Seeking Safety from Trauma

Over the last decade we have seen a deluge of spilled ink and sermons delivered on the topic of Trauma (capital letter intended).   Therapists and other clinicians are wont to see Trauma as the cause of all mental/emotional distress and disorder.  Payers and regulators want to see Trauma informed care as the standard for all services.

Please don't misunderstand and think I am about to argue against trauma as a factor of etiology.  I am not.  Please do not think I am going argue against trauma sensitive care.  I am not.

I do, however, have to take issue with a number of things.  One of which, I will briefly introduce here, is an intuitive response to emotional trauma (or the vision of Trauma in the mind's eye of the therapist).  I have noticed a tendency among my colleagues to fix Trauma through the exclusive use of invoking Safety (capital letter intended).

What is Safety?  It is a mythical destination we point people to who we believe are wounded by emotional trauma.  In its simplest and cliched manifestation, it is the "safe place" we tell people to go to inside themselves when they are distressed by Traumas past or current.  In its most Utopian manifestation, it is the construction (socially and physically) of a space (or whole communities) designed to remove all sources of trauma and reminders of trauma.  A Safe place is a place where people speak to each other exclusively in soft and supportive tones.  A Safe place has no rules to remind us we are not in control.  In a Safe place no one tells me I am wrong.  A Safe place is a place without "no".

The idea of creating Safety seems to come to some practitioners by intuition and without need for training.  For other practitioners (e.g., Sandra Bloom) it is a treatment model that is bottled, trademarked and sold, but more than that it is a morally driven world view.  It is true by faith and has to be defended against the unbelieving (read: medical model).

Why do we need to create Safety?  Because Trauma doesn't just hurt in the moment, it continues to harm day after day, year after year.  Life's little annoyances and disappointments are more than they are.  They are reminders of the Trauma.  Triggers and re-triggers.  It harms even when the individual has no idea it continues to harm.  Why?  Because the clinician believes.  Sometimes the individual doesn't even know they were Traumatized.  In those cases, the true believing therapist has to help the individual remember . . . (we know where that leads).

That's the reasoning for it.  I can't fault the premise (that psychological trauma hurts), but I doubt the conclusions.

So then, does creating a Safe place help?  I feel the need to ask, if only because so many around me seem to take it on faith.

I haven't come across so much empirical evidence apart from the some apocryphal study about mice and cat hairs.  But maybe this Trauma-Safety dilemma has a corollary in Happiness?  Seeking Happiness for the Sad seems like a very similar impulse to me.  And in that realm I think we do have some evidence that tells us it is a fool's quest.  Turning Sadness into Happiness through the power of affirmations, replacing negative self talk with positive self talk, while intuitively sensible, turns out to be the psychological equivalent of trying to catch a rainbow.  Every time I tell myself I'm beautiful and smart and wonderful, the opposites of those things echo in the mind and I have to increase my affirmations louder and louder to myself, but in the end, affirmations in a vacuum do not lead to Happiness.

Could the quest for Safety be a similar fairy tale?  A nagging doubt tells me so.   The fact that no one questions it, makes me worry all the more.

• Focusing so exclusively on Safety paradoxically highlights an individual's vulnerability.
• Focusing so exclusively on past Trauma reifies victimhood and takes the person out of the here and now.
• By focusing on victimhood we take away a person's agency.
• By focusing on the past we can't change, we forget the here and now where a person actually does have the power to change things.
• By externalizing cause and effect we have taken all control away from the person.

Considering these things, is it any wonder that we see so many people taking part in this therapeutic approach sink deeper and deeper into dysfunction?

Bipolar Paradigm Swings

But seriously folks, there really is a problem with the trauma fad.  Just the other day, I had a therapist tell me, without blinking an eye, that 95% of mental illness is caused by trauma.  And, as you might imagine, coming from a therapist, the statement was made with the upmost in self-important tones with flavor highlights of virtuous condescension.

Yes, obviously, she read it off a brochure, or somewhere in all that blather on the web that has taken the place of brochures.  But where did this “fact” originate in the first place?

Looking back to the mid-20^th century, there were any number of theorists who promoted the idea that schizophrenia was caused by trauma, or at least, early childhood events and social environment.  Generally speaking, dating back to this era, we have the idea that a child bonds with a parent (the word “attachment” is quite chic at the moment), the parent psychologically hurts the child’s sense of self—typically through abuse, neglect or ambivalence (this is the basic trauma)—and, the child ultimately develops schizophrenia or just about any other diagnosis you can think of for that matter.  Here we have the infamous “schizophrenicgenic” mother who relates to her child in an ambivalent or abusive manner and causes the child to become insane in adulthood.  The theoretic underpinning is the (now dated) belief that schizophrenia is a result of a weak ego that disintegrates and is overwhelmed by the id when the subject is faced with the challenges and pressures of adult life.

