Richard Benjamin presentation

Trauma Informed Care in Practice – Engaging the Left and the Right Hemispheres Meeting the Challenge: Trauma Informed Care and Practice Conference Mental Health Coordinating Council of NSW Sydney, June 23 and 24, 2011

Introductory comments
Thankyou !!!
Complexity of the suffering and of the responses required
About the slides, really just one message !
[email_address]
Own views, not necessarily those of MHS
Patient, clients and consumers (people !)

Summary
People presenting with mental health problems do so for many and varied reasons
Schizophrenia and bipolar disorder - significant genetic and other biological components - and are traumatic in and of themselves
Others present with a wide range of traumas, suffered at many different ages, and these traumas may frequently play a significant or even central role in the way they present to mental health clinicians
Some patients with psychotic illnesses have suffered significantly with other trauma and then both are important

Summary
My focus today will be on trauma itself, not psychotic conditions - should not undermine the significant difficulties experienced by this group
Much has been written about trauma and its effects, but this knowledge is complex and not necessarily widespread or well-implemented
Sometimes, both the patient and the clinician are unaware of the connection between the symptoms and the trauma , or they underestimate the significance of the connection
Implementing this knowledge should lead to a much better understanding and better outcomes for many

Part 1 - “How we are put together and how we are taken apart: the concept of affective interchange and the impact of trauma”
1. An introduction to affective interchange via some curious studies
2. The work of Trevarthen and Schore
3. Statistics and sequelae of abuse and trauma
4. “Suzie”

Part 2 - “Using principles of affective interchange and trauma to inform mental health care”
1. Some trends in current Western culture, and their potential relevance to mental health services
2. Useful concepts from the Conversational Model – the powerful effects of early emotional trauma, “Eric”
3. Historical trends in psychiatry and their relevance to trauma and care, especially the DSM system
4. Affectively informed trauma-informed care, including “David”

1. What are these shows about ?
“ Reading” people - faces, body language, non-verbal cues
Purport to show that there is some magic, some way of telling “the truth” without this being divulged verbally
Are they valid ?

1. Paul Ekman, the FACS and the micro-expression
“ Lie to Me” based on work of Ekman
Mentored by the great Sylvan Tomkins, developer of “Affect Theory”
Tomkins - affects or emotions are innate, hard-wired, and a powerful motivational force - felt that we organise our lives to maximise the positive emotions and minimise the negative
Include joy, excitement, surprise, fear, anger, disgust, anguish, shame

1. Ekman cont.
Studied facial expressions for over 40 years
Multiple, and frequently, very isolated cultures, in normal individuals, psychiatric patients, in adults and in children, when they react appropriately, under-react, over-react, lie and tell the truth
Believes that there are over 10,000 possible expressions, wrote in 1978 the Facial Action Coding System – the first atlas of the face - a systemic description in words, photos and films of facial movement in anatomical terms

1. Ekman cont.
Perhaps most famous for having identified the facial signs that betray a lie
Did not set out to do this, was asked by psychiatry trainees, to help with safe discharge - studied a film of one such patient, “Mary,” suicidal, 100 hours - anguish
Coined the term micro-expressions for very fast facial movements lasting less than 1/5 of a second that are an important source of “leakage” revealing an emotion a person is trying to conceal

1. Ekman cont.
What the science shows - much more broadly than Ekman - is that it is possible to detect affect and emotion with careful study
However it is affective interchange between people that is incredibly important in how they are put together , for better or for worse, and how they can be put back together
This information comes primarily from infant and psychotherapeutic studies, but I want to look at a few more indirect studies first…

1. Surgeon litigation study
What do you think would best predict the rates at which a surgeon would be litigated against ?
Error rates ? Infection rates ? Mortality rates ?
Conversations recorded – surgeons and patients
2 groups – surgeons sued at least twice, and those never sued
Looked at just 40 seconds of tape, 2 patients, 2 x 10 second slices

1. Litigation
Studied just tone, pitch and rhythm; not the words
Rated sections on anxiety, warmth; and hostility, dominance
Could predict on just this information which surgeons had been sued – those with ratings of higher dominance and lower concern, and which hadn’t been sued – the reverse
Meaning – negative affective interchange - respect
Ambady N et al, Surgery, 2002

1. Predicting how long a relationship will last ?
John Gottman - studied married couples since the 80s
Analyses affective interchange in 20 categories (usual plus defensiveness, stonewalling etc) via videotape and measurements of heart rate, sweating, movement
Can predict with 95% accuracy after one hour of videotape whether a couple will be together in 15 years
To stay together need 5:1 positive to negative
Most telling negative is contempt (or, not respect)
Eg Carrere S, Gottman M, Family Process, 2004

1. NIMH 1985 Depression Study - Redone 2006
The original study demonstrated that imipramine with clinical management was significantly more beneficial than clinical management alone for depressed patients (also looked at IPT and CBT)
This study ignored the potential effects that psychiatrists themselves may have on their patients and re-analysed the data to reconsider this factor

1. 2006 study cont.
Variance in Beck scores – 3.4 % due to effect of medication
- 9.1% due to the psychiatrist
Variance Ham-D scores – 5.9% due to the medication
- 6.7% due to the psychiatrist
That is, the effect of the psychiatrist was equal to or greater than the effect of the medication
One third of psychiatrists demonstrated better outcomes with placebo than another third demonstrated with the active medication
Meaning ……… McKay KM, 2006

1. Junior doctors study
One time and motion study of non-consultant hospital medical staff in Sydney demonstrated that junior doctors spend only 15% of their working day in direct clinical contact with patients (Westbrook JI et al, MJA, 2008)
A commentary on this study encouraged medical staff to 1. physically see the patient 2. talk to the patient and take a clinical history, and 3. perform a relevant clinical examination (Lancashire, B, MJA, 2009)
Meaning – come to your own conclusion !!

