Helping consumers add years to their lives, VI: The implications of ACEs and a trauma-based treatment model

This is the sixth in a series of blogs devoted to examining the barriers that block persons presumed to have major mental illnesses from living longer and more effective lives. This time, I thought it might be more useful for those of you who have been reading this series of blogs to write a follow-up to my last blog, where I first introduced the notion of replacing the disease model with one rooted in trauma and that utilizes ACEs for explanatory purposes. The “jobs” blog will wait.

I explained in "Replacing the Disease/Biological Model with ACEs" why I thought the disease model had to be replaced: it is underpinned by suppositions about biological or genetic causes for serious mental illnesses that have little data to support them; and it relies principally for treatment on neuroleptic and other psychoactive medications, which dramatically shorten life expectancy. Finally, I explained that I viewed serious mental illnesses as existential in nature, i.e., problems in living, that required psychosocial solutions, principally the teaching of social skills and skills of emotion regulation. Accordingly, the model I was proposing was not concerned with etiology or cause but primarily with treatment, as well as with questions of epistemology—why do certain individuals experience psychotic episodes—and ontology—how are these individuals to be in the world and what is their individual self-identity to be?

On further reflection, however, I believe the real starting point for this discussion is even more basic: why do we need a model at all?

Persons who undergo psychotic episodes, and their family members, usually want some sort of explanation as to why they’ve gone through what they have. It’s probably less counter-intuitive to acknowledge that traumatic experiences could well cause individuals to have psychotic symptoms now that mental health practitioners and the general public have acquired some familiarity with PTSD and the persons who suffer its consequences, particularly combat veterans, 9/11 survivors and witnesses and other terrorist attacks, survivors of natural disasters and victims of sexual assault and domestic violence. Yet, very few Americans, including mental health professionals, have much awareness of the centrality of trauma in the lives of persons considered to suffer from serious mental illnesses.

In a survey published in 2002 by Maxine Harris and colleagues of the trauma histories of men and women treated at Community Connections, the treatment program Dr. Harris directs in Washington, D.C., the prevalence of lifetime exposure to sexual or physical violence was as follows:

• For men and women diagnosed with serious mental illnesses: 43-81%, depending on treatment setting and trauma definitions;
• For women addicted to substances: 55-99%;
• For homeless women diagnosed with serious mental illness and substance abuse disorders: 97%;
• For all homeless women: 43%

… of childhood sexual abuse:

• For women hospitalized in in-patient psychiatric units: 55-63%;
• For women treated in out-patient settings: 40%;
• For men, depending on population sampled and definitions: 4-76%

… of violence and physical abuse:

• For homeless women, by childhood caretaker or other adult in household: 66%;
• For homeless women, by an intimate partner: 63%
• For all women: 20%
• For all men: 33&1/3%.

By way of comparison, approximately two-thirds of the 17,000 essentially middle class respondents in the ACE—adverse childhood experiences—study reported at least one ACE and over 20% reported three or more. Only three of the ten ACE questions refer to physical, emotional or sexual abuse, but each of the ten does involve a traumatic life event to which the respondent was exposed as a child. (C.F. #V for overview of ACEs study.)

The trauma surveys I conducted in my program of 150 women clients in 2005 and 269 men clients in 2006, all of whom diagnosed with serious mental illnesses, revealed the following:

… for the women, whose mean and median ages were 43:

• 51% were victims of sexual abuse as children and/or adults;
• 48% were victims of physical abuse;
• 9% were perpetrators of sexual abuse;
• 13% were perpetrators of physical abuse.

… for the men, with mean and median ages of 41:

• 11% were victims of sexual abuse as children or adults;
• 25% were victims of physical abuse;
• 3% were perpetrators of sexual abuse;
• 13% were perpetrators of physical abuse.

Finally, for the women—63% of those who were victims of sexual abuse also had histories of substance abuse; were also more likely to be diagnosed with affective disorders than women in the program who had not been sexually abused;

… for the men—78% who were victims of sexual and physical trauma had histories of substance abuse; and, unlike men in the program without trauma histories, had a higher incidence of affective disorders and lower incidence of schizophrenia.

