Trauma model of mental disorders

The trauma model of mental disorders, or trauma model of psychopathology, emphasises the effects of physical, sexual and psychological trauma as key causal factors in the development of psychiatric disorders, including depression and anxiety{{cite journal |last1=Jeronimus |first1=B.F. |last2=Ormel |first2=J. |last3=Aleman |first3=A. |last4=Penninx |first4=B.W.J.H. |last5=Riese |first5=H.|journal=Psychological Medicine|year= 2013|volume=43|issue=11|pages=2403–15|title= Negative and positive life events are associated with small but lasting change in neuroticism|doi=10.1017/s0033291713000159|pmid=23410535|s2cid=43717734 }} as well as psychosis, whether the trauma is experienced in childhood or adulthood. It conceptualises people as having understandable reactions to traumatic events rather than suffering from mental illness.

Trauma models emphasise that traumatic experiences are more common and more significant in terms of aetiology than has often been thought in people diagnosed with mental disorders. Such models have their roots in some psychoanalytic approaches, notably Sigmund Freud's early ideas on childhood sexual abuse and hysteria,Candace Orcutt, Trauma in Personality Disorder: A Clinician's Handbook (AuthorHouse, 2012). Pierre Janet's work on dissociation, and John Bowlby's attachment theory. There is significant research supporting the linkage between early experiences of chronic maltreatment and severe neglect and later psychological problems.Main, M. & Hesse, E. (1990). "Parents' unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism?" In Greenberg, M., Cicchetti, D., and Cummings, M. (Eds.), Attachment In The Preschool Years: Theory, Research, and Intervention. Chicago: University of Chicago Press.

In the 1960s trauma models became associated with humanist and anti-psychiatry approaches, particularly in regard to understanding schizophrenia and the role of the family.{{Cite book|title=The Divided Self|last=Laing|first=R.D.|publisher=Tavistock|year=1960|location=London}} Personality disorders have also been a focus, particularly borderline personality disorder, with the role of dissociation and 'freezing responses' (more extreme reactions than fight-flight when someone is terrified and traumatised) thought to have a significant role in the aetiology of psychological disturbance.{{Cite journal|last=Dillon, J., Lucy Johnstone, L. and Longden, E.|date=2012|title=Trauma, Dissociation, Attachment and Neuroscience: A new paradigm for understanding severe mental distress|url=http://www.psychologyintherealworld.co.uk/resources/special_edition_JCPCP_on_complex_reactions_severe_trauma.pdf|journal=Journal of Critical Psychology, Counselling and Psychotherapy|volume=12}} Extreme versions of trauma models have implicated the fetal environment and the trauma of being born, but these are not well-supported in the academic literature and have been associated with recovered memory controversies.{{Citation needed|date=February 2020}}

People are traumatised by a wide range of people, not just family members. For example, male victims of sexual abuse report being abused in institutional settings (boarding schools, care homes, sports clubs).{{Cite journal|last=Holmes, G. Offen, L. and Waller, G.|date=1997|title=See no evil, hear no evil, speak no evil: why do relatively few male victims of childhood sexual abuse receive help for abuse related issues in adulthood?|journal=Clinical Psychology Review|volume=17|issue=1|pages=69–88|doi=10.1016/S0272-7358(96)00047-5|pmid=9125368}}

Trauma models thus highlight stressful and traumatic factors in early attachment relations and in the development of mature interpersonal relationships. They are often presented as a counterpoint to psychiatric orthodoxy and inform criticisms of mental health research and practice in that it has become too focused on genetics, neurochemistry and medication.

History

From the 1940s to the 1970s, prominent mental health professionals associated with neo-Freudian and psychodynamic psychology proposed trauma models as a means of understanding schizophrenia, including Harry Stack Sullivan, Frieda Fromm-Reichmann, Theodore Lidz, Gregory Bateson, Silvano Arieti and R.D. Laing. Based on their clinical work, they theorized that schizophrenia appears to be induced by children's experiences in profoundly disturbed families and reflects victims' attempts to cope with such families and live in societies that are inherently damaging to people's psychological well-being. In the 1950s, Sullivan's theory that schizophrenia is related to interpersonal relationships was widely accepted in the United States. Arieti's book, Interpretation of Schizophrenia, won the American National Book Award in the field of science in 1975. The book advanced a psychological model for understanding all the regressive types{{definition needed|date=January 2025}} of the disorder.[http://www.associazionesilvanoarieti.org/english/sa_curriculum.html associazionesilvanoarieti.org] {{Webarchive|url=https://web.archive.org/web/20070311164744/http://www.associazionesilvanoarieti.org/english/sa_curriculum.html |date=2007-03-11 }} – page on Arieti (mostly in Italian)

Some of the psychogenic models proposed by the non-biologic psychologists, such as that of the "schizophrenogenic mother", came under sustained criticism from feminists who saw them as 'mother-blaming' and from a psychiatric profession that increasingly moved towards biological determinism.{{Cite book|title=Histories of Psychiatry, In C. Newnes, G. Holmes & C. Dunn, This is Madness: A critical look at psychiatry and the future of mental health services|last=Newnes, C|publisher=PCCS|year=1999|location=Ross-on-Wye}} From the 1960s, pharmacological treatments became the increasing focus of psychiatry, and by the 1980s, the theory that family dynamics could be implicated in the aetiology of schizophrenia became viewed as unacceptable by many mental health professionals in America and Europe.{{cite book |last=Hahlweg |first=K |title="Familienbetreuung als verhaltenstherapeutischer Ansatz zur Rückfallprophylaxe bei schizophrenen Patienten", in M. Krausz, D. Naber (eds.) Integrative Schizophrenietherapie |publisher=Freiburg: Karger |year=2000|display-authors=etal}} Before his death in 2001, Theodore Lidz, one of the main proponents of the "schizophrenogenic" parents theory, expressed regret that current research in biological psychiatry was "barking up the wrong tree".{{cite web |url=http://www.yale.edu/opa/arc-ybc/v29.n21/story14.html |title=Yale Bulletin and Calendar |accessdate=2015-02-27 |url-status=dead |archive-url=https://web.archive.org/web/20150227065407/http://www.yale.edu/opa/arc-ybc/v29.n21/story14.html |archive-date=2015-02-27 }} – article on Theodore Lidz Like Lidz, Laing maintained until his death that the cause of both schizoid personality disorder and schizophrenia was influenced by family relationships.{{Cite book|title=R.D. Laing: A Biography|last=Laing|first=Adrian|publisher=Harper Collins|year=1997}} Some more recent research has provided support for this. For instance, child abuse has been shown to have a causal role in depression, PTSD, eating disorders, substance abuse and dissociative disorders,{{cite journal |last=Kendler |first=K |journal=Archives of General Psychiatry |title=Childhood sexual abuse and adult psychiatric and substance use disorders in women |volume=57 |pages=953–959 |year=2000 |doi=10.1001/archpsyc.57.10.953 |pmid=11015813 |issue=10|display-authors=etal|doi-access= }} and research reveals that the more severe the abuse the higher the probability that psychiatric symptoms will develop in adult life.{{cite journal |last1=Mullen |journal=British Journal of Psychiatry |title=Childhood sexual abuse and mental health in adult life |volume=163 |pages=721–32 |year=1993 |doi=10.1192/bjp.163.6.721 |first1=P. E. |pmid=8306113 |issue=6|s2cid=4694330 |display-authors=etal}}

Judith Herman's book Trauma and Recovery has heavily influenced therapeutic approaches