How to Compound Trauma

It's actually easy.

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

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Last week, I watched a lecture entitled “Developments in the assessment and management of PTSD.” It was part of the educational program for the local college of psychiatrists, although this one was put on by a large private hospital company, which meant I was deeply suspicious even before it started. I sent a brief commentary to our critical psychiatry group last week.

The speaker began by telling us how and where he trained, including some scenic photos of a number of hospitals. The emphasis was almost exclusively on post-traumatic mental disorders in veterans, with a few mentions of police. The first part of his talk covered recent developments in guidelines used to reach the diagnosis. These came from the RANZCP, American Psychiatric Association and American Psychological Association. They were based around the DSM-5 diagnostic criteria and have hardly changed since the term was first introduced in DSM-III in 1980. There wasn’t time for a point-to-point comparison of the various guidelines or how they are actually developing.

Part two covered “Working with military and veterans,” meaning the various treatment options available. First line of management is psychological, and he listed about eight different types of psychotherapy, with the controversial EMDR getting most of the time. EMDR was introduced in about 1987 by a psychologist who, while on a walk in the country, found that if she flicked her eyes rapidly back and forth, she could cope better with upsetting thoughts. The process involves the patient talking about bad events which have led to the problems, while moving the eyes side to side or up, down and around.

Next line of treatment is drugs, meaning SSRIs (essentially fluoxetine, sertraline, paroxetine and venlafaxine), followed if necessary by antipsychotic drugs including risperidone, quetiapine, brexpiprazole and so on. A diagnosis of psychosis is not necessary. The antihypertensive drug prazosin was mentioned for people suffering from Nightmare Disorder. There was practically no mention of treatment of sexual dysfunction, which is more or less universal among people suffering post-traumatic states. ECT also didn’t get much time although it is commonly given to veterans.

The lecture concluded with a discussion of care pathways for PTSD sufferers, which was heavily oriented toward the military. It mainly consisted of lists of agencies available as well as slides of web pages from various veteran support groups, accommodation or alcohol and drug rehab programs and so on. Naturally enough, the extent and quality of this support varies dramatically from one state to the next, and between countries. He mentioned one program that seems to have peaked recently, companion animals, including dogs and horses, although there was no mention of the astounding costs involved. This section included some figures for admissions from 2019-20. There were 10,700 admissions for serving members and a remarkable 200,600 for veterans. This would have to be for all hospital admissions so it wasn’t much help (the speaker used the word “hospitalisation” rather than admission; I assume they’re the same thing). This ended the lecture proper but I couldn’t stay for questions.

I’d have to say this was probably the most boring talk I’ve sat through in many years. In a steady monotonous drone, the speaker read from slides of lists or web pages from different agencies but there was no critical analysis. For example, we were not told of how, from its humble beginning one day in the woods, EMDR has grown into a great and profitable industry, almost de rigueur for veterans in this country, except it has no established scientific basis. It’s been said that anything effective about EMDR is not new, it’s simply part of what psychologists do, and anything new is not effective. Others have called it “purple hat therapy,” meaning that one day, somebody wears a purple hat while delivering an otherwise normal form of therapy; it works, so he patents the idea that it was all due to the purple hat (and, unstated but assumed, grows rich on the proceeds).

Similarly, how are drugs to work in this condition? Are they specific or just acting as general tranquillisers, albeit toxic and addictive ones? This is where the lecture failed as education: we weren’t told what PTSD is. In particular, there was no attempt to define that elusive quantity, stress. After his irrelevant introduction, he simply launched into guidelines of assessment, the impression being that the guidelines tell us all we need to know. Tick a few boxes and the diagnosis spits out. Patient’s upset, send him to a psychologist. Patient drinks, off to alcohol program; he’s depressed, prescribe drugs; he doesn’t improve, admit to hospital, prescribe more drugs and maybe ECT. That’s it. There was no explanatory content at all, the speaker simply assumed we’re all on the same page and went from there. Everything was descriptive: describe the lists of symptoms; describe the different forms of psychotherapy and then lists of drugs; describe NGOs and other agencies. However, when it comes to humans, description is not explanation. Describing an agitated or unhappy person is not the same thing as explaining that person’s distressed mental state, but explaining it determines the specific treatment. In the absence of any attempt at explanation, we end up with a one-size-fits-all program where, if it works, it was because of our program but if it doesn’t, it’s because you’re difficult but pay us anyway. Which, of course, is what it’s all about. Money.