2. Baby’s first caress, Mary Cassatt, 1891

2. The Protoconversation
Term popularised by Colwyn Trevarthen in 1970’s
Refers to the intimate exchange of facial expression , utterance (baby-talk !) and movement that occurs between mother and baby, from the first moments of life (also dad and others!)

2. The Protoconversation cont.
“ Mothers align their faces with the baby…their faces are exaggeratedly mobile in every feature and these movements are synchronised with gentle but rhythmic and accentuated vocalisations….the infants show intent interest with fixed gaze, knit brow and slightly pursed lips and relaxed jaw…they exhibit an affectionate pleasure…with smiles of varied intensity, coos, and hand movements”

Innate, moment-to-moment matching
Partners increase their degree of engagement and facially expressed positive emotion together
When emotion becomes too intense, baby gaze averts, mother backs off and awaits cues for re-engagement
The responses are carefully timed – mother tunes in, allows baby to recover, attends to cues to re-engage
Represents a transformation of inner events - each creates an inner (psychophysiological) state akin to the other ( Beebe and Lachmann, 1988)

Coupling – being with
Matching and Representation – trying to reflect understanding
Amplification – bearing affect or encouraging healthy growth
Fabulous principles– development, pathology, therapy

2. “Affect Regulation and the Origin of the Self” 1994
Allan Schore - an American Psychologist, one of the first to bring together fields of study previously unrelated – neuropsychology, affective neuroscience, developmental psychology, trauma theory, psychotherapy – most importantly – affect regulation - a major interest of all groups
Looks at infant development and pathology, but relates this to adult pathology and a great starting point or template for studying what happens “in between,” the normal and the abnormal, and a potential way of responding
Does not suggest that all or even a great majority of trauma occurs at this time, but the “in-between model” is helpful

2. Schore
Perhaps the most important paradigm shift in developmental neuroscience – to the inter-subjective
“ Events that occur during infancy, especially transactions within the social environment, are indelibly imprinted into the structures that are maturing in the first years of life. The child’s first relationship, the one with the mother, acts as a template, as it permanently molds the individuals capacities to enter into all later emotional relationships

2. Schore
These early experiences shape the development of a unique personality, its adaptive capacities as well as its vulnerabilities to and resistances against particular forms of future pathologies
Indeed, they profoundly influence the emergent organisation of an integrated system that is both stable and adaptable, and thereby the formation of the self”
(Schore, 1994)

2. Schore
Schore says that what is most important in this interaction is mutual gaze, or eye contact . He writes, “The mother’s emotionally expressive face is, by far, the most potent visual stimulus in the infant’s environment, and the child’s intense interest in her face, especially in her eyes, leads him/her to track it in space, and to engage in periods of intense mutual gaze

2. Schore
Schore calls this the co-creation of a dyadic (two-part) attachment system, which allows the caregiver to regulate the child’s affective states – mother can amplify positive states, and minimise negative affective states – the “good enough mother” – transition from one state to another
Of course can be mis-attuned – depression, neglect, dismissal etc – SHAME very important
Precursor of dissociation
How long the child remains in intense negative affect states though to be crucial in the development of pathology

2. Still face video
WARNING
http://www.youtube.com/watch_popup?v=apzXGEbZht0&vq=medium#t=12
Right click, open hyperlink, and expand window

2. Schore
Total brain volume increases 101% in the first year (Knickmeyer, 2008)
Experience-dependent maturation
Mother creates the hardware and downloads the software

2. Schore
Verbal, conscious and serial information processing takes place in the left hemisphere (LH)
Unconscious, nonverbal and emotional processing occurs in the right hemisphere (RH)

2. Schore
RH dominant first 3-4 years of life
The right orbitofrontal cortex is the hierarchical apex of the limbic or emotional system – a major control centre over all of the autonomic nervous system (hence affect and regulation go together)
“ If a significant proportion of the early emotional experiences one has are due to activation of the fear system rather than the positive systems, then the characteristic personality that begins to build up…is one characterised by negativity and hopelessness” (LeDoux, 2000)

2. Schore
Severe attachment trauma may damage these RH circuits
This might affect the capacity to play, attachment, empathy, affect regulation – all related to mental health
“ Hospitalism” of Spitz, Roumanian orphans, anxiety, depression etc
This RH pattern – the “non-conscious hemisphere” would account for the nonverbal nature of much traumatic memory - t hat is, it cannot necessarily be remembered or spoken

2. Summary of Schore
Brains are “plastic,” and are co-created in the context of the mother-infant dyad
Sequelae of early abuse and deprivation may take many forms, or may predispose to problems later on; some adults do not have the “hardware,” let alone the “software”
This model of understanding the importance of affective interchange could be applied to the development of pathology at other developmental stages
Therapeutic responses that are empathic - that are carefully attuned to the emotions of the sufferer - may be more likely to be effective

3. Statistics
1/1,000,000 (Kaplan and Saddock, 1976)
20% Australian women CSA
Only 10% ever reported to any authority (Fleming, 1997)

