05. Psychiatrically injured not inherently flawed

There is currently a debate raging in the psychiatric community. The particular areas of controversy centre primarily on the difficulties experienced by victims of very severe childhood trauma neglect and abuse.

 

Some academics argue the diagnostic criteria for borderline personality disorder should remain but the name should be changed to remove stigma and more accurately describe the condition. Dyslymbia, emotional dysregulation disorder and many others names have been suggested.

 

More progressive thinkers recognise that the whole concept of personality disorder is archaic and deeply flawed.

 

Some academics suggest that complex post-traumatic stress disorder type II is a more accurate description of the distress experienced, since the symptoms experienced by severe childhood trauma survivors are reactions to external events. I particularly approve of this stance, especially when the concept of ‘psychiatric injury’ is employed. It must surely be clear that distress following abuse is not an inherent flaw in the survivors brain, but rather a disorder emanating from the external circumstances that subsequently injure the brain.

 

The irony is that PTSD type I is a category that has been legitimised and accepted for some time.  Denise Russell in her seminal work Women, Madness and Society points to the centuries old tendency to label women with “disorders” that stem from the intolerability of the situations they find themselves in, and that it is patriarchal psychiatric attitudes that shape such normal reactions into a pathology.  PTSD Type I is most often connected to returning MALE combat veterans, and is an accepted diagnosis.  PTSD Type II is often associated with FEMALE survivors of abuse – yet it is not widely accepted.

 

Another area of research centres on dissociative disorder. This research is invaluable to understanding the needs of survivors. It is very relevant to understanding the concept of traumatic memory, and explains how intense the grave symptoms can coexist within an apparently normal person.

 

There is also growing evidence to suggest that severe and long-lasting neurological damage is caused during early brain development.  This is most likely to occur within children who are abused or emotionally damaged by both parents and have no other external influence of emotional stability, and occurs when the brain is forming as early ages between birth and four years old.  This theory is helpful in elucidating how prevention is of utmost importance, and also in removing any blame for a patient failing to respond to therapy.

 

Yet many psychiatric professionals who actually practice are far removed from cutting-edge debates. Many old-school psychiatrists, so entrenched in the older bio-psychiatry model, refuse to accept change, even refusing to investigate the possibility of  PTSD type II and Dissociation exist.

 

There is a tendency of psychiatry to fail to treat sufferers of psychiatric injury with the specific needs they have.  Psychiatric Injury and Mental Illness, whilst can overlap, are not necessarily the same thing and should be treated distinctly.  Survivors of childhood trauma and repeated rape, just like victims of military conflict and disasters are suffering from psychiatric injury.  A failure to treat psychiatric injury distinctly from other mental health conditions such as schizophrenia amongst many others can lead to extremely serious re-traumatisation sequalae in patients.

 

The problem is that whilst the dinosaurs refuse to engage with the new and crucial areas of research, and whilst academic rival egos pit themselves against each other to “win” the argument on their particular fields of research, it is the patients who suffer- the majority of whom are the victims of the worst forms of cruelty humans can commit.

 

Because there is no officially recognised classification or category for such patients mainstream psychiatrists often continue to treat patients inappropriately causing severe damage and re-traumatisation.  Bio-psychiatry traditionally sees the patient as a disordered mind.  Yet the sickness lies in child abuse and a society that continues to cover it up – not in the minds of those who rationally and legitimately experience traumatic stress as a result.  It is time psychiatry fully engaged with the progressive areas of research and got a move on with the debate. It is time the debate is understood by those practising in the profession. And it is time that distinct reified categories are reconsidered since every abuse victim is likely to have individual and distinct therapeutic needs and differing life experiences affecting our ability to cope with adult life.

 

The debate affects our current attitude to psychotherapy also. We have an over reliance on behavioural modification and a lack of understanding on adequately addressing the origins of the emotional pain itself.  There are so many different types of therapy that it is not difficult to do more harm than good by the wrong therapy been assigned to the wrong patients. Proponents of different therapies will often claim that their particular therapy is the ‘best’. Many councillors and psychotherapists whilst well-intentioned, are so ill informed that they are not able to appropriately assess which patients are suited to certain therapies.