Starting in about 1994, veteran health services in Australia were privatised, and are now run entirely on a profit basis. The Dept. for Veterans’ Affairs (DVA) simply pays the bills, so the incentive to admit people to hospital is very powerful. I’m not sure whether any of the private hospitals employ their own psychiatrists; mostly, they don’t, the psychiatrists are self-employed but the same incentive is there. There are limits on how many times a patient can be seen as an out-patient, but those limits don’t apply to in-patients, so that’s what happens. In particular, the psychiatrists devise various “treatment programs” where patients attend the hospital all day, five days a week for four weeks or so, for a variety of sessions on how to relax, cutting out the smokes and booze, exercise, individual and group sessions with psychologists including the lucrative EMDR, and so on. In between, they see the psychiatrist who “titrates” or “fine tunes” the drugs, meaning starts and stops drugs willy-nilly. The only costs I ever saw for these courses were ten years ago, starting at $20,000 for 20 days as an out-patient (very inconvenient for anybody who has to travel across the city), up to $40,000 for 30 days. In-patient treatment doubles that.

Clearly, war is very, very profitable, especially as there’s precious little evidence that this huge expenditure does any good. Also, all the other people whose heads are messed by traumatic experiences hardly get a mention, which may have something to do with their being poor. Now, as I know too well, saying things like “This is a waste of time and money” (usually abbreviated to WOFTAM; here if you can’t guess) provokes a fierce reaction from those in the industry, the sort of reaction you see in people whose incomes are threatened. I know this because I used to say it, and was dumped as a result. I spent the better part of ten years in the DVA system, including five years as head of department in the only DVA hospital in the state. Over many years, I personally assessed and managed probably two thousand veterans and serving members of the military, covering every one of this country’s military stuff-ups since 1915 (see case of Mr Walter K, case 5.7 in [1], who broke down at about 9.30am on July 19^th, 1916, and never recovered).

As the chief psychiatrist of the hospital, I was able to reduce the number of admissions dramatically (not using ECT greatly helped with that process). As a private psychiatrist contracted to the Dept of Defence and DVA, I hardly ever admitted people to hospital. I rarely prescribed antidepressants, never used antipsychotics unless the patient was actually psychotic, no ECT or TCMS or such like, and wrote two suicide reports for the coroner in all that time. One was for an elderly man who had been in and out of hospitals for decades, was in chronic pain and had no family (i.e. he was at serious risk of suicide) and the other for a man in his 30s who drank very heavily and was found dead soon after discharge, surrounded by about 50 empty beer cans and with a sausage roll stuck in his throat.

These figures say only this: It can be done. It doesn’t need teams of earnest therapists wrestling with the demon of mental disorder in hugely expensive private hospitals. People can get over the worst of it and get on with life, albeit a different life than before. However, nobody wants to know that; as a result of putting these figures to the Department, my contract was abruptly terminated and the lucrative PTSD bus rolled on uninterrupted. I’m certainly not the only one who takes a low-key approach to these matters but nobody wants to know how to save millions each year by getting people off drugs.

I mentioned this last week in my comments to the critical psychiatry group and something very strange happened: one of the members asked: “Can you share how you worked with your patients with PTSD and the insights you gained?” I say it was strange because in all those years, nobody ever asked, and when I tried to tell anybody, they secretly arranged for my contract to be cancelled. Why did nobody ever ask? They don’t want to know, as Upton Sinclair noted many years ago: “It's difficult to get a man to understand something when his salary depends on his not understanding it.”

However, the question put me on the spot: How did I manage without hospitals and all their expensive staff and paraphernalia? Come to think of it, I don’t actually know. All I know is that I don’t like hospitals, they’re very bad places, so the best way to deal with mental problems is catch them early and near the patient’s home before things get out of control. To me, that’s absolutely elementary. Get the psychiatrists (and psychologists, and social workers and nurses) out of the hospitals, into the suburbs and into the small country towns, build rapport with the local staff, provide personal service to the patients, take proper histories and it all falls into place. This is not rocket science. You don’t even need an MRI scanner.

Trouble is, the systems in place are not set up for that. I may have mentioned a visit some years ago to a big hospital in Detroit where I was shown around by the director, a very cultured psychiatrist from West Asia. The entire system was simply medieval. Patients were generally brought in by the police on orders; they were stripped of their clothes and put in a night gown, then let into a large ward with beds down each side. After a while, an elderly nurse wheeled in a trolley with a light (for night time) and a computer. With the patient sitting on the bed and everybody else standing around to help, she took the patient through a standard questionnaire and recorded the answers.