3. Stats cont.
US ACE study – over 17000 adults
11% children suffered emotional abuse, 30% physical, 20% sexual, 23% exposed to family alcohol abuse, 9% exposed to mental illness, 12% witnessed assault of their mothers (Felitti, 1998)
BUT ALL HAVE EMOTIONAL EFFECTS – ALL ABOUT LACK OF RESPECT OR VALUE

3. Stats cont.
36,600 children in substantiations in Australia in 2007, prevalence of abuse was likely to be between 177,000 and 666,000 children
Best estimate of the actual cost of child abuse incurred by the Australian community in 2007 was $10.7 billion, may be as high as $30.1 billion
(“Cost of Child Abuse in Australia,” 2008)

3. Stats cont.
98% of public mental health patients some exposure to trauma (Mueser, 1998)
97% homeless women with SMI have experienced severe physical and sexual abuse; 87% of this group as both child and adult (Goodman, 1997)
Female psychiatric inpatients – 50% suffered CSA, 44 CPA, 64% either, 35% both, males slightly less (Read, 2004)

3. Stats cont.
One community survey revealed that 85% of women previously admitted to a psychiatric hospital had been sexually abused before the age of 16; the more severely abused were admitted 5-16 times more frequently
Those abused had also 20-70 x the rate of suicidal ideation, depending on severity (Mullen, 1993)

3. Stats cont.
Abused inpatients
Have earlier first admissions
Have longer and more frequent hospitalisations
Spend longer in seclusion
Receive more medication
Are more likely to self-mutilate
Have higher global symptom severity
(Beck, 1987)

3. Stats cont.
Creamer and McFarlane – general population PTSD 1.3% (3.9% in US) (2001)
Severely mentally ill – 275 in and outpatients – PTSD recorded in the chart for 2% of patients – when re-interviewed 43% of patients met criteria for PTSD (Mueser 1998)
Mueser felt that the co-morbidity of PTSD was often missed, however:
“ Many providers may assume that abuse experiences are additional problems for the person, rather than the central problem…” (Hodas, 2004)
May be safest to presume that anybody seen in an inpatient psychiatric ward may have been abused, and to treat them as such – the concept of “universal precaution” used elsewhere to minimise harm

3. Adult sequelae of childhood abuse
Brain injury and neurological impairment
Smoking, obesity, STDs, heart disease, cancer, CVA, diabetes, liver disease, bone fractures
Developmental delay, poor academic achievement
Juvenile delinquency, adult criminality, violence and murder
Revictimisation, and trans-generational victimisation
Promiscuity, teenage pregnancy and prostitution
Homelessness
Premature death

3. Sequelae
Psychological - self-esteem and self-hatred, guilt, shame, affective numbing, sense of powerlessness, difficulties with trust and interpersonal relationships
Suicidal behaviour and deliberate self-harm, aggression
Substance abuse
Hyper-vigilance, anxiety, depression, post-partum depression
Somatisation disorder, eating disorders, chronic pain
Dissociation and dissociative disorders
PTSD and Complex PTSD
Borderline personality disorder
Even psychosis and bipolar disorder
(Many authors – but Malinosky-Rummell, Green, Beitchman, Finkelhor)

3. Sequelae - children
In children, seminal work of Terr (1991)
Type 2 – repeated trauma most important
“ Subsequent unfolding of horrors creates a sense of anticipation”
Leads to major attempts at psychological self-defence via denial and psychic numbing, self-hypnosis and dissociation
“ Developmental Trauma Disorder” (Van Der Kolk, 2005)

3. Sequelae - syndromes
No diagnostic category in adults for sequelae of childhood abuse – PTSD does not suit well (even for those traumatised in adulthood, Van der Kolk 2003)
Gelinas “Incest Recognition Profile” (1983) - range of symptoms – affective, guilt, DSH, nightmares, dissociation – most commonly, “become part of the wall,” or “float near the ceiling and look at what was happening”

Ellenson , also post-incest, focussed on the mental state, especially content of symptoms
Syndrome – nightmares, dissoc, phobias etc, perceptual disturbances – feeling that there is an evil entity in the house, hearing a child cry out or intruder sounds, recurring visual hallucinations involving objects in peripheral vision, tactile hallucinations of being touched or held down
Those who had suffered more severe abuse could also hear more elaborate voices – persecutory voices that “railed at the survivor inside her head…calling her whore, bitch, slut,” also “directive” voices goading toward self-harm

Judith Herman, 1992
Perhaps the first to more thoroughly conceptualise adult sequelae of childhood abuse - Concept of Complex PTSD
Focus on domination, “totalitarian control” - history of abuse over a prolonged period
Lack of accurate diagnostic category serious consequences – connection b/w symptoms and abuse often lost, responses by medical system often replicate those of the abusive family
Proponents have tried for 20 years to have accepted into DSM

3. Complex PTSD (DESNOS)
History of abuse over a prolonged period
Alterations in affect regulation
Alterations in consciousness
Alterations in self-perception
Alterations in perception of perpetrator
Alterations in relations with others
Alterations in systems of meaning

3. Neuroscientific findings in trauma
Too much to review
Epigenetic – Schore – emphasis on right brain and affect regulation – brain is created within a social context
Memory – explicit, implicit, hippocampus
Survival mode, cortisol, glutamate, cell death, dissociation, misinterpretation, fragmentation – especially in the hippocampus
Corpus callosum also adversely affected by early trauma – smaller middle portion in paediatric inpatients with histories of abuse – decreased communication between hemispheres and increased laterality

