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

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.