 

The horrendous fact is that the vast majority of councillors, psychotherapists and psychiatrists are let loose, clueless, and having received no abuse-specific training whatsoever.  Most have no idea of the meaning of Trauma Bonds and Stockholm Syndrome, let alone the complexities of post-traumatic stress disorder Type II and Dissociative disorder.  Yet mainly claim to be experts!  It is my opinion that it is precisely the lack of even basic abuse specific training that accounts for the failure of much therapy.  Functional therapeutic alliances are virtually impossible to form if the therapist is inadvertantently reproducing feelings of helplessness and invalidation of the original abuse – simply because of basic lack of training or understanding.  (I had a good hearted Oxford educated therapist for 18 months – despite her good intentions and clear intellect she had never received any training on abuse issues or Trauma Bonds etc.  She failed to recognise a pattern of abuse that was happening at the time – and thus the therapy was flawed from the start….  She unquestioningly followed the rule book of the status quo)

 

How long is it going to take what is recognised by both progressive thinkers and the survivor community, as obvious and essential, to filter down to the hoards of so-called “professionals” out there?  Because the damage being done is gravely dangerous.  Some victims go totally untreated and are written off as untreatable, some are misdiagnosed, stigmatised, blamed, given the wrong medication or electric shock. How long is it going to take for these people’s pain to be dealt with appropriately?  In the meantime patients – victims of childhood abuse- deteriorate into exacerbated depression, alcoholism, drugs, and even suicide, to escape the pain.  People are dying because of this situation.  How can this be morally justified in a so-called civilised society?  A society that blames the victim, and where psychiatry currently fails one of the most vulnerable groups in society. 

 

The Hippocratic oath states thou shalt do no harm.

 

 

Borderline Personality Disorder. (BPD) – a convenient misdiagnosis – a social construct. The ultimate Silencer.

 

Voluntary Sector Agencies working in the field of childhood neglect and trauma regularly try and encourage the psychiatrists to attend training seminars on Trauma and abuse – but it is sadly the case that mainstream NHS psychiatrists are mostly too arrogant to attend saying “there’s nothing worth knowing that we don’t already know”.

In the end, psychiatrists prefer to blame the patient rather than admit it might be the system that is mistreating them.   Thus, often, the dreaded term Borderline Personality Disorder is employed to justify why these patients have failed to improve. 

 

Many patients would agree that some in the medical profession can display an air of arrogance when it comes to mental health.  But let assume there are really some of them who do care – and want to see results.  They have studied their books and feel knowledgeable.  They (think) they know what’s what!  So when they see a patient who has been severely abused as a child (otherwise known as an adult survivor) display symptoms and behaviours that cannot be fixed by drugs, regular counselling or CBT… it has been, and still is, often concluded that it must be the patient who is at fault.  They are difficult, noncompliant, attention seeking, selfish, and above all, dangerous, and to be kept well clear of.

 

Obviously it couldn’t possibly be the approach of psychiatry to these clients that could be the very problem!!!!!

 

Such attitudes towards victims of abuse re- traumatise and re victimise the already powerless and depressed individuals.

 

Increasingly, more progressive thinkers now realise that BPD is an erroneous and pejorative diagnosis.[1]

 

For a start it saves health care providers, and large insurance companies huge sums of money.  Many so-called professionals who use the term “personality disorder” in relation to abuse survivors, still regard it as totally incurable. The result is that patients are written off, with no appropriate (if any) treatment offered at all.  = huge amounts of money saved.

 

Secondly, if all the psychiatrists were to admit that BPD didn’t exist and recognise that the so called disgnostic criteria are natural responses to trauma – that in fact (in the case of severely sexually abused adult survivors in particular), can be classed, for example, as a type II post-traumatic stress reaction[2], and curable…… how could they stomach that?