3. Neuroscience
“ Traumatic experiences persist primarily as implicit, behavioural and somatic memories, and only secondarily as vague, over-general, fragmented, incomplete and disorganised narratives”
(Van der Kolk, 2003)
They are not usually available in the form of an autobiographical narrative, and, seemingly unattached to other experience, are stored as images, sensations and emotions in the right brain

3. Neuroscience
Neuroimaging studies in those with “simple” PTSD (ie adults with single traumas) show that when re-exposed to trauma-related stimuli there is hypoperfusion in the left PFCX, in the hippocampus and in Broca’s area, and increased activation in the parrahippocampal gyrus, the posterior cingulate and the right amygdala

3. Neuroscience
As the LH is usually dominant, and contains Broca and Wernicke, in those with PTSD there is more affective than linguistic processing and failure of the LH is especially important as it does not tell the sufferer that the memory does not belong to the present
(Peres, 2008)
Presumably more important/complex in older childhood trauma/memories

4. “Suzie”
WARNING
“ Suzie” was a public mental health patient for 25 years
She was first seen in the child psychiatry service with “behavioural problems,” she later spent time in juvenile detention facilities, then in the drug and alcohol service, and finally in the adult mental health service
Throughout this period she was seen to be angry and violent, “attention-seeking,” BUT ALSO needing to “block out emotional pain,” suffering with nightmares and overdosing
Retrospectively she added that she was always anxious, had never felt good about herself, had major difficulties in relationships

4. “Suzie”
First presented with psychotic symptoms three months after giving birth
Voices of “cartoon characters”, “barking dogs,” “put” in head by infant daughter
Eight consecutive psychiatrists diagnosed her with schizophrenia over several years
Eventually a therapist started to talk to her about her childhood
It soon became clear that she had been systematically and ritually sexually abused by her stepfather and others, and that her mother was not emotionally avail and had not been able to protect her, and that the abuse history was first detected during her drug and alcohol treatment

4. “Suzie”
The voices of the “cartoon characters” she heard were eventually recognised as a particular favourite that she watched on TV after school; she dissociated to this protective character whilst being abused and later experienced this as a voice
The “barking dogs” that her baby “put” in her head she similarly recognised as a real noise that she had dissociated to whilst being abused on one occasion

4. “Suzie”
Over four years, Suzie’s therapy progressed and her multiple antipsychotic and antidepressant medications were withdrawn, and the patient was ultimately discharged from the service
Suzie is NOT representative of most of the psychotic patients I see, however the lesson learnt was about listening, trying to put symptoms into context, and always considering the role that trauma might play

4. Summary
Suzie not schizophrenia but Complex PTSD
She was subjected to ongoing abuse and could not escape
She could not regulate her affect or emotions
She did not value herself
She had complex relations with others
She could not make links between abuse and symptoms and dissociated

4. Link to affective interchange
Childhood sexual abuse has much broader effects of course than the abuse itself
It can only occur in atmosphere that is not protective or aware
The harm is also attributable to the age and frequency of abuse, and the relationship of the abuser to the abused, and the betrayal
The abuse is of course the ultimate in relation to lack of respect and contempt

4. Link to affective interchange
No normal attachment likely
No normal RH development
No normal development of affect regulation
No-one listening, being with, nourishing
The repair occurred when someone got beyond the symptoms and listened to the story
When they really listened – joined
When they tried to reflect back their understanding of what happened – representation
When they sat with all the pain, and also looked for positives - amplification

Conclusion
We are all put together in the context of others (not withstanding some very significant genetic/biological factors)
Histories of trauma and abuse are very common in those presenting with mental health problems
These histories may be not be totally relevant to the presenting problem, they may be partially relevant and additional, and in some cases they may be totally explanatory
Identifying the trauma allows not only for its relevance to be understood, it allows the patient to be heard, sometimes for the very first time, and it may point to a completely different treatment pathway

End part 1 !!

Trauma Informed Care in Practice – Engaging the Left and the Right Hemisphere Meeting the Challenge: Trauma Informed Care and Practice Conference Mental Health Coordinating Council of NSW Sydney, June 23 and 24, 2011

“ Using principles of affective interchange and trauma to inform mental health care”
1. Some trends in current Western culture, and their potential relevance to mental health services
2. Useful concepts from the Conversational Model of Psychotherapy – the powerful effects of early emotional trauma’ “Eric”
3. Historical trends in psychiatry and their relevance to trauma and care, especially the DSM classif system
4. Affectively informed trauma-informed care, including “David”

Summary Part 1 *
We are all “put together” in the context of others
Histories of trauma and abuse are very common in those presenting with mental health problems (not withstanding some very significant biological factors)
These histories may be not be totally relevant to the presenting problem, they may be partially relevant and additional, and in some cases may be totally explanatory
Identifying the trauma allows not only for its relevance to be understood, it allows the patient to be heard, sometimes for the very first time, and it may point to a completely different treatment path

1. Iain McGilchrist
Seminal text, “The Master and his Emissary; the Divided Brain and the Making of the Western World,” 2009
Drawing on an enormous body of research, case material and history, argues that the two different hemispheres have not merely different skills but wholly different perspectives on the world
The LH is designed to exploit the world effectively, mainly for the purpose of “getting and feeding,” is narrow in focus, sees things abstracted from content and broken into parts, prizes theory over experience, prefers mechanisms to living things, lacks empathy and is unreasonably certain of itself