None of the foregoing supports trauma as causative of serious mental illness. Again, that’s not my principal concern. If anything, the data depict trauma as co-morbid with substance abuse and affective disorders. Nor do they rule out the possibility of a basic biological vulnerability on the part of persons presumed to have serious mental illnesses; but, more importantly, they do offer explanations as to why these individuals do what they do—their bizarre symptoms and behaviors—and are who they are—strange, out of touch, outside, other. These are folks who, in the main, have been beaten and abused close to death for most of their lives.

The data, by inference, also serve to paint a picture of a society that is cruel, particularly to the “other”, and of a public mental health system that cannot help or protect them and is often a prime party to their oppression. I was re-introduced to the notion of oppression when I read, about 10 years ago, Frantz Fanon and the Psychology of the Oppression, published in 1985 by Dr. Hussein Bulhan, a Sudanese psychologist teaching at Boston University. This was at a time when we were working with parolees with serious mental illnesses, and I was seeking to understand why mental health practitioners and programs were so reluctant to help them.

Was it something about the parolees or was it the mental health system itself that presented the greatest barriers? I had originally read Frantz Fanon’s The Wretched of the Earth 30 years earlier. Fanon was a Martinican psychiatrist who wound up in Algeria treating the torture victims of the French secret service as well as their torturers during the Algerian revolution of the 1950s. He was witness to men and women so brutalized that they had surrendered their very identities, their social and personal sense of self, to those who had brutalized them; and he came to believe that the brutalized could only regain their sense of self, their lives, by taking the lives of their oppressors. One might remember that the Black Panthers analogized Fanon’s formulations when they spoke of racism in this country as domestic colonialism.

Accordingly, “oppression” is a very loaded term. Bulhan defines it much more broadly than Fanon, viz., as an interactive social phenomenon involving more and less powerful persons, wherein the former, via acts or threats of physical or psychic violence, projects his/her more loathsome aspects of self onto the less powerful and the latter introjects them as her/his own. In short, the more powerful gains a sense of self at the expense of the latter who loses it, a process also outlined by Goffman in Asylums.

These acts of oppression and violence can be structural or societal and institutional, as well as inter- and intra-personal. In Bulhan’s inclusive taxonomy, structural or societal violence can take the form of poverty, racism, patriarchism, homophobia, unemployment, the death penalty; institutional violence can be seen in police violence against persons of color, the incarceration of persons of color and poor persons for serious mental illnesses, the tracking of children of color and poor children into special education classes; and personal violence can consist of violence against others and against self, including suicide, self-mutilation, anorexia and bulimia.

The principal consequence for those being oppressed is a sense of general alienation – from self, others, including the oppressor, from their own culture, and from creative and meaningful social practice or social roles. In sum, oppression and its violence impede the development of an individual’s self-identity and must be regarded as risk factors that increase an individual’s vulnerability to psychopathology. What can offset the adverse impact of oppression is an individual’s resilience and the extent to which the environment in which the individual resides is facilitative or supportive or not. Werner and Smith define resilience as a person’s constitutional or characterological resources that assure that an individual’s personal development will not be blocked even under adverse environmental circumstances.

They emphasize that a person’s resilience is not a universal constant but waxes and wanes and is dependent on a series of variables … the person’s life cycle stage; gender; cultural context; the severity of the stressor the person is experiencing; and the accumulation of stressors over time. The key factor in enhancing a person’s resilience and in reversing the downward trajectory of a person’s life, no matter the person’s age, is what they term a “facilitative environment”, viz., one that provides nurturance, support and validation, as well as learning and vocational opportunities. They cite as examples, in a number of studies published largely in the 1980s, effective nurturing, particularly by the person’s biological or surrogate mother; the father’s esteem and respect for the mother; an accessible support system, including supportive teachers and religious figures; and military or volunteer service that served to remove the person from a toxic or unsupportive environment.

I concluded then, as I do now, that persons presumed to be seriously mentally ill possess a great deal of resilience. How else could they have survived what all have gone through? Indeed, in the powerpoint presentation I developed ten years ago to persuade mental health practitioners of our clients’ innate potential for recovery, I posed “oppression” and “resilience” as poles of a dialectic that could only be resolved by our “clients” themselves. Specifically, I believed, and still do, that persons presumed to have serious mental illnesses need to organize themselves as a civil rights movement whose objective would be the reclamation of what I termed their community citizenship, viz., meaningful social roles and participation.

