The Trauma Challenge
A Neo-Medical Model for Psychiatry.
Trauma evokes a cognitive fog in the child’s mind which then perpetuates itself, sometimes indefinitely, blocked there because only unimpaired cognition can clear it. This has two main consequences. One, it renders the conventional medical approach counter-productive. Two, since this fog prevents sufferers from knowing that the trauma has stopped, it provides an exceptionally clear target for treatment – convincing the sufferer that the abuse is now over. Closer examination of the nature of healing, leads to a review of what distinguishes living processes from the dead, a distinction that has yet to receive an acceptable scientific formulation. A revised medical model for psychiatric pathology is described in which fear is seen as the pathogen analogous to the cholera ‘germ’ – the conclusion being that just at you cannot get cholera as long as the sanitation remains intact, so all psychiatric symptoms remit in a fear-free zone. Existing clinical evidence for this is briefly reviewed.
The key to unravelling psychiatry is understanding trauma. The human mind is peculiarly vulnerable to trauma, especially when young – a blind-terror is induced which turns cognition off. Cognition ceases. The mind is ‘ill’. It pays the child not to know what is happening, or who is doing what, to him or her. This is variously described as ‘denial’, dissociation, projection, repression – what have you – the upshot is that the child daren’t look, so cannot see. Repeat, DAREN’T LOOK, SO CANNOT SEE. The child works on the malperception that “full cognition or visualisation of this event is TERMINAL”. And once the child stops seeing, and this can happen quite suddenly especially pre-verbally, then they are thereafter incapable of telling whether or not the trauma has stopped. “This isn’t happening to me” leads inexorably to the inability to say or think or believe that “this has stopped happening to me” – or even very clearly what “this” is.
Two things follow. (1) The medical profession is hamstrung by it. (2) The 100% remedy for it is assured – you and I know it has stopped, and our (simple but not easy) task therefore is to persuade the sufferer that today’s reality prevails, that yesterday’s trauma is now over. But we must accomplish this without ever being either parental, or re-traumatising, both of which are relentlessly easy to do.
Take (1). “Listen to the patient, s/he’s telling you the diagnosis”, said William Osler, arguably the finest clinician of the last century. But those who have been traumatised are determinedly not even telling themselves. They will swear black and blue that ‘nothing happened’, that their childhood was ‘magical’, that parents could never have been better, and how wrong it would be to breathe a word of criticism of them, and so forth. To admit otherwise is to re-traumatise themselves instantly, as easily as can any ham-fisted professional breezing insensitively in. Their only remedy against the pain of abuse, is to ‘have it NOT happen’ – so woe betide those who wish, prematurely, to prove that it did. Sadly this ‘remedy’ of ‘daren’t look, so cannot see’ which was the only one available to any small infant, is now precisely what gums things up in adulthood.
So the orthodox medical approach is scuppered. It’s like a man with a broken leg, vociferously denying it’s painful, or that he has a limp – the customer is king, even when they’re obviously in deep trouble. And doctors have no licence to treat ‘complaints’ that are not complained about. But they do have a licence to link the items complained about, to earlier ‘unseen’ problems – but only, and forever, with the sufferer’s consent. This is uphill work, since it is invariably coupled with prodigious resistance from the sufferer against doing any such thing – and there you have today’s doctor’s dilemma.
So a different clinical approach is required – not an easy thing to ask of a profession steeped in tradition since Hippocrates. Instead of taking what the patient says at face value, the clinician needs to ‘listen’ exceptionally carefully, to ‘hear’ the bits that are being left out, or stumbled over, and to bring these, with invariable courtesy, and scrupulous consent, to the sufferer’s attention. Never in a parental or authoritarian way, but always as an informal offering, on a take it or leave it basis. To do otherwise, is to cast yourself unequivocally into the role of the adult abuser in the sufferer’s distorted perception, and thereby reliably invite anger and rage commensurate with the abuse, here visited (irrationally) on your own ham-fisted self. The abuse did occur, despite the ‘denial’ that it did not – but more importantly, it has actually stopped, which the sufferer also actively denies. Pressing this prematurely can be disastrous if not fatal.
