Wednesday, October 5, 2011

You Want to Talk About Mental Health, Then Let's Talk Trauma

Ho hum, another week to make us aware of mental health problems, and to help bring an end to the stigma that accompanies mental illness.

Forgive me if I am less than excited, cynical even. Expressing such feelings, I wrote a two-part blog about the Canadian Mental Health Association's version of mental health week this last spring. Here is Part 1 and Part 2.

My problems with both CMHA's Mental Health Week, and now this autumn version from the Canadian Alliance on Mental Illness and Mental Health is that they skim over the surface of what needs to be communicated with the public.

The problem isn't just stigma on the part of the public, or that people are unaware, though it's important to deal with each. There's also a problem of stigma and lack of awareness among mental health care professionals, including psychiatrists and nurses in mental health.

The current Mental Health Week from Oct.2 to 8 honors people who have lived with mental illness. I am always glad to honor those with mental illness, who have done well in overcoming its limitations, and finding significant measures of healing. These people are heroes.

The problem is that these special weeks are essentially public relations exercises, which too often seem to me to leave people with a sanitized and superficial sense of today's mental health issues. They only present the tip of the ice berg, and if that's all we keep on doing once or twice a year we are not likely to make much progress.

More to the point, the tip of the ice berg hardly gives us a clue as to what lies beneath the surface, and why it is so vital we identify and deal with what is hidden. In mental health, in so many ways, we are dealing with the secrets and what is hidden; the more we remove what is hidden and disclose secrets, the closer we come to having a healthy understanding of mental health problems, and attitudes worthy of a well informed public.

So here, let me drop a statistic on you: From 50 to 70 per cent of people admitted to in-patient psychiatric units or to out-patient programs have some history of childhood sexual abuse or trauma. We've known that for well over a decade.

But if you look at the diagnoses and treatment plans for these patients, most often you'll see damn little that reflects their trauma hsitories. You'll find the usual mood disorders and personality disorders, but very seldom a diagnost of PTSD. As long as we go on treating mood disorders and personality disorders, with no appreciation of underlying trauma issues, we will fail to get the robust results in treatment for which we hope.

The general public doesn't know that.

The general public doesn't know that many hospital psych units and mental health practices make it clear they do not deal with trauma issues or childhood sexual abuse. I worked at a major tertiary care  hospital where I was told we didn't deal with sexual trauma issues because it was an acute care facility, and trauma treatment was long term.

Only a few of us actively deconstructed that seemingly respectable "out" for not dealing with trauma issues. We appreciated how some of our patients told us they felt when they wanted to talk about sexual trauma, and were shut down. In that context, I was a chaplain. Patients could self-refer to me, and many did because the word went around that I would listen and honor whatever they brought to me. The psychiatrists and nurses who felt they couldn't deal with sexual trauma in an acute ward, paid short shrift to the commonly accepted wisdom that patients will often initiate voluntarily a discussion of their sexual trauma when they are ready.

The general public doesn't know that a lot of psychiatrists and other therapists do not/will not do trauma therapy even in those cases when a first year psych resident taking a basic history would be able to document significant trauma. Very often, whether by the residents or the attending psychiatrists the right questions are not being asked. If they were asked, the case conceptualizations for these patients would be different, as would the subsequent treatment plans.

And I haven't even touched the issue of borderline personality disorder and other personality disorders which often co-occur with poor childhood attachment and subsequent traumas, especially childhood sexual trauma.

In such cases, in many professional psychiatric settings, a genunine hostility toward such patients develops and, contrary to the literature, psychiatrists, nurses, and others perpetuate a mythology that such patients can't really be helped, that they are manipulative, and that they don't really want to help themselves. I have, categorically, found all of that to be untrue, initially in terms of my own clinical observations as a chaplain, and then, in the literature, after I began my learning as a therapist. Further, I find basing professional practice on such mythology, and perpetuating such beliefs if prejudicial toward patients, lacks basic respect and compassion, and most to the point, denies out patients their rights and needs to the very best of mental health care we can offer.