I had been struck in the description of the resiliency studies by the absence of psychotherapists and other “professional” helpers as members of the facilitative environments that promoted the study subjects’ resilience and successful outcomes. It appeared to me that the helpers in those studies were able to negotiate two difficult dialectical dilemmas: social control versus social change, or to whom were they really accountable? and nature versus nurture, or could the individuals they were trying to help really change? In my estimation, they did so by remaining true to their mission, viz., to help those whom they were helping free themselves of the limitations that their family and community and larger societal environments might have ordinarily imposed on them.

I believe, in accordance with Bulhan, that mental health practitioners have a third to address, one which Bulhan terms the “pathology of the self—mental illness; loss of personal functioning; assumption of the powerless patient role—versus “pathology of liberty—loss of ability to self-actualize via meaningful social praxis or functioning; loss of a valid social role. My many years of practice experience have persuaded me that most mental health practitioners have little appreciation of the latter, i.e., pathology of liberty, and have no training appropriate to the task. In other words, it has never been posed to them as their mission. Rather have we all been trained, particularly over the course of the past 30 years, to tell the persons with serious mental illnesses we presume to help that they are sick, will be sick, probably for the rest of their lives, and will be better off to accept their roles as patients. Now that’s oppression!

That’s why I prefer the trauma paradigm. How much more effective and rewarding to tell a person undergoing a psychotic episode, when she/he is able to ask, that she/he is the victim of probably lifelong abuse; that she/he can learn skills and strategies that will prevent or mitigate future episodes, should they occur; that, over time, she/he will be free to make life choices regarding roles and relationships, much as we all do. That’s known as self-determination! One final note: I’ve succeeded in piquing the interest of a local New York City advocacy organization to have some of its members participate in a very modest study to determine correlations, if any, between ACEs scores, serious mental illnesses and duration/severity of illness. Will keep you posted.

If any reader is interested in carrying out a companion study, please advise. Thanks. My next blog will focus on jobs for persons now being treated in the public mental health system.

References:

1. The ACEs Study: For a fuller exposition of facts and analysis, log on to https://www.cdc.gov/ace/findings.htm.
2. For an illustration of ACE’s applicability to standard medical practice, c.f. the article in the March 21,
3. 2011, edition of The New Yorker, “The Poverty Clinic,” by Paul Tough.
4. Bulhan, H.A., Frantz Fanon and the Psychology of Oppression, Plenum Press, New York & Lon don, 1985
5. Carney, J.A., “Sexual Abuse of Men & Women with Serious Mental Illnesses: Assessment, Diagnosis & Treatment,”
6. powerpoint presentation, January, 2007, revised
7. Carney, J.A., “Oppression & Resilience: A Dialectic with Crucial Implications for the Rehabilitation &
8. Recovery of Persons with Serious Mental Illnesses,” powerpoint presentation, September, 2001
9. Fanon, F., The Wretched of the Earth, Grove Press, New York, 1968
10. Goffman, Erving, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, Knopf
11. Doubleday Publishing Group, New York, 1961
12. Harris, M., and the Community Connections Trauma Work Group, “Trauma, Recovery and Empowerment: A Clinician’s
13. Guide for Working With Women In Groups,” 2002, www.ncstac.org/index
14. Harris, M., Landis, P.C., eds., Sexual Abuse in the Lives of Women Diagnosed with Serious Mental Illness,
15. Harwood Academic Publishers, 1997
16. Werner, E., Smith, R., Overcoming the Odds: High Risk Childrennfrom Birth to Adulthood, Cornell U. Press,
17. Ithaca & London, 1992

More on "Helping consumers add years to their lives"

• Helping consumers add years to their lives (Part V): Replacing the Disease/Biological Model with ACEs
   
• Helping consumers add years to their lives (Part IV): The Beginning of the End of Institutionalized Housing in New York City
   
• Helping consumers add years to their lives (Part III): Psychoactive Drug Dependence & Harm Reduction
   
• Helping consumers add years to their lives (Part II): The metabolic syndrome monitoring protocol and other tools
   
• Helping consumers add years to their lives (Part I): Training case managers and clients to be partners in primary healthcare advocacy