Friday, May 20, 2011

So What's Up With Mental Health Week? Part 2

Trauma and post traumatic stress disorder (PTSD) are more common than most people realize. As I said in the first part of this reflection on Mental Health Week, if depression is considered the common cold of mental health, then PTSD is the influenza - a virulent kind of flu which ranges from mild to deadly.

Every fall media and the public focus on the coming "flu season," and medical officers of health across Canada and the US are frequent media circuit visitors. But there is no season for trauma - year after year, month after month, trauma wreaks more havoc and costs more than any flu season in recent memory. It could be argued that even if the avian flu scare had materialized whether it would have been as expensive and deadly as the trauma experiences and aftermath millions of Canadians and Americans live with daily.

Trauma is the real pandemic facing us, but we seem prepared to do bloody little about it.

As far as I'm concerned, based on clinical experience and the literature, the facts support this perspective. Therefore,  it is beyond mystifying and ironic that the Canadian Mental Health Association (CMHA), which held its 60th annual Mental Health Week at the beginning of this month, essentially fails to recognize the frequency and seriousness of trauma in its public materials.

At the end of the First Part, I said, "There is a supreme irony in what I have been writing," and that I would disclose that irony in Part 2.

Let me name the irony in two words: Barbara Everett.

I met Everett almost 10 years ago when she spoke at a Winnipeg conference on ethics in mental health care. In her presentation, and personally, she reflected a knowledgeable and compassionate presence. As a result, I bought her book, which she wrote with Ruth Gallop: The Link Between Childhood Trauma and Mental Illness ~ Effective Interventions for Mental Health Professionals. This book ranks up there with Trauma and Recovery by Judith Herman, which I mentioned in Part 1.

When Everett wrote the book, and when I first met her, she was executive director of CMHA's Ontario Division.

How ironic! This irony loudly shouts out the disconnect in CMHA's public messaging between what is known and what is actually communicated. But CMHA is not alone in this regard.

Many other not-for-profits who have an information or advocacy role in mental health are not any better. And beside them would be some of the psychiatrists, psychologists, social workers, private agencies, hospitals and regional health authorities who have a professional responsibility for providing care. This problem, it needs be stated at the outset, exists among many professionals as much as it does among not-for-profit agencies such as CMHA.

Why does any of this matter, and why should it concern everyone?
  • People who have survived sexual and/or other serious trauma may be stigmatized, and receive either no treatment (though they may seek it), or substandard care. Two reasons for this are lack of funding for treatment, and an apparent unwillingness by government, insurers and other funders to increase spending in this area.
  • Many people, especially women, who have suffered serious trauma are diagnosed (sometimes incorrectly) with borderline personality disorder (BPD). Very often trauma issues, even if known to clinicians, are not dealt with once the BPD diagnosis is made. But that's not the only problem. As Everett and Gallop note in their book, "clients diagnosed with BPD are viewed so negatively by many professional staff that they often receive inadequate or inappropriate treatment and care." I have personally observed this problem in hospital and community settings in Winnipeg. Many of my own clients and patients have also complained of poor treatment, and little or no availability of treatment options which would focus on trauma.
  • Lack of sufficient and proper trauma care for all those in need ought to be considered as an inhumane act of omission by those whom society would generally look to as being knowledgeable and responsible in the mental health field. Inhumane because post traumatic stress problem create for many trauma survivors a kind of profound suffering which defies both belief and description. Exposure to the kind of suffering experienced by some trauma survivors is one cause of the distancing from trauma shown by some  professionals, agencies, and even some of the people responsible for clinical training of psychiatrists and psychologists. And, of course, the cost in dollars if accessible, high quality care was available.
  • Data offered by both Everett in The Link Between Childhood Trauma and Mental Illness and Herman in Trauma and Recovery: The Aftermath of Violence ~ from Domestic Abuse to Political Terror show a high prevalence of serious trauma in society. Some studies show childhood sexual abuse rates of 35% or more for women, and 20% or more for men. We know that according to a study quoted in Herman's book that 40% to 60% of people in out-patient psychiatric programs and 50% to 60% of  in-patients reported childhood sexual abuse. My experience suggests these figures are on the low side. In First Nations communities, whether in Canada or the US, childhood sexual abuse figures in the community at large may range from 70% to 90% or higher. Herman notes that "in one study of psychiatric emergency room patients, 70% had abuse histories." 
  • The suffering for abuse survivors is horrendous, and often leads to life-long inability to trust anyone, to form healthy relationships, or to fulfill potentials which often are obvious to clinicians taking the time to learn about their patients. Not surprisingly, on many alcohol and addiction in-patient units, one finds among the patients a frequency of trauma similar to what is found on the psychiatric units. And among these patients, are also the various psychiatric diagnoses which survivors are given, including BPD, depression, anxiety, bipolar disorder, and so on. While these diagnoses are not necessarily wrong, I have so often wondered why the very histories and symptoms of trauma have not resulted in the appropriate DSM4 diagnosis of post traumatic stress disorder.
It's beyond the scope of this post to do much other than make the point that trauma is the 800-pound gorilla in the room that many of those most responsible for providing information and effective, humane, and compassionate care seem so able to ignore.