1. McGilchrist cont.
The RH has a more generous understanding of the world, sees things in context, more holistically
Demonstrates a broader and much more vigilant attention, the purpose of which appears to be maintaining awareness of signals from surroundings, especially in the social context of friend or foe, and is involved in bonding in social animals, and is the seat of empathy and emotional understanding

Emphasises the need for the two hemispheres to work together, in balance
But, at least in Western culture, believes there is evidence of a power struggle, with the LH becoming increasingly dominant
Result is a dehumanised society, rigid and bureaucratic, obsessed with structure and mechanism, at a huge cost to happiness and the world around us

1. What a LH dominated world would look like
Increasing specialisation of knowledge, and substitution of knowledge for experience and wisdom
Skills become more algorithmic, regulated by administrators
Humans would be seen as more mechanical, produce in quantity, not quality, loss of individuality
The social bonds between us would become neglected, pervading stance - paranoid
Individuals and governments all feel greater need to control, with a perception of a greater need for security

1. What a LH dominated world would look like
Accidents and illnesses would be blamed on others
There would be less insight, less willingness to take responsibility for one’s actions
There would be less self-control and more anger
Reasonableness would be replaced by rationality
Displays of emotion would become more difficult, and there would be increasing difficulty in understanding non-verbal communication

How much of this do you see around you, in the wider world ? How much in government, service provision and in mental health ?
Getting anywhere seems to be some sort of steeplechase involving rules, entry criteria, paperwork and multiple professionals and services
McGilchrist thinks the RH is losing the battle
Will return to this later when looking at classification in psychiatry – seems to be highly relevant

George Bush

2. Conversational Model
Russell Meares and Robert Hobson
Meares - Sydney-based international expert on trauma and personality development
Worked intensively in the UK with patients now known as “borderline”
With Hobson devised an empathic therapy involving the integration of childhood trauma (in adults) in the context of a very finely attuned therapeutic relationship
For those suffering with the borderline condition and related disorders, very broadly applicable

Meares has focussed his work on emotional traumata
For the purposes of today – most important are two concepts – that of the traumatic memory and the expectational field
Repetitive, early attacks upon value – belittling, humiliation etc – lead to the formation of a complex of traumatic memories which are largely unconscious (RH, “subconscious fixed idea,” “you are worthless” becomes “I am worthless”); this very different type of traumatic memory
Often dormant until triggered by an event – almost always interpersonal

Now intrudes and may obliterate ordinary self (road rage – this is invalidation, inpatient declined a phone call who gets angry or self-harming, etc)
The complex includes the form of relationship in which the trauma took place – the patient now feels herself ugly or worthless for example, and at the same time the patient feels herself to be in the presence of someone who is, for example, critical or controlling, locating an experience that came from the past as occurring in the present
Ie this is what happens “in-between”

2. The Expectational Field
“ The unconscious traumatic memory system potentiates the repeated development throughout the individual’s life of the form of relatedness in which the experience of trauma arose”
That is, the trauma is repeatedly relived with others
“ Borderline patients have generally endured a childhood in which they were abused, rejected or neglected. When they present to psychiatric facilities, they are often abused, neglected or rejected” (Meares, 2005)

2. The Expectational Field
In order for the original trauma to be re-enacted, the expectational field requires a “host”
Anybody may unwittingly become this host – might begin to feel bored, or sad, or angry, or might not believe a story offered – might offer advice or suggest they cannot help – may often in fact really be speaking in the voice of the original abuser
Awareness of this phenomenon, and the principles of co-regulation of affect, and containment as suggested by the protoconversation and by Schore, can make for a dramatically different outcome

2. “Invalidation”
Childhood abuse, Complex PTSD, Trevarthen, Schore, Meares – demonstrate that much trauma that we see in mental health services is that perpetrated by one person upon another , all “emotional” abuse in a way – not respecting the essential dignity of another - Meares might call this “invalidation,” not giving value
Invalidation may be subtle, may go unnoticed, but with very damaging effects
Regardless of the presenting issue all suffering with mental illness need to be respected and heard (this is “old-fashioned therapy” approach)
It would seem to be self-evident that this should be done, but this is not always the case, multiple systems not necessarily well set up for this to be a primary focus, and in fact may be partially set up inadvertently not to listen (not intentionally !)

2. “Eric”
“ Eric” had been a fire-fighter who had been diagnosed with Posttraumatic Stress Disorder
He initially talked to me about a car accident that he had attended in which a young woman had been killed by an intoxicated driver
Eventually he said that he “froze” in a house fire and had to leave the job

2. “Eric”
Was indeed very anxious and avoidant, and had been admitted several times with suicidal ideation, and was barely functioning either vocationally or in family life
He had been trialled on a number of different antidepressants and had had two trials of CBT, all to no avail

2. “Eric”
In an expressive therapy, informed by the principles of the Conversational Model, Eric soon added that he had had a very difficult father, and that he grew up in fear of his father’s “wrath”
He said that his father was always yelling at him, and belittling him, and that that had made him feel small and unworthy

2. “Eric”
“ You never lived up to his expectations. We grew up in absolute silence, everything was done dad’s way”
He and his brother were never allowed to run about or play in the house
Eric soon came to the conclusion in therapy that every time he had a conversation with anybody he was expecting the wrath of his father, and that he never offered an opinion of his own