The dilemma is especially sharp when questions arise as to whether the abuse did in reality occur, or not –the ‘false memory syndrome’ quagmire. However, in practice only the severity or otherwise of the current symptoms are relevant clinically – it’s the remnants today that matter, not precise detail of how they arose – and in all cases they need eliminating, 100%. The more severe the symptoms and the more life-threatening (which is the doctor’s prime concern) – then the more solid is the evidence for past trauma. It’s not what actually occurred, which is less important clinically, it’s what remains today from what occurred then. Here again, the absolute pre-requisite for resolving any such dilemma is a sound, respectful, but above all trustworthy clinical rapport.
So to (2), the remedy. Every child falls over (and for some, mum dies), and it hurts. For those who receive immediate, reliable and trustworthy support, childhood pain is ephemeral, and psychiatric symptoms few. Where support is delayed, unreliable or deceptive, long-term effects can be gruesome. Indeed they tend to last until such time as the support that was initially missing is made good – which is the only legitimate objective of today’s therapy. A deficiency model for psychiatric symptoms.
You know with 100% certainty that the trauma is over – the sufferer in front of you does not. Your task is to convey this belief, this ‘fact’ from you to them. So a pre-requisite on your part is to believe it yourself, at least to believe that this is the problem, the chief problem, if not the only problem. Since this runs counter to medical training – let’s take another concrete medical example.
If, as a doctor, you are asked to heal cut skin, you have no doubt as to what you need to do. Keep it clean and dry, so as to avoid pathogens, especially infection. No problem here. You don’t actually do the healing yourself, your uncontroversial task is to facilitate it – you can make it better, or you can make it worse – but the actual process of healing is out of your hands.
Moving from lesions of the skin, to those of the mind – the sufferer in front of you is still being traumatised today, mentally. This elementary clinical fact took me decades to grasp, and even today surprises. The abuse, as far as the sufferer is concerned, continues, indeed it is about to happen ‘next’. The paralysing symptoms are not so much ‘flash-backs’, as ‘flash-surfacings’ – the original trauma has become ‘frozen’ as in a ‘freeze-frame’ – it never went away. Cognition, as mentioned, has ceased. Mentally, the sufferer is therefore blindly (and impotently) waiting to be raped, tortured, kidnapped, abandoned, starved, emotionally deprived, or otherwise dumped at death’s door, all over again. And that’s all. The trauma has never stopped in their minds – this is the lesion, the pathology. Cognition just doesn’t apply – it’s not functioning, it’s been put on hold, as if their life depended on it. And until it starts again, all manner of weird and wonderful symptoms are concocted, limited only by the creative imagination of the human mind – their immediate effect is to befuddle the doctor with endlessly variegated symptoms, their ultimate purpose to defer the inevitable ‘end’ which the sufferer is convinced lies just around the corner, perpetuated irrationally by the persistent cognitive fog.
As usual in any practical application, certain rules-of-thumb prove themselves more useful than others. Video can help, since actually seeing ‘blocking’, and indeed ‘unblocking’ or ‘blossoming’ as described, tends to be more convincing than textual descriptions. There really is no substitute for direct hands-on experience.
A NEO-MEDICAL MODEL FOR PSYCHIATRY
What have gambolling lambs and blossoming bluebells to do with psychiatry? Well, it’s about being alive –neither can gambol nor blossom after they die. The scientific community has been disgracefully slow to grasp the elemental difference between being alive and being dead, and sadly today’s psychiatry suffers as a result. Though scientists have cheerfully taken Relativity and Uncertainty in their stride, they persist in fumbling the difference between in vivo and in vitro. Even something as abstruse and hard to come by as anti-matter is nowadays quite acceptable, whereas the most vital thing about being alive – its adaptability – is not.
Starting with the simplest possible example. Living skin heals, but dead skin doesn’t. The chemicals are the same, the physics is not. Thermodynamics needs updating. All non-living things fall to bits, over time, their disorganisation or ‘entropy’ inexorably increases. Contrariwise all living things organise – they exhibit the property of ‘negative-entropy’ – ‘nentropy’ – until they die, when they don’t. The medical profession relies on nentropy, or something closely akin to it, for whatever healing it does manage to achieve – so if you dismiss this property of life as being ‘unscientific’, too vague or just irrelevant, then you not only jeopardise clinical progress, but also condemn psychiatry to enduring nihilism.
