or neglect. It can also include adverse experiences such as the loss of a significant caregiver eg through divorce or death.

The aftermath of this type of trauma shows up in relationships, where it is more difficult to trust others or ourselves. Survivors may feel too little or too much, be fragmented or compartmentalized, have difficulties with resilience, or have a cruel inner critic. They may carry intense shame or a sense of being unlovable for which there appears no antidote. This and a host of other problems of loving and living, shadow the lives of people who have experienced complex trauma. However, we also know that healing is possible.

Why has Trauma Treatment Changed?

We know a lot more now. For example, the Adverse Childhood Experiences Study (ACES) in the US is a longitudinal study of around 17,000 people, started in the eighties to help understand why some members of Kaiser Permanente health fund were obese. Researchers randomly picked ten criteria for the study. Unexpectedly, this study has since shown that the greater the number of adverse childhood experiences, the greater the risks of adverse sequelae- including physical, mental and emotional issues. Also, the signs and symptoms of adverse experiences may not show up for many years.

For more information, go to https://www.cdc.gov/violenceprevention/acestudy/

The ACES study tells us that people who have experienced complex trauma are more likely to have difficulty maintaining stable employment or stable relationships and are over represented among those who are admitted to hospital, attempt suicide or suffer from addictions.

Also, many branches of science have advanced massively in the last two decades. Fields including endocrinology and neuroscience are providing astonishing new facts about the brain and body which includes the discovery of neuroplasticity and a growing awareness of how stress harms the body.

Neuroplasticity is how we learn, and it is also the way the brain adapts to different environments to enable survival. Thanks to people like Schore and Siegal, we now know that how the brain works is shaped by the environment -especially our earliest experiences with people. Experience changes the brain, body, and emotions, and vice versa.

People with complex trauma show brain structure changes visible on scans, for example their amygdalas may be enlarged. Their nervous system is wired to be more sensitive to threat, harder to calm down or relax, or sometimes harder to get going. Stress hormones such as adrenaline are oversupplied, causing difficulties with sleep, gut and many other issues.

Steven Porge’s work tells us that when activated/anxious (in Sympathetic Nervous System arousal) we cannot listen properly, make good decisions, or digest the past. Therefore it is essential to help create a calm and settled state in the patient before we start any therapy. 

Also, many survivors of childhood trauma carry implicit or procedural patterns, tendencies and memories in the body. These are not accessible via the prefrontal cortex (thinking brain), eg wordless terror, shame or disgust that is pre-verbal- so doing talk therapy alone is of limited usefulness. 

There is higher risk of mental health issues such as depression and anxiety, addictions, psychosis, paranoia or OCD, difficulty regulating emotions, and more risk of physical health issues such as obesity or other food issues, sleep disturbances, poor self-care, chronic pain issues, sexually transmitted diseases, heart attacks and immune system disorders among other consequences.

Clinicians who are untrained in complex trauma may try their best to treat the presenting symptoms while missing the underlying cause. In a recent report in the Neuropsychotherapist, they report on a study showing childhood trauma is often missed or not enquired about at all by treating clinicians.

Luckily, there is growing momentum in the world, from people like Lou Cozolino, Allan Schore, Bessel Van Der Kolk, David Wallin, Steven Porges, Pat Ogden, Janina Fisher, Martin Tiescher, Peter Rossouw and Dan Siegal. These are among the many new thought leaders that are inspiring change and illuminating the path for effective treatment for complex trauma. Interestingly, there is a limited role for medication in the new paradigm, as the biological approach is not effective on its own.

For example, Porge’s polyvagal theory has been widely adopted as part of the new understanding of how the nervous system is impacted by complex trauma, and what to do about this. His theory is, in my experience, extremely useful, as it explains and normalizes many common difficulties, and leads to many non- drug ways of treating distressed states.

Pioneers like Janina Fisher have adapted the work of Richard Schwarz (Inner Family Systems) to help work with the complexity of the individual who is fragmented in both subtle and obvious ways.

Based on research by the Blue Knot Foundation (formerly ASCA – see ASCA Guidelines for Trauma Informed and Trauma Sensitive Service Delivery, 2012), it is recommended that clinicians who work with complex trauma are trained in at least three different modalities, at least one of which is body oriented.

We who work in the field should also be aware of the broader societal issues that impact care and treatment for this already disadvantaged group, and be able to advocate for education and change where this is appropriate.

In summary, over the last two decades there has been a revolution in the treatment of complex trauma, moving away from traditional labels or approaches to encourage a more holistic framework which includes the body and relies less on talking or simply taking medication.

 

In the next blog I will write more about the system issues that impact effective treatment, and in the third and final blog for clinicians to start the year off I write about how to shape practices to be more consistent with world best practice in treating complex trauma.

International Trauma Conference in Melbourne, 2016

I haven’t had time to attend the whole thing, but it is amazing to see over 2000 delegates here in Melbourne for the conference this week. As usual Pat Ogden, Stephen Porges, and Allan Schore are here, and inspiring.  This year I have enjoyed Martin Teicher, Dan Siegal and others. Martin shares some wonderful scientific research results on the aftermath of trauma, you can find it on Google, WordPress, by adding his name.

Trauma is still the “elephant in the room” in terms of public health policy, and is still missing from public discussions except in a very limited way. The survivor is still all too often blamed (via the rigid DSM criteria which is not evidence based, if not the Catholic church, the defence forces, etc), for their symptoms. Actually, I believe survivors are incredibly brave, tenacious and valiant to have survived, especially when we review the outcomes from the ACES study in the USA.

This study as reported by Martin shows the significant long term effects of adverse childhood experiences. Basically the higher the number of adverse experiences, the more likely the person is to have not just emotional and cognitive consequences, but also physical consequences including changes right down to the genetic level, heart attacks, addictions etc.

So this week I really feel inspired to acknowledge and thank all the scientists, clinicians and others who have travelled from US, UK and Europe to be here for the Conference. A special nod to Sue Carter re the importance of oxytocin in love and bonding. And to Dan Hughes for bringing such warmth and humour to this difficult topic.

Their long labours  research and experience in working with trauma now give us a legitimate voice to begin a more sophisticated and compassionate public discussion about how we view and treat trauma survivors. The Royal Commission into Institutional Abuse misses the great majority of abuse which occurs at the hands of family.

The science also enables us to confidently say that trauma can be healed. And finally, perhaps, we can now stop judging and blaming victims, and work together to ensure they are honoured and supported throughout the healing process.