2. “Eric”
He thought people could see through him and that his greatest fear was of being “found out, a fraud,” and of making mistakes; this was probably why he really left the fire-fighting job, and why he had not been able to hold down any subsequent jobs
Eric eventually realised that he had initially expected his new therapist to tell him how to get better, just like his previous therapists and his father would have done; when this did not happen, he realised that he could “take part” in his own therapy, that he was worthy of existing in his own right, and in relation to another - this can only happen with awareness of what is “in-between”

2. “Eric”
He slowly grew in confidence within and then outside of the therapy, and eventually retrained as a driving instructor
After three years, his therapy was terminated, and Eric described being happy both at home and at work
No symptom had ever been individually targeted
The much earlier traumas of invalidation by his father were much more significant than the “PTSD,” anxiety or depression, structured therapy in the form of CBT had failed because it failed to consider what was happening between the patient and the therapist, and medication had been of no use similarly because it failed to address the underlying problem

3. How did we get to be here; focus on symptom and medication?
Psychiatry much more than any other branch of medicine is subject to trends and paradigm shifts that are not always merit-based, or balanced, and sometimes different treatments offered to the same patient can appear to be almost polar opposites
Understanding some of the background history is absolutely critical when trying to understand where we are now, how we got here, and how things might – or might not - change into the future

3. The History of Psychiatry is Brief
Psychiatry as a specialty was not practiced before the 19th century
Care provided in asylums had been primarily custodial, and conditions were poor, and often brutal
A new therapeutic optimism inspired by the Enlightenment in the 19th century led briefly to the provision of more humane care
But this optimism was soon overrun by the large numbers of patients taken into asylums around the turn of the 20 th century

3. Rake’s Progress, 1732-33
Englishman William Hogarth
It depicts the fall of Tom Rakewell, through gambling and prostitution, into madness, in Bethlehem Hospital (Bethlam, or Bedlam)
The women are fashionably dressed because they are there for a social occasion, to be entertained by the antics of the inmates

3. History
“ In the 18 th century, people used to go to Bethlem to stare at ‘the lunatics.’ For a penny, one could peer into the cells, view the freaks and laugh at their antics, generally of a sexual nature or violent fights. Entry was free on the first Tuesday of the month. Visitors were permitted to bring long sticks with which to poke and enrage the inmates. In 1814 alone, there were 96000 such visits” (Shorter, 1997)

3. History
Classification in psychiatry began essentially in the 1890’s with Emil Kraepelin’s great division of all the psychoses into two groups – manic-depression, or bipolar disorder, and dementia praecox, or schizophrenia, and this is still the basis of the DSM
There were however two groups of psychiatrists around this time – the “Somatiker” – who generally attributed mental disorder to brain disease (“Biological psychiatrist”) and – the “Psychiker,” or analyst, who emphasised the emotional causes (therapist or counsellor). The “Psychiker” held sway from the turn of the century until the mid 1960s (Ellenberger, 1970)

3. History
Around the turn of the 20 th century there were a great many brilliant people working in analysis, philosophy and psychology – William James, Jean-Martin Charcot, Pierre Janet, Sigmund Freud, Carl Jung to name a few
Freud left the biggest legacy
Much of this is has been incredibly beneficial: the importance of really listening to the patient’s own story, the therapeutic relationship, the concept of transference etc

3. History
Unfortunately however when it came to trauma he was not helpful
Freud heard repeatedly of sexual assault and incest; he described his belief in a causative relationship between incest and the symptoms of hysteria in his “Aetiology of Hysteria” in 1896
He retracted this theory within a year, primarily because the society he existed within at the time could not hear of it

3. History
“ For close to a century, these patients would again be silenced. The dominant psychological theory of the next century was founded in the denial of women’s reality. Psychoanalysis became a study of the internal vicissitudes of fantasy and desire, dissociated from the reality of experience. Freud concluded that his hysterical patients accounts of childhood sexual abuse were untrue. The study of psychological trauma came to a halt ”
Judith Herman, 1992

3. History
However, several paradigm shifts were important around the middle of the 20 th century
First, the introduction of the antipsychotics led to the process of deinstitutionalisation, which led to the development of community or public mental health services outpatient psychiatry, and to the prominence of biological psychiatry once again
In addition, the Women’s Movement and studies of rape and sexual abuse in children, and the study of the after effects of war in Vietnam Vets, led to a resurgence in interest in trauma

3. History/DSM
These studies were bolstered by the publication of the DSM-III and the inclusion of the diagnoses of PTSD, and Borderline Personality in 1980
Especially important to note that not only did the diagnosis of PTSD give credibility to the sufferer it also named up the aetiology, rare for DSM
But also important to note this did not occur for the Borderline condition, despite the similarities

3. Back to classification - DSM
5 revisions since 1952, 5 th full version due 2013
DSM-III in 1980 part anti-analysis, created especially to assist with improving the uniformity of diagnoses – Rosenham 1973
Designed primarily to assist with research and communication
DSM-IV(-TR) has almost 300 diagnostic categories, and multiple diagnoses or “co-morbidity” are the norm
DSM does not “cut nature at its joints,” it does not follow Medicine’s routine use of Occam’s Razor, or the theory of parsimony, which states that “entities must not be multiplied beyond necessity” (William of Ockham, c 1285-1349); multiple symptoms in medicine lead to a search for one disease