Perhaps it was with that in mind that Everett and Gallup wrote:
Given the high prevalence rates of childhood trauma among psychiatric clients, it seems only sensible that inquiry should be mandated in all mental health settings. After all, it is unethical to ignore suffering, and clients "tell" all the time, in their life experiences, their behaviors, and their symptoms. In addition, knowing about an abuse history is central to understanding clients' other problems and is an important ingredient in comprehensive treatment plans and competent referrals.

Very early in my chaplaincy career, I found myself trying to respond as best I could to in-patients diagnosed with BDP, and who were generally being just "tolerated" on the ward. At times I questioned whether I was observing accurately, and whether my conclusions were correct.

I felt reassured, when I discovered what Herman had to say about about childhood sexual abuse survivors and others diagnosed with BPD, and two other diagnoses often given to survivors: dissociative identity disorder, or somatization disorder. As becomes apparent from reading Herman's words, she's saying that not only are professionals often not part of the solution, they also add to the problem, even revictimizing the survivor (italics added for emphasis):
Survivors of childhood abuse, like other traumatized people, are frequently misdiagnosed and mistreated in the mental health system. Because of the number and the complexity of their symptoms, their treatment is often fragmented and incomplete. Because of their characteristic difficulties in close relationships, they are particularly vulnerable to revictimization by caregivers. They may become engaged in ongoing, destructive interactions, in which the medical or mental health system replicates the behavior of the abusive family.
Patients, usually women, who receive these diagnoses evoke unusually intense reactions in caregivers. Their credibility is often suspect. They are frequently accused of manipulation or malingering. They are often the subject of furious and partisan controversy. Sometims they are frankly hated.
These three diagnoses are charged with pejorative meaning. The most notorious is the diagnosis of borderline personality disorder. This terms is frequently used within the mental health professions as little more than a sophisticated insult.
 The diagnoses Herman mentions also are given, correctly or otherwise, to people with traumas caused through something other than childhood sexual abuse, for example from combat, physical abuse as a child, torture at any age, kidnapping, etc. And though this post most frequently refers to childhood sexual abuse, much of what's been said remains relevant whatever the cause of the trauma. 

All that has been quoted here, I have observed. The problems exist till this day, and when attempts are made at providing better access and care, these efforts are usually thwarted by inadequate budgets and funding.

We should and must expect more from agencies whose own mandate is public awareness and advocacy, such as CMHA, when it comes to information and lobbying to resolve these problems.

And as much as we should expect more from these agencies, we should expect at least as much from the professionals and those who teach them. We have an ethical responsibility to respond well to whatever our clients and patients present. And if they present with trauma, so be it. I believe part of our ethical responsibility is to do what we can to change the fact too many people suffer from trauma which is either treated badly or not at all. Some of them simply suffer, and to a great degree often those close to them also suffer as cherished relationships are stressed and broken, and chaos seems to generally prevail. Sometimes, this suffering leads to suicide.

With no end to the causes of trauma in the foreseeable future, is it too much to expect a compassionate and humane response to the results of trauma? On the part of all concerned. Professionals who treat. Governments who provide funds. And private not-for-profits who should do far more advocating to both professionals and governments.

These books are worthwhile reading for clinicians, and for those training in psychiatry or psychology.The authors of both books are well respected.

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