Ill Or Injured: Shifting the Emphasis to Trauma in Mental Health Diagnosis and Treatment

SPEAKING OUT

Ill or Injured: Shifting the Emphasis to Trauma in Mental Health Diagnosis and Treatment

Matthew S. Costanzo Savannah, Georgia

Topic: This contribution examines the disparity that exists between research that identifies the prevalence of trauma among mental health service users and the low frequency of adequately diagnosing and treating trauma in practice. For this author, the important question to pose is “Could behavioral health services be persistently erring in both diagnoses and treatment approaches to adequately assist and support service users?” Purpose: The author proposes an alternative service model which is aligned with the prevalence of complex trauma. Data is presented that supports the high incidence of trauma among service users as well as the historical efficacy of relationship-based treatment. Sources Used: Personal experience is shared in conjunction with an overview of research in support of the prevalence of trauma and the efficacy of relationship-based treatment. Conclusions and Implications for Practice: Shifting our diagnostic focus away from biomedical illness to be inclusive of trauma-based, developmental injury will align mental health and rehabilitation practice more adequately with research and encourage improved diagnostic accuracy and a shift toward relationship-based treatment interventions, thereby hopefully improving outcomes for our service recipients.

Keywords: trauma, public mental health, recovery, systems change, diagnosis

The dominant theory and services provided in American psy- reactions to the current circumstances, or indications of the extent chiatric hospitals and clinics continues to view mental “illnesses” of earlier trauma. I contend that a shift in perspective would clearly as biomedical conditions that can be best addressed with pharmaco- influence treatment decisions. logical treatments (Insel, 2015). Although the introduction of recovery As a survivor of both mental illness and the mental health principles, evidence-based practices, and trauma-informed care are system, as well as in my role as a service provider, I’ve come to encouraging trends, I believe that a fundamental shift in our believe that a shift toward an emphasis on contextual factors, that approach to mental health diagnoses that includes the developmen- is a trauma-based diagnostic and treatment model, would improve tal and social context of the lives of individuals served are critical diagnostic accuracy and outcomes. Such a shift could occur with a dimensions that we should strive to understand and to more effec- more comprehensive implementation of trauma theory, the recovery- tively assist our service recipients. In this article, I am proposing oriented approach, with the primary reliance on relationship-based that to have confidence in treatment as usual, with its ubiquitous interventions and a foundation in ethological theory that is concerned reliance on medications and nonindividualized group therapy, is with the adaptive or survival value of behaviors and their evolutionary naïve in light of the complexity of the conditions to be treated and history. I have observed that this formulation of theories, approaches, that to be passively aware of this without any concomitant action and interventions has worked before, and, I believe, it works because on our parts is a major oversight. it is in accordance with what we are as humans, how we hurt, and how This naïveté regarding treatment as usual is demonstrated by the we heal. In making my case for a trauma-based model, a review of This document is copyrighted by the American Psychological Association or one of its allied publishers. attribution of symptoms to biochemical factors while simultane- some historical work can serve to demonstrate its value and validity. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. ously conferring ownership for poor outcomes onto the individuals seeking treatment (Datta, 2014). Treatment as usual may lead to Trauma Theory: A Contextual Perspective the inadvertent exacerbation of symptoms (Bentall, 2003; Bloom & Farragher, 2010; Caplan, 1995; Carlat, 2010; Healy, 2002; A contextual approach to the interpretation of maladaptive be- Whitaker, 2010). From a trauma-based perspective, one might havior radically affects diagnostic assessment. The impact of stres- interpret these same behaviors as maladaptive survival strategies, sors, developmental pitfalls, and factors such as stigma, which manifestations of dissociation, nonverbal cries for help, protective often accompany maladaptive survival strategies, can create complex deviations in personality. Therefore, though a schizoid-type or bipolar disorder may have origins in a biomedical condition, it’s of equal or greater likelihood that disorders may derive, and are Correspondence concerning this article should be addressed to Mat- exacerbated by, the compounding effects of adverse life events and thew S. Costanzo, Independent Practice, Sea Oats Lane, Savannah, stressors (Bloom, 1997). In such cases, the symptoms might be Georgia 31411. E-mail: [email protected] better categorized as cumulative or a complex posttraumatic stress