3. DSM
Increasing controversy in many areas, for eg:
Depression/bipolar – 79% of a non-clinical group diagnosable with a condition over 20 years, can be diagnosed bipolar now without suffering mania, over 200 different “types” of depression available (Parker, 2008)
Adult bipolar disorder (Zimmerman, 2009), Anxiety disorders (Starcevic, 2008), Psychosis (Read 2004, Moskowitz 2008)

3. DSM
Increasingly criticised for being reductionistic, with an over-emphasis on the biological, for over-medicalising and over-simplifying the human condition, and for pharmaceutical company conflicts of interest for panel experts, potentially promoting an emphasis on disease
Drives treatment availability, treatment training, and reimbursement in US, with flow-on effects elsewhere

3. DSM
Criticisms culminated in what has been called the “Pax Medica” – a model described recently – combination of DSM, Prozac (or Big Pharma), and the rise of the “evidence-based therapies”
Seen to be erroneously founded on theories of chemical imbalance in the brain, with an inappropriate emphasis on symptom-based diagnoses, and on specialised treatments and techniques
Which together have been seen to have, “Medicalised psychology and psychiatry in a way that has become so pervasive it’s almost invisible, like the air we breathe”
(Linford and Arden, 2009)

3. The Loss of Sadness
Or, “How Psychiatry Transformed Normal Sorrow Into Depressive Disorder” Horwitz, AV, Wakefield, JC, 2007
Argue that whilst depressive disorder exists and can be a devastating condition, the apparent “epidemic” reflects the way that the psychiatric profession has reclassified normal human sadness as largely an abnormal experience, as the diagnosis of depression fails to take into account any personal context
Foreword written by the architect of DSM-III, Robert Spitzer

3. DSM – LH and RH
DSM was designed to help more accurately categorise mental health syndromes, to enhance research and communication amongst colleagues
Very unlike most of medicine – less rarely does the “diagnosis” assist with the treatment planning and prognosis, as there is much less aetiology/pathogenesis
The focus on delineating “Axis 1” conditions, mirrors McGilchrist’s left hemisphere concern about an overly narrow, “scientific,” mechanistic and fragmented focus, at the expense of a more holistic, emotional and social perspective
Is perfectly reasonable with added RH perspective

4. Trauma-informed care
A specific movement that originated in the US in the mid 1990’s as a result of community distress over coercive inpatient treatments and coercive treatment of children in schools
Aims to educate especially in inpatient and residential units about the high prevalence of traumatic experiences in people who receive mental health services, and of the widespread bio-psycho-social effects
Also of the not uncommon finding that public MHS may be insensitive to such patients and not infrequently re-traumatise them

4. Principles
Patients should be inherently valued
Staff should ask about abuse and trauma
Neutral, objective and supportive language should be used
Staff should always take care to avoid shaming and humiliating patients

4. Principles
Treatment plans need to be individualised
Treatment plans need to include an understanding of triggers, early warning signs and individually created strategies
Institutions should be open to outside parties including advocates and consultants
There should be an organisational commitment to trauma-informed care

4. What the affective interchange science tells us
Recognise that some distressed patients may be “in” unconscious traumatic memories
Are essentially “in” the past
Sit quietly beside (or below), not in front
Listen, listen, if not sure what to say there is no necessity to talk, but you will need time , and possibly space
When responding use few words, and a gentle voice
Patients do not usually respond well to reassurance when in a trauma zone, nor to questioning

4. Affective interchange
Understand that the quiet presence of a clinician alone (when possible, safe, not driven by psychosis) may help a patient regulate their emotion with you
Trying to reflect how painful things might be for the patient will often be helpful
Unlike the protoconversation, direct eye-to-eye contact is usually too hard, but the other principles apply – to-and-fro exchanges, use of similar language, and tone
Note that if a patient has engendered strong feelings in a clinician then it is useful to share that with a colleague, and not with the patient (this expec field)

4. Affective interchange
Use the person of the clinician to treat then
Proactively engage, actively listen, preferably early
Contain and co-regulate
Do not think the patient could or should be able to do it by themselves – the science says they may not be able to (no hardware, software)
Have “protected therapeutic time” to do this

One reason a dog can be such a comfort when you’re feeling blue is that he doesn’t try to find out why

4. “David”
“ David” has been a public mental health patient for 30 years
In his early life he used substances extensively, and he had also been incarcerated on multiple occasions
His numerous discharge summaries usually referred to the diagnoses of “depression” and “personality disorder”
He had most frequently presented with suicidal ideation and irritability, and had been seeking somewhere where he could feel safe

4. “David”
He often became agitated during the admission process and had frequently required “take-downs,” and the use of involuntary medication
He had been abandoned by his mother at the age of four to institutional care, where (when a little older) he was regularly “drugged” with antipsychotics and forced to complete sexual acts
The medication offered to him in the treatment setting was sometimes exactly the same as the medication used to “drug” him in childhood

4. “David”
When the problem was reconceptualised as Complex Post-traumatic Stress Disorder, when seeking admission the inpatient staff were alerted to his previous institutional experiences – that was the major intervention
No further takedowns were necessary
The patient was not able to tolerate regular therapy to attempt to look at nightmares and flashbacks, but he did well in supportive case management informed by trauma principles, with the need for admission eventually receding

4. Traumatic memories
Suzie’s voices
Eric’s fear of ridicule
David’s “takedowns”
All examples of deep-seated traumatic memories or the system’s response to them
All went undetected for many, many, many years
All controlled their behaviour and other’s responses
However when seen through the lens of psychiatry/DSM and trauma can be understood