“This must be very expensive,” I said to the director. “It must cost you $1000 every time anybody comes through that door.”

“It’s $1,132,” he replied briskly.

“I could show you how to do it for about $250 per person,” I offered.

“Not here you couldn’t,” he announced cheerfully. “Corruption and institutionalised ineffiency, that’s what it’s all about.”

He was right, and it’s universal. The system rewards itself. The patients are simply the raw material for a self-sustaining industry. Instead of a dispersed service offering individual care, psychiatrists lurk behind the locked doors of their hospitals or cluster in high rises in expensive parts of the city, handing out questionnaires and ordering brain scans (soon to become genome assays). Instead of seeing people as humans reacting to their circumstances to the best of their limited abilities, they view them as biological preparations just needing the right combination of chemicals to fire them up inside. And instead of seeing themselves as groping in the dark due to lack of a model of mental disorder, they’re convinced they have mental disorder pinned to their dissecting boards. Or maybe visualised in a PET scanner, that bit’s not clear. But what is clear is their conviction that they can’t possibly be wrong and anybody who questions them is malicious.

To go back to the lecture that started all this, I think the reason the speaker didn’t say what he believed PTSD to be is because he didn’t know. He knew he had to talk about biology but, in the first place, there’s no consistent evidence for primary biological causes. Granted, every now and then we read a report of a “breakthrough” in understanding it. Somebody has come up with some results of scans or gene studies or blood hormone assays and is convinced this is it, the “biological cause” of this mental disorder is clear and specific treatment will soon roll off the production line. Inevitably, it goes nowhere. Second, if all mental disorder is biological, how can a purely psychological event produce lasting changes to the brain? No idea. However, when it came to talking of possible psychological causes of the problem, he was equally at sea as he had no theory of mind and no model of mental disorder. Given that level of intellectual vacuum, waffling on about questionnaires and drugs and cuddly dogs seemed like a viable strategy to stay in the job.

On the other hand, we could jump to a psychological explanation. At 18, young Jimmy joins the army. He’s keen as mustard, learns quickly, is cheerful and helpful and doesn’t argue. He’s always known he’s good with his hands, he likes fast and noisy machines and knows he can get along with practically everybody just by telling a few jokes. In short, he’s an ideal recruit. In due course, his unit ships overseas but after six months, something terrible happens. For the first time in his life, he’s in pain, seriously disillusioned with what they’re doing, unable to sleep, off his food, doesn’t see anything to laugh about and just wants to get away from the mayhem and be left alone. Instead, nobody listens, people sneer at him and it quickly gets worse. He finally gets home, found to be unfit for service and is discharged. Now, he is bitter, totally alone, feels nobody cares or tries to understand. His confidence has gone, he sees the world as a dangerous place and all the people around him as deceitful and likely to stab him in the back. If anything startles him, he reacts badly, either flying into rages or dissolving in panic but he soon learns that alcohol will settle the worst of it. People prescribe tablets but they’re worse, he’s gaining weight and the last of his sex life has withered and died. That’s all stock-standard stuff. Walter K showed every bit of it a hundred years ago.

There is a perfectly adequate psychological explanation for all this. From feeling safe and secure in a predictable world with pleasant people around him, he now believes he is in a dangerous and treacherous world where everything is potentially a disaster waiting to explode. He used to like people; now he sees them as critical and unhelpful, or just trying to cheat him of his rights. Worst of all, he feels betrayed. He only ever wanted to enlist but the army broke him then threw him out without another glance. He used to be proud of his physical body; now it has totally let him down. He can’t lose weight; has no sexual interest but who would look at him anyway; he panics at the drop of a hat as he expects everything to go wrong and lives on a hair trigger; his guts play up; muscles and joints ache; he panics if people get too close and has to rush away, everything.

It’s all due to his changed belief system, it’s all psychological. Now, he believes the world is dangerous and believes people can’t be trusted, so therefore he is constantly highly aroused and irritable and worn out and sick of everything. Any brain or hormonal changes are secondary to his belief state. This is such an economical model but because psychiatrists are locked into their notion of biological reductionism, they just can’t see it.

References:

1. McLaren N (2018). Anxiety: The Inside Story (see below).

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.