 

They would have to confront the implication that they had refused to help countless treatable clients; some of whom may have subsequently committed suicide; others whose lives had continued to deteriorate when they could have been helped.  The psychiatric profession would have to admit that they had perhaps inadvertently played a part in the institutional abuse of victims who were already trying to cope with the effects of horrific childhood sexual and physical trauma.

 

It would take considerable amount of courage for a health professional to take that on board.  There is resistance- enormous resistance- to admitting such abhorrent failings.

 

It is arguable that the diagnostic criteria of BPD can all be seen as rational and natural responses to childhood trauma.  Denise Russell comments on the extreme tendency in psychiatry to actively deny the consequences of child abuse as psychiatric injury.

 

“ of course it is true that no one wants to believe that the abuse is that bad, and there could still be a Freudian influence, but I think something more is at stake. The news is very threatening to the biological model which is dominant in research and teaching, and it is this model which attracts research funding, often from the pharmaceutical companies. One can imagine that this funding would be under threat if causal accounts of psychiatric disorders don’t appear to relate to biology.”

 

Will the DSM (American Diagnostic and Statistical Manual of Mental Disorders) eliminate the turn BPD from its next edition?  I had hoped so, but have been told not to expect it in my lifetime.  After all there is so much money at stake, so many reputations are on the line, so many vested interests.

 

 Stigma and Punishment

 

Certainly BPD is a terrible stigma. So terrible that it is considered worse than schizophrenia or manic depression. If you are diagnosed with borderline personality disorder few healthcare professionals want to touch you with a barge pole.

 

On the news, mass murderers and rapists, sick paedophiles etc are referred to as suffering from an “incurable personality disorder”.

 

But why should the very victims of such criminal individuals be tarnished with the same brush?  It is abhorrent that survivors of incest or child abuse should suffer the same stigma (in a mental health context) as a murderer!

 

And whilst some of those convicted criminals receive counselling in prisons, sky TV boxes, recreational facilities rent free living -what to the victims get?

 

Well, if they are unfortunate enough to get institutionalised they have to suffer archaic and inhuman conditions.  Imagine a severely suicidal victim of childhood incest being locked up for six months.  During this time she has to endure mixed wards – sharing communal space with sometimes sexually deviant men who frequently touch her inappropriately and threaten her.

 

She has to hear the screams of schizophrenics, paranoid patients, hallucinatory psychotic people, day and night. Incessantly.  In the bathroom she may experience seeing human excrement smeared on the mirrors on walls and doors.

 

And the psychiatrists? How do they treat her?  Well if she’s not getting any better, not responding to treatment = bpd= a nuisance= non compliant= lazy =won’t help herself= not worthy of help.

 

God forbid that living in the burning fires of hell of such an establishment might make her depressed, or even just a little angry.  Well, then they will list anger management onto the list of her symptoms !

 

I recently tuned in to an online broadcast given by a University lecturer in the USA on the subject of BPD.  He said “borderlines have a tendency to really get at you – find your weaknesses and exploit them”.  As an example he relayed the story of a patient who meeting a newly qualified junior doctor had expressed dissatisfaction at this and apparently highlighted his lack of confidence as a new member of the team. 

 

Here lies a very disturbing problem indeed.  That this lecturer was classifying legitmate dissent as a symptom of her personality disorder.  This is a sure fire way to avoid accountability.

 

This is especially useful to ignore patient complaints and write their concerns of as difficult behaviour.  The general consensus being to ignore such complaints to avoid “being sucked into their manipulative games”.  With no accountability a person who legitimately complains about grossly negligent behaviour can be written off as borderline with impunity.

 

Could it not be that this girl may have been repeatedly re-traumatised by untrained “professionals”??  Could it not be that perhaps she had every right not to want that to happen to her again?  Rather than labelling this patient as manipulative and exploiting vulnerability could the lecturer not have seen the more compassionate view – that just maybe her reaction was not only sane but legitimate and in the interests of her very survival?

 

Misdiagnosis is a frequent occurrence. Patients are frequently misdiagnosed and drugged up on all sorts of chemicals designed to treat patients with entirely different illnesses. So drugged that they are unable to be bothered to talk or defend herself from the inappropriate advances of the disturbed male patients.

 

And how is the perpetrator doing?  If he’s in prison he may have his skybox  but the vast vast majority of paedophiles never get caught.  So where are they? In the garden having a barbecue? On holiday surrounded by family and friends? …..  with no stigma.

 

Victims are rarely believed, and generally people react by saying “poor man, to be falsely accused” .  These men who have caused so much hurt have their dignity, jobs, families and social support mechanisms intact.  They have their whole lives ahead of them.

 

Okay, so now what about the victims who don’t get hospitalised?  Will generally they go through the mill of antidepressants etc…. if they are very very lucky maybe anxiety management or CBT will be offered to them – and my God will they be told to be grateful.  However such treatments are often ineffective for the extreme symptoms of Type II PTSD.

 

So the victim who does not get the better fast enough rate might get comments like this…

 

You’re not helping yourself

you need to grow up and take responsibility

the stop attention seeking

you have had plenty of help, you don’t deserve any more

you are difficult

you are un- compliant

you show signs of frustration

you show signs of aggression (God I wonder why!!!!!!!!!!!!)

we cannot help you; and your writing you off of books

you are manipulative

you challenge authority (good, it needs challenging!!!!!)

you will only accept treatment on your own terms and this is unacceptable.  (Well, if that means not wanting to be reabused /re traumatised by so-called “therapy “, then yes- treatment on your own terms might be good)

the reason your husband hits you is because you have a masochistic personality disorder you need to take responsibility for this and we will not intervene – you need to learn to do it for yourself

 

Problematic Psychotherapies

 

An area that I consider to be highly problematic is the concept of “therapeutic communities” such as the Cassell in London.  I have met many people who have been abused in such institutions, where they have gone to live as part of the “community” in order to get “behavioural modification”.  Unfortunately such “therapeutic communities” are anything but therapeutic. They entirely endorse the concept of borderline personality disorder as a diagnosis, they claim that patients should not be “manipulative” and should “take responsibility”.  All work is done on the basis of behavioural modification, and from the many people I’ve spoken to “therapeutic communities” represent possibly the worst form re- traumatisation a victim of abuse can ever go through. 

 

The concept of “taking responsibility” implies the sufferer somehow should deny the legitimacy of their feeling and behave in a way which causes the least irritation to others.  It also implies some sort of moral flaw rather than recognizing the pain of psychiatric injury.

 

The term “taking responsibility” is often levelled at people who exhibit suicidal tendencies and other self harming behaviours.  Through lack of understanding those around the victim may feel manipulated, baffled and exhausted with the behaviour. (This can be a boundary issue which I refer to in more detail later on).  But psychiatric injury is about psychic pain. 

 

If someone had been injured in a car accident and had a crushed appendix – if they were screaming out in agony would they be told to “take responsibility for their own appendix”?  How would that work?  They would have to drive to hospital and perform the operation, without anaesthetic on their own – say whilst reading a medical encyclopaedia??”

 

It is a dangerous popular myth that people who talk about suicide or do half hearted attempts never succeed in actually dying by suicide.  Nevertheless, some suicidal gestures are often referred to as cries for help.  Even if the gestures are just cries for help ( not all are – many are genuine attempts to escape life) then what is so wrong with asking for help?  The fact is that asking for help in such a manner *is* taking responsibility for the situation because many survivors don’t know what else they can do.  After a life of trauma and chaos they lack the coping strategies for normal life – let alone coping strategies to deal with the dinosaur of a psychiatric practice.  If you’re drowning and don’t know how to swim, then it’s not abdicating responsibility to ask someone to throw you a life ring.

The people that really need to take responsibility are the psychiatrists who continue to re-traumatise, label and stigmatise vulnerable trauma survivors.  They need to take responsibility for their gross incompetence and the moral consequences of such abhorrent treatment.  It the equivalent of walking away from a drowning human being – saying “take responsibility for the fact you were never taught to swim, and watching them drown before you”.  Its morally disgusting.