Essentially, childhood trauma perpetrated by an adult (to who the child is bonded) results in the development of a weak ego.  A weak ego results (later in life) in flooding of impulses and internal stimuli emanating from the subconscious.  Hence, insanity.  Neat little theory and it was quite the rage in the 50’s but slowly declined in subsequent decades and by 1990 had very little following in professional circles.

You can dig even deeper into the intellectual history of psychology.  Freud comes to mind and he had his antecedents in previous beliefs about the causes of insanity going all the way back to Plato and Hippocrates.  Hippocrates, as you might imagine, saw insanity as caused by an imbalance of humors in the body, but Plato interpreted it as reason being overwhelmed by emotion (but before you get too excited keep in mind that Plato also advocated that people who were sick and not likely to contribute should simply be killed).  This is just to point out the old nature versus nurture or, more correctly, mind (or spirit) versus body debate goes way back to ancient times and has been with us ever since.

Fast forward:  Prozac was approved by the FDA in 1987.  One of the first atypical antipsychotics, Clozaril, was made available in 1989.  The schizophrenicgenic mother idea had been on the decline for a very long time and the biomedical model was on the rise, driven by pharmaceuticals and helped along by National Alliance for the Mentally Ill, an advocacy group whose core mission was to combat the blame-the-parents stigma resultant from the schizophrenicgenic mother hypothesis.

All this is really to point out the pendulum swing in mental health ideology.  The biomedical approach was on a high in the 1990’s, most famously expressed in the NAMI slogan, “Mental Illness Is a No-Fault Brain Disease.”  At the height of it, you couldn’t use the word trauma without being jumped on and re-educated on the biological basis of mental illness.

My, how things change.  In 15 years, things have more or less reversed, and clinicians are barraged with trademarked treatment models and consumer activists and mental health reform all aimed at eradicating what we were training people in 15 years ago.  Even key players in the designing of the DSM-III and IV are coming out publicly to denounce the very basis of psychiatric diagnosing.   Now the only word that matters is trauma.  Trauma is the cause of mental illness and the only possible cure is to understand and validate the trauma.  We seem to have come full circle.  Attachment theory again finds the source of all psychopathology to emanate from problems in early attachment and early developmental trauma.  We are pretty much back to the schizophrenicgenic mother concept in all but name.*

I exaggerate only slightly for emphasis.

The, I hope obvious, problem with all this is that these bipolar paradigm swings are not based on advances in knowledge so much as fickle swings in popular sentiment.

We are simply replacing one reductionist model (mental illness is a no-fault brain disease) with another reductionist model (95% of mental illness is caused by trauma).  Not that reductionism is all bad.  Even Stephen J. Gould pointed out the crucial importance of reductionism in the scientific process.  Newton described gravity with a simple but elegant formula.  Darwin reduced all that complex biological diversity down to a few core principles of evolution.  But, this is not what we are seeing in mental health.  Although it wears the cloak of empiricism, it looks a lot more like political ideology or hopeful religious beliefs.  It all comes down to wishful thinking.  People build treatment models and cherry pick research results, all in order to bolster what they already believe or what they want to believe.

The mental health field would be a much more healthy and functional endeavor if we all just decided to be honest with ourselves and each other.  We want to help people, but we don’t really know what the hell we are doing.

* Of course, as gender beliefs have changed over the years, it is now more likely that we will see the father as the source of trauma/abuse/neglect/ambivalence as opposed to the mother.

Recovery or Denial?

“The Recovery Model.”  It sure sounds good, don’t it?  Recovery is one of the now buzzwords.  So, what does it really mean?  Did someone find a cure for schizophrenia?  Because, if they did, it’s a well kept secret.

The recovery model promotes the idea that people can recover from mental illness.  This is an important concept for a lot of reasons, not the least of which is that it promises to counter the phenomenon of people getting labeled and institutionalized and then forgotten.  It challenges the neglectful attitude that people can’t get better.  It highlights the fact that some problem behaviors are actually a result of institutionalization and over-medication.  It provides hope.  These are good things.

It is also used by state human services departments as a rationale for cutting or even eliminating funding for secure residential care for people with severe psychiatric disabilities.  The result?  People with severe disabilities are forcibly moved to community placements, and if-and-when they don’t make it, they end up on the streets.

That sure-as-shit don’t sound like recovery to me.