368 SPEAKING OUT: ILL OR INJURED 369

disorder, introduced by Luxenberg, Spinazzola, and van der Kolk trol, direction, and the biomedical approach to treatment (Bloom, (2001). van der Kolk’s work broadly expanded the idea of expe- 1997; Burrow, 1984; Foucault, 1961). riential etiology to include the vast numbers of individuals who The principles of early social psychiatry are the link between a have suffered repeatedly in less pronounced ways leaving a deep contextual understanding of etiology and moral treatment, milieu impact on an individual’s mental health (Luxenberg et al., 2001). therapy, and the recovery-oriented approach. Early social psychi- It is my opinion that these individuals account for the majority of atry was formed around two principles, both of which are arguably those erroneously diagnosed with severe and persistent mental ethological in nature. illness. • Human behavior can only be understood in the context of Mueser and colleagues identify that approximately 90% of those the total social environment. seeking inpatient services are trauma survivors and 43% warrant a • A meaningful interrelationship exists between the behav- diagnosis of posttraumatic stress disorder. By contrast, only 2% to iors of one individual and all institutions and groups. 4% have a mention of trauma in their recorded diagnosis (Mueser et al., 1998; Mueser, Essock, Haines, Wolfe, & Xie, 2004). An The Role of Medication even more telling set of findings come from the Adverse Child- hood Experiences study, which correlated levels of adverse child- Remediation via corrective experiences is a demonstrably more hood experiences with poor physical, mental, and behavioral out- appropriate treatment than psychopharmacology and the one-size- comes later in life. According to findings from the Centers for fits-all approach to group therapy common to public hospitals, Disease Control and Prevention (Anda et al., 2006): even where a biological component to etiology exists (Bloom, 1997; Courtois, 2004; Mueser, K. T., Drake, R. E., Sigmon, S. C., Prevention and remediation of our nation’s leading health and social & Brunette, M. F., 2005). Medication may facilitate the healing problems is likely to benefit from understanding that many of these process by temporarily alleviating some of the more severe symp- problems tend to be co-morbid and may have common origins in the enduring neurodevelopmental consequences of abuse and related ad- toms as presented, but is not typically sufficient for healing. verse experiences during childhood. (p. 183) Engaging the service user in a meaningful and empathetic way, while providing the corrective experiences (e.g., resocialization) These findings indicate a failing to effectively identify posttrau- necessary to create lasting change enables that person to learn to matic stress disorder and complex posttraumatic stress disorder navigate their symptoms effectively in the longer term, while among people who have been “misidentified” as being severely establishing the kind of life that makes that navigation worthwhile. and persistently mentally ill, leading to the high probability that This is the most promising direction for improved outcomes symptoms of trauma go misdiagnosed, leading to inappropriate across the spectrum of mental health treatment settings. The prac- and ineffective treatments (Courtois, 2004). tices espoused in the original Milieu Therapy (Jones, 1968), the trauma-centric milieu of the Sanctuary Model (Bloom, 1997), or The Recovery-Oriented Approach: An Ethological and the medication-free methods of the Soteria Model as envisioned by Social Perspective Loren Mosher (Toresini, 2007), show us variants on the end goal. However, factors that work against implementing alternatives in- The ethological strategy draws insights and approaches from the clude the pharmaceutical industry’s influence and myriad bureau- needs of humans and other mammals as they occur in their natu- cratic and logistical factors. Advocacy and action within both the rally existing communities. Anthropologists and zoologists have professional and peer communities are needed to create the polit- demonstrated the universal importance of early caregivers, com- ical and social will to see that everyone in need of treatment gets munity, and the essential existence of empathy in maintaining the kind of help that can make a difference. cohesion in herd species (Bowlby, 1981; De Waal, 2010; Harlow, 1959). I have highlighted ethology to ground a context-based Conclusion diagnostic model and relationship-based treatment methodology in the wealth of hard science ethology provides. Ethological research Current treatment for U.S. citizens living with the results of supports the recreation of an environment that provides corrective trauma and misdiagnosed as severely and persistently mentally ill experiences in response to problematic ones, as in original natural focuses on the arguably minor role of genetics (Bentall, 2003) and This document is copyrighted by the American Psychological Association or one of its allied publishers. communities. pharmacological interventions. This is instead of addressing other This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. This ethological and empathy-based perspective is neither rad- pertinent factors such as context, life experience, and the myriad ical nor innovative. Although moral treatment found spurious complexities of living in the modern world. Trauma theory and the justifications for its methods, those methods were observed to be recovery-oriented approach shift the orientation of psychiatric care beneficial to the individual (McGovern, 1985). After World War theory from an internal focus to one that assesses and addresses II, social psychiatry attempted to codify the needs of humans in these contextual factors. their community, which led later to an effort to implement these Promising movements in the mental health community point principles in the form of milieu therapy (Grob, 1991). Like moral toward this care paradigm. Even within the bulwarks of the med- treatment, both social psychiatry and milieu therapy receded into ical establishment there is a push to incorporate childhood victim- the background of mental health care (Cumming & Cumming, ization in the diagnostic lexicon, as van der Kolk’s efforts to 1962; Dwyer, 1987). Now, the recovery-oriented approach and incorporate early trauma and complex trauma as a precursor to trauma theory rearticulate their principles, maintaining continuity illness in the DSM–5 (American Psychiatric Association, 2013) with these earlier models, each of which demonstrated signifi- demonstrate (van der Kolk, et al., 2009). However, these efforts cantly better outcomes than current ones based in authority, con- remain outside the mainstream orientation of behavioral health 370 COSTANZO

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From blaming the patient to blaming the brain: Mad in Received December 4, 2015 America. Retrieved from http://www.madinamerica.com/2014/11/ Revision received August 11, 2016 blaming-patient-blaming-brain/ Accepted September 20, 2016 Ⅲ