One of the most influential experiences I had as a medical student was the opportunity to work with a psychiatric patient with multiple personality disorder during my inpatient rotation at a tertiary care center. Already inclined toward psychiatry, I had read every popular book I could find about the brain, human behavior, and mental disturbances in additional to my regular textbooks. Multiple personality disorder was a popular topic in the mainstream paperback press then, but I never thought that I would meet someone with the disorder.
My resident at the time felt he had scored a coup, because he was the only one of the patient’s many psychiatrists to consider and diagnose her rare condition. At the time of intake, she had been diagnosed with three alternate personalities. By the end of my rotation, about a year later, she was reported to have nearly 20. As a medical student, it never occurred to me to ask why her condition had gotten worse over time rather than better.
The 1980s brought other disturbing and dramatic events to the forefront of mental health care. Therapists in disparate parts of the country began to report cases of patients who suddenly recalled horrific memories of degrading and violent sexual abuse committed by organized cults. These reports of satanic ritual abuse led to intense investigations by local law enforcement as well as the FBI. Families were torn apart, as falsely accused members were alienated from one another or even criminally prosecuted.
Eventually, the drama died down. Falsely accused family members had their convictions overturned based upon expert evidence regarding false memory syndrome caused by hypnotically induced memories or improper questioning of child witnesses. A series of malpractice suits were filed against trauma recovery therapists based upon negligent use of hypnosis, failure to recognize the effects of suggestion, and improper diagnosis. Juries awarded some of the highest damages ever recorded for psychiatric malpractice. To this day, the FBI has found no evidence of any organized satanic child abuse rings.
All this was uncomfortable to watch even from a distance, but I’m glad I had this experience in my formative years as a psychiatrist. And this all seemed like a remote memory until recently, when my state started requiring all public mental health clinicians to receive education in trauma-informed care.
Trauma-informed care requires a clinician to be mindful that many psychiatric patients have had significant exposure to sexual and physical abuse, domestic violence, and other life events that make a person sensitive to being retraumatized. Trauma-informed care means being cautious and conservative with regard to the use of physical interventions or other measures that could inadvertently reenact a previous traumatic event. Trauma history is associated with many adult psychiatric conditions that we see in our patients: mood disorders, substance abuse, and maladaptive behaviors. According to this training, trauma-informed care would require the clinician to assume that a patient who presents with these problems has had a history of abuse or other traumatic experiences.
The first time I went through this training, my response was inexplicably visceral. I had a sickening sense that I was watching history slowly repeat itself. I wondered if the trauma informed care people knew that their training could cause a traumatic reaction like mine.
While I don’t question the fact that childhood trauma is real or can cause significant adult psychological problems, I’d be more comfortable with mandatory trauma-informed care training if the trainers would recognize and acknowledge certain risks inherent in their approach.
They should acknowledge that patients with a trauma history are likely to fear abandonment or punishment. In order to avoid this, a trauma patient may consciously or unconsciously confabulate symptoms in order to keep the therapist interested and engaged. Failure to differentiate between historical truth and narrative truth was a key issue in the development of the satanic ritual abuse debacle. Trauma recovery trainers should recognize that screening for trauma may not be appropriate under certain circumstances. For example, screening for past trauma would not be appropriate in a jail intake setting, where the incarceration process itself may be inherently traumatic. Finally, while trauma is associated with many psychological problems, the answer to all problems is not trauma recovery therapy. Substance abuse treatment, medication, and standard rehabilitation services can be beneficial even when separate from or without trauma-specific therapy.
This leads me to my final point: There is nothing specific to trauma-informed care that is specific to a history of trauma. The need to be sensitive and humane, and the need to be cautious and judicious about physical interventions, is just good psychiatric care. And we don’t need a law to require training in humane care.