The fact is, there are some people who will get better with treatment (or sometimes even without) and there are some with more severe conditions who will not recover and need continuing treatment and care.

Yet again, we have a treatment model that is not based on science, but on political and economic expediency and because there is so much political correctness and complacency in the system, very few seem willing to speak up about it.

Dr. Munetz put it with nicer words than I can muster in his letter to Psychiatric Services (APA journal):  Denial of Mental Illness

Maybe, just maybe, this is the beginning of an honest discussion of the issues.  That would be real hope.

An Outline of Farce in the Public Mental Health System

As I see it . . .
This is just a partial list to get started with.  Not in any particular order.

• Blind Advocates—There is a tendency among mental health workers to advocate blindly regardless of actual clinical need. This is far more true in the mental health system than is found in the developmental disability services arena or the addiction treatment arena.
• Blind advocates will misrepresent the truth about their clients to potential landlords, employers and even other mental health professionals in order to get their client whatever he or she wants without consideration for the fact that by not addressing the underlying problems they are simply setting their client up for another failure.
• Some professionals will implicitly or explicitly promote fraud as they look the other way when their clients lie about income and symptoms in order to maintain entitlements.
• We’re All Disabled—creation and promotion of disability. Some mental health professionals seem to be of the opinion that any client who comes to them or their program should get cash disability payments. Some go so far as to misrepresent the severity of the clients' condition in order to help them get disability. Very little thought seems to be given to the fact that someone who is not truly disabled will ultimately be detrimentally affected by being told they are now disabled (and shouldn’t work) and by being escorted into the Social Security trap.
• You Need My Help—nurturing or creating dependence on the therapist and the system. It is truly overwhelming how much of public mental health resources (Medicaid and Medicare) are channeled into treatment models that have no positive clinical outcomes except the promotion of more mental health services.
• Cherry Picking—therapists and programs who are only willing to work with favored (i.e., easy-to-work-with) clients and unwillingness to work with clients with actual severe disabilities with difficult behaviors associated with their disability. Where does this leave people with severe disabilities? Overcrowded state institutions or the street. Where is the compassion?
• Pseudoscience—use of pseudoscientic data to bolster vacuous treatment models. Just take a few examples, out of many:
• Eye Movement Desensitization and Reprocessing—belief that having a client track a moving finger or object with their gaze while concentrating on a stress inducing thought will reduce symptoms of mental illness.
• Neurolinguistic Programming—assumes that by tracking another's eye movements and language, an NLP trainer can shape the person's thoughts, feelings, and opinions (There is no hard evidence to back this up).
• Emotional Freedom Technique—tapping acupuncture points with your fingertips. The principle behind EFT is that negative emotions can cause disturbances in the body's “energy field.” Your tax dollars hard at work, tap, tap, tap . . .
• Diagnostic Fads—faddish use of popular diagnostic categories and treatment models. The result is overwhelming increases in certain diagnoses due to popularity rather than objective facts. There are a number of reasons behind diagnostic fashion crazes but the primary driving force seems to be a widespread culture of pathologization of day-to-day problems. People are increasingly demanding that personal and interpersonal problems be described through a disease model and treated with medications or other quick fixes. Added to this is the commercial pressure from the army of therapists out there looking for business and, of course, the massive influence of the pharmaceutical industry. Some examples of diagnostic fads:
• ADHD—this seemed to peak in the Nineties and was driven by schools, parents and society at large moving away from traditional methods of child discipline and seeking new forms of behavioral control for the modern child (Ritalin^Ò). In its heyday, in the late Nineties, some elementary schools had upwards of 25% of young boys diagnosed and on these medications. Its popularity has diminished, only a little, because of the rampant problem of boys and girls on amphetamine-based medications growing up (all too quickly) into methamphetamine addicts.
• Bipolar Disorder—this is a very real and serious disease. However, sadly, it is very poorly defined. Many professionals are confused by the diagnosis and do not really understand it. It has become a very convenient label to throw at anyone with mood and behavioral difficulties (gee, isn’t that the entire human race?). This diagnosis became very widespread in the Nineties and was, and still is, very popular among adults who just want something to deal with emotions that get in the way of professional and relationship successes. It got another boost in the 20-Ought decade when anti-depressant drugs were found to increase the likelihood of teen suicide. The solution? Yeah, we'll just slap a Bipolar label on ‘em and feed ‘em Lithium Carbonate for breakfast. Problem solved.