4. Things that we do well
Mainstreaming , medicalising to make legitimate and to de-stigmatise
Use of documents that encourage holistic view eg ISP
Identifying risk
Nursing/providing care with warmth and compassion
Involving consumers and carers more and more
Utilising contemporary treatments eg second generation medications, modified ECT
Being more transparent and accountable with respect to record-keeping, oversight, incident review

4. Things that might be unhelpful
Automatically using the “psych” cubicle, searching, removing possessions without due thought
Involving multiple staff, each for short periods, and asking multiple questions, whilst not listening intently and not taking one comprehensive history in a therapeutic fashion
Favouring cross-sectional over longitudinal histories
Medicalising if this means removing symptoms from context

4. Things that might be unhelpful
Using “take-downs” and seclusion too frequently, not involving trained staff early enough, medicating and secluding patients with histories of abuse at greater rates than other patients
Using fish bowls (both ways)
Being insensitive re conversations – eg ward rounds
Not providing enough therapeutic time

4. “Talking with acutely psychotic people,” Len Bowers, UK*
The work of (mental health inpatient) nurses is generally highly regarded by patients (Rogers 1993) and nurses can relate many critical incidents where their interactions with patients have been highly valuable (Cormack 1983)
However many research studies have found low rates of interaction, with only 8-21% of nurses time spent this way (Altschul 1972, Sanson-Fisher 1979)
Not much literature with respect to the acutely mentally unwell, so studied the work of 28 senior nurses

4. Talking cont.*
Some recommendations including keeping interactions relatively short, joining in in activities etc
Most helpful findings centred around things like – careful first approach , showing warmth, care, respect , avoiding being intrusive, being honest, simply sitting or spending time, focussing on the patient as a person rather than on their symptoms, using slow pace, short sentences, regulating own emotional response
Hearing what patients experiences were, accepting them, seeking to understand their effect on patients
These recommendations then are essentially the same then as those for the traumatised patient

4. Talking cont.
For there to be a (greater) focus on trauma, talking, listening and therapy there needs to be :
Greater understanding at the highest levels
Greater value placed upon this
Appropriate training
A different ward set-up
With more time, time, time

Areas to address Mindset Trauma is widespread Not obvious Even less appreciated Social connectedness Legislation Income, housing Education and training Jobs Funding and policy Federal versus state Bodies Education and training Promotion Coal-face Champions “ Ward design” Training Supervision

4. Funding
Because of the difficulty in accepting the paradigm the most important issue from my perspective is aiming at nothing less than dedicated state-based funding
A national body might drive change initially and stop inefficient state-based re-invention of the wheel with respect to tools/policy, but no help if no state funding unless the funding paradigm changes
Funding should be percentage of total budget, must be recurrent and must be ring-fenced

4. Coal-face
Must have champions
Wards should be reshaped/redesigned – physically – this will visually demonstrate change to all
Concept of protected therapeutic time as normal policy - will also quickly demonstrate what is seen to be considered to be important by senior management
Need to train at all levels
Need to think about employing people to be actively therapeutic – in statement of duties, regardless of background training etc

4. South Carolina Study, Frueh C et al 2001*
Looked at 245 clinicians in outpatient facilities
Only 30% had 6 hours or more trauma training
93% of staff however said they felt comfortable or somewhat comfortable working with trauma
The proportion of patients rated as having trauma-related difficulties was however rated as very low
A strong relationship was however noted between hours of training and perception of trauma-related difficulty, that was not related to education or experience

4. Why we might be so slow to act
The entrenchment of the current biological paradigm, and the relative obscurity of the newer paradigm, and the length of time required to change any paradigm - decades
The reality of short-lived political cycles and of government funding (secl and restraint eg)
Management, case-mix, funding, so many other issues
My recent experience

4. Tucci study*
In 2006, child abuse was perceived as less concerning to the public than the rising cost of petrol, and problems with transport and roads
31% of respondents stated that they would not believe children’s stories about abuse
43% of respondents felt so poorly informed on the issue that they were unable to guess the number of reported cases of child abuse, whilst those prepared to estimate significantly underestimated the problem
Tucci et al, 2006

Final comment
Much is known about trauma and the mentally ill, but this knowledge has not yet been widely disseminated or applied
Application of this knowledge will make for much more human and empathic mental health services, with better, more holistic “diagnosis” and better outcomes
There will be significant resistance to change from some quarters, but the tide may be turning, this conference and the amount of interest generated may be hugely beneficial

Selected bibliography
Affect Regulation and the Origin of the Self, Allan Schore, LEA, 1994
Affect Regulation and the Repair of the Self, Allan Schore, Norton, 2003 (updated, briefer, whilst still comprehensive)
The Metaphor of Play, Russell Meares, Routledge, 2005
Emotions Revealed, Paul Ekman, Holt, 2007
The Loss of Sadness, Horwitz, Oxford, 2007
Trauma and Recovery, Judith Herman, Basic Books, 1992
The Master and his Emissary, Iain McGilchrist, Yale, 2009
The Use and Misuse of Psychiatric Drugs, Joel Paris, Wiley-Blackwell, 2010
The Conversational Model – www.anzapweb.com

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Richard Benjamin presentation

by mhcc on Jul 27, 2011

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Richard Benjamin presentation — Presentation Transcript