The professional responses described above are the ultimate in stigmatizing patients - and from the very people who should know better. The resulting stigma, I dare say, is far worse than that arising from a poorly informed public.

So mental health weeks, these nice little public relations events which make us feel warm and fuzzy, and perhaps make a few people sufficiently aware that their attiudes will change, are nice. And it may delude a few people in not-for-profits into believing they are doing something substantive, while giving a chance for pharmaceutical companies, and others who have a stake in the mental illness business to feel good about themselves.

Meanwhile, those of us who have worked with the whole range of mental illness, and who do not refrain from identifying and assessing such contributing factors as early attachment, trauma hisotry, and so on, are left feeling we live in different world. That's mainly because we do live in a different world - one where we want to identify and work with a patient's core issues, no matter how difficult or challenging or messy it is for us.

I have worked as a chaplain and a therapist. At least 75% of my patients and clients have experienced significant trauma, most often childhood sexual abuse. In addition to that patient cohort I've worked with new immigrants, refugees, and former combatants, who in addition to sexual traumas have experienced trauma from combat, torture, from living in the midst of civil strife.

When I reflect on the many people I have worked with since the 90s my unfortunate observation is that more often than not, their psychiatrists have not been interested in learning about their trauma histories, though that could have lead to more effective psychotherapy and medications.

In addition, and very sadly, I've found that psychiatrists, ward staff, and other professionals are often uninterested in having a meaningful, and evidence-based discussion, about patients whose main issue is borderline personality disorder.

To make matters worse, the United Stated and Canada have growing numbers of combat veterans, suffering from all that follows exposure to combat trauma including PTSD. Vets have unique problems dealing with PTSD because, though they are in the relative safety of home, their experiences of basic training and combat exposure have created a massive cultural shift for them. Back home, many vets feel they no longer fit in with their families and friends. They are strangers in their own home communities. Such feelings heighten the pain, complexity, and risks of PTSD. Not surprisingly, we see many examples of vets who act out in various ways, experience varying levels of psychosis, and who even attempt to kill themselves.

As a chaplain, as a therapist, I say categorically we have enough empricially validated data to be able to design treatment programs for our vets who have returned home, as well as the millions of people in North America who suffer decades after experiencing childhood sexual abuse and other traumas.

Why don't the mental health associations who say they're concerned about stigma and awareness dig a little deeper, and show a willingness to do the anti-stigma and awareness building work which clearly needs to be done?

And instead of focusing the pr guns solely on the public, bite the bullet and realize that some of those who most perpetuate stigma, lack of awareness, and even ignorance are among the medical profession and others who work with people with mental health problems.

If I can see signs our mental health organizations are digging deeper and putting some of the onus on us professionals, then perhaps I will be less cynical about mental health weeks and various pr events focused on mental illness and mental health.


  1. In a situation with a patient who had been brutalized by police for many years, and whose chronic depression (rendering him disabled and on a disability pension) and PTSD were directly as a result of that trauma, he experienced the most shocking behavior by so-called therapists. Clearly, they were not familiar enough with PTSD to be treating him. When he was triggered by recounting his trauma, and had a classic angry outburst, all THREE therapists reacted by calling police, and turning him back over to his abusers.

    While it is true he said things like "They will pay for what they've done to me" it was also clear (had these "therapists" taken the time to get to know their patient) that this completely non-violent man was talking about legal remedies such as a law suit. He was NOT in any way indicating potential harm to himself or others. Therefore, the "duty to report" was merely an excuse and an "out" for these incompetent mental health workers to get rid of a patient they were ill-equipped to treat. In the 3rd case, knowing what had happened to him previously, the patient even had had a lawyer draw up a legal agreement which the therapist signed saying he would NOT call police, but call the lawyer first. The therapist breeched that agreement and the patient ended up back in the hands of those who had traumatized him.

    I am astounded at that colossal degree of unprofessionalism by people who are treating the most vulnerable patients.

  2. Trauma is another serious mental condition that is overlooked by many people. We don't realize the gravity of this condition until we experience it first hand. Some patients who are traumatized are not able to go back to their normal state of mind. Some of them live in paranoia and fear for the rest of their lives.

    autism lawyer