• Dissociative Identity Disorder (AKA Multiple Personalities)—Where do you even begin with this one? So for one thing, it’s very very questionable whether this is even a real disease. But, the point I wanted to make here is that this diagnosis has mushroomed quite recently. You might remember the big implanted/recovered memory scandal of a few years ago? Yeah, well all those mentally unbalanced therapists who were driving that bus are still out there and still practicing. Now they don’t do the recovered memory thing anymore because they don’t want to get sued, but they are pushing this diagnosis hard. It is a sick, sick thing when a therapist plants and nurtures a mental illness in a client for their own emotional and financial gain.
• Posttraumatic Stress Disorder—yes, this is real, but it is way overdiagnosed. Humans are, in fact, quite resilient. I am here to tell you that not everybody who has experienced trauma needs to take drugs or spend money on a therapist. PTSD is on the crest of a wave right now. There are some therapists out there who have reduced their professional vocabularies down to a single word: Trauma. Yes, understanding trauma is very important for promoting mental health, but in the hands of confused but well meaning professionals, it leads to drowning in past traumas with absolutely no clue about how to help a person recover and build resilience.
• Autism Spectrum—another very real and very serious disease that has become exceedingly popular and chic among parents and even among adults who have only very minimal signs of the disorder.  Here is another case of individuals with severe disabilities losing resources to people who don't really have a disability
• The Paradigm Pendulum—quick radical changes in paradigms based, not on science, but on politics, popular culture, political correctness, and economic incentives/pressures. This problem has plagued psychology/psychiatry from the very beginning. The human brain is maybe the most internally complex organ known to biology and empirical science (not psychology) is only now beginning to scratch the surface of this amazing complexity. So what has driven psychology/psychiatry over the past century? I don’t know what you call it, but isn't empirical science. So, lacking a true empirical basis, what drives these paradigm shifts? Ideology and wishful thinking, I say. That’s why the history of paradigms in psychology looks a lot more like the history of politics than it does medicine. There are thousands of theoretical models out there, most of whom bit the dust long ago, but there is a bigger pattern in which the culture seems to go back and forth between the two great paradigms of the biomedical model and the psychosocial model. In recent history, the biomedical paradigm gained overwhelming ascendancy in the Eighties and into the Nineties on the Prozac locomotive and the “chemical imbalance” explanation-for-everything. Now that’s out, the new slogan is “trauma,” and the psychosocial paradigm is king. But, the cracks in the façade are already developing and there is a building swell of genetics research that’s threatening the party-line. Look at your watch, give it 10-15 years and the medical model will be back on top again. You can put money on it.
• I’m Not Mentally Ill But You Have to Support Me and Serve Me—psychiatric consumers and survivors who represent their own personal interests but packaged as social activism. How many times can someone unironically claim there is no such thing as mental illness, yet on the other side of their mouth, demand more and more services from the mental health system? It is a fact that very few people who publicly represent themselves as consumer/survivor activists have ongoing severe mental illness. As a consequence, the interests and needs of people with severe disabilities continue to go unheeded. Decades after “deinstitutionalization” we still have people with severe mental illness housed in deplorable conditions in institutions, prisons, emergency shelters, and the streets. Are these people represented by the self-styled activists? Not that I see. But, the full-time activists are marshalling all their energies to address their personal pet peeves while many of them fraudulently continue to draw down social security payments. Listen, Buddy, if your doing networking and activism 60 hours per week, you are perfectly capable of getting a job just like anyone else and you have no right to take public disability payments intended for people who can’t work.
• Drug Money—psychiatric medications are big business, in fact, prescription drugs have the biggest profit margin of any major industry, even bigger than the petroleum industry. Where do they spend their money? Just like any for-profit industry, a sizeable portion of expendable resources goes into promoting their products. This certainly includes advertising. It also includes funding biased research that promotes their products; flooding journals and literature with redundant studies that promote their products; deceptive “public education” campaigns; creating and financing activist and consumer groups that promote their products; etc. You get the idea. It has a huge huge impact on beliefs and practices in the mental health field. When encountering McScience^Ò, buyer beware.
• Let’s Play Pretend—politically correct professionals who willfully misdiagnose or simply avoid properly identifying personality disorders or any problem that fails the political correctness test. Borderline Personality Disorder, as one example, is often diagnosed, incorrectly, as depression, bipolar, PTSD, and dissociative disorders. This is pervasive and causes no end to problems in mental health programs where the actual issues are misunderstood or ignored. Conflicts occur between professionals resulting from attempts to address and discuss the problems while not being free to identify the problems properly. Resources are taken away from disabled individuals in order to support massive amounts of services to individuals who are not significantly disabled and may not even have a severe mental illness.