 

Even more mainstream therapies such as Cognitive Behavioural therapy are arguably damaging.  According to Darian Leader

“: instead of getting to the root of the problem, we just address the surface symptoms. It’s like imagining that killing a few terrorists will get rid of terrorism, rather than exploring the factors that give rise to it. In this new dark age, a century of sociology, anthropology, and history and philosophy of science has been ignored.

CBT-style therapies were last used on a mass scale in China in the cultural revolution. Separated from loved ones – having perhaps witnessed their murder – people were taught to deny the legitimacy of their symptoms: depression was just the outcome of false beliefs.”

 

I think we should be very wary of labelling victims of long term abuse.  Surely to be sad and distressed as a result of abuse is sane!  Would it not be true insanity to react any other way?  Humans have emotions – that what it means to be human and our emotions have primordial survival functions.  Are victims of long term abuse mentally ill or are they just people who are a problem to society and the state.  Look at dictators such as Stalin – he branded opponents as insane…  The only illness is that of a society that does not want to face unpleasant truths about the way we treat one another – a society that is not truly ready to accept that young children are being abused behind closed doors every day.

 

Furthermore, this is especially true in the case of people who have been sexually abused in childhood and then subsequently re-traumatised for decades (sometimes longer) by the psychiatric system.  It would be insane not to react with sadness and despair….  those with depression ‘the so-called ill’ may actually be the sanest people on this planet.

 

Rather than being dehumanised these people deserve respect.  Of the ones that have not been completely destroyed by institutions they are often some of the most highly educated and informed people around.  More often than not their very survival has relied on them knowing far more about psychotherapy or about the latest developments in science, than the highly paid and respected psychiatrists who treat them.  And yet it is these psychiatrists that hold the power over vulnerable people’s lives. 

 

A psychiatrist can decide whether or not to write in your notes whether or not you are a compliant or noncompliant patient.  They can say whether you have a nasty disposition, they have the power to say whether you’re a good or bad human being, whether you are worthy or not worthy of help, they can lock you up against your will, drug you against your will and take away power of attorney. 

 

These people whose very choice of discipline means they are trained to be detached, often have no training whatsoever on how to communicate with other people on a human level. 

 

The problem is that the term “treatment resistant” can become a self fulfilling prophesy.  Because patients have been repeatedly abused not only by members of their own family but a multitude of therapists, establishing any sort of therapeutic alliance becomes nigh on impossible.  Because the patient rationally distrusts the therapist.  It can sometimes take from six months to two years for trust to develop to a sufficient level for therapy to take place.  If trust is eroded enough times, and if re-traumatisation or withholding of appropriate services is withheld for enough years, the psychiatry has created a self-fulfilling prophecy.  Then they can quote the “statistics” to “prove” how their theories of incurability and mortality are correct.

I understand that one of the main arguments against reclassifying BPD is that

 

1)       A small percentage of those who are diagnosed report no history of sexual abuse.

2)       It is estimated that only 50% of those who have been sexually abused in childhood ever display BPD diagnostic criteria.

 

Point 1 could be explained by the following in my opinion.

 

Lack of disclosure of abuse, Lack of memory of abuse (severe dissociation), less obvious but pervasive “emotional abuse” or just that the people have been categorized inappropriately – mis diagnosis is after all not uncommon!

 

Point 2

 

Many factors influence how well a person can recover from sexual abuse.  Including whether the child had to self disclosed or whether the perpetrator was caught in the act.  Support of family..  was the child believed?  The severity of the abuse, the length of time the child was abuse, how often…  The number of perpetrators involved..  The existence of a co abusive Mother, and or lack of extended family.

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[1]

 

 

[2] Borderline Personality Disorder Reconsidered   In J.E.B. Myers, L. Berliner, J. Briere, C.T. Hendrix, T. Reid, & C. Jenny (Eds.) (2002). The APSAC handbook on

child maltreatment, 2nd Edition. Newbury Park, CA: Sage Publications.