‘Nentropy’ is hardly the most poetic way of distinguishing the living from the dead – but non-scientists will be astonished to learn that no prominent scientist, and certainly no theoretical physicist even attempts it. In practice, the notion of nentropy circumvents problems of teleology, of creationism, of theology and of a ‘life force’. Its chief drawback is its vagueness – how to define it. Worse, this is a problem that cannot be solved by ever tighter definition. Indeed there is a sort of Verbal Uncertainty Principle at work here – the tighter the definition, the less the meaning. Thus the three most important words of all – pain, fear and intent – have maximum meaning but zero definition, yet we use them perforce every day, if not every minute. If ‘pain’ were proscribed from everyday medical vocabularies, on the grounds of being hopelessly indefinable, which it is, this would relegate a rather noble profession to veterinarianism.
So to the wider picture. The medical model works. Cholera no longer decimates, provided we keep the sanitation intact; even AIDS is relenting. However, present-day psychiatry, where suicide now kills more than breast and prostate cancer combined, needs a refurbished model, one that takes account of nentropy or its equivalent – we need a neo-medical model. If you cannot avail yourself of a scientific basis for choice, intent or emotion, you risk ending up with the notion that humans are mindless unfeeling robots, painfully close to the condition today’s so-called anti-psychotics are designed to induce. Those who pass laws mandating the use of such drugs, and indeed those who prescribe them, should each swallow a single dose so that they know from direct personal experience just what these chemicals can do to the human soul, or to our nentropy.
If skin can heal itself with minimum non-drug support, why can’t minds? The medical methodology that works so well with cholera – keep the pathogens at bay – works equally well in psychiatry, given a practical psychiatric pathogen. Pain is the commonest of all symptoms in medical practice, so it is not surprising that its mental equivalent, fear, holds the same key role in psychiatry. It’s simple really – where leg pain obviously stops you walking properly, so fear stops you thinking straight. This is trauma at work – a terrified infant stops thinking – and threats you cannot think about, you can never resolve.
Just as aseptic surgery saves more lives than its predecessors, so fear-free zones save more minds than current alternatives. But as with the battles over germ theory in the late 1800’s, it is not easy to persuade the medical profession and significant others, that an invisible, amorphous, and utterly indefinable pathogen can inflict so much havoc. Kaiser Wilhelm’s Chief Chemist shot himself in 1901, because he got cholera so spectacularly wrong. And male midwives refused point blank to wash their hands between deliveries – it was a point of pride in their professional training. Many, including psychiatric staff, dispense fear to their charges, as a matter of course, “for their own good”, an approach Alice Miller castigated as such, in 1980. Suggesting that fear is the crucial psychiatric pathogen is decidedly uphill, especially since there’ll never be a microscope or Petri dish to help – only willing, observant, benevolent human beings.
So let’s follow an abbreviated Koch’s postulate, and look at the available clinical evidence. A basic fear or terror, can readily be found clinically in every conceivable psychiatric disorder – from paranoia, psychopathy, anorexia and other self-harms, bulimia, manic-depression, psychosis, bi-polar, and in all versions of schizophrenia and in all varieties of personality disorder. Improving on Koch, there is already adequate clinical evidence that eliminating this pathogen by means of establishing fear-free zones, cures psychiatric disease. The early Quaker Retreat in York, 1796-1850s, had better rates of curing psychosis than ever since [www.madinameria.com], as have Loren Mosher’s Soteria Houses [loc cit]. At a recent Hearing Voices Network conference, wonderfully brave individuals gave graphic accounts of overcoming gross trauma, thereby eliminating their earlier severe psychoses. Just as the antidote for cholera is sanitation, so the antidote for fear is trust. And, since you cannot get cholera if the sanitation remains intact, so psychiatric symptoms cannot persist in fully fear-free zones. Essentially it’s the healing hand of kindness, with insight.
The challenge is not lack of evidence, it’s drawing conclusions, joining up the dots, lifting the cognitive fog. Human Rights are therapeutic. which though rightly revered in our wider society, are generally regarded as too ‘unscientific’ to prevail in current psychiatric settings. Sadly today’s psychiatry poses the real underlying “TRAUMA CHALLENGE” – what you daren’t look at, you simply cannot see.
Dr Bob Johnson www.DrBobJohnson.org Thursday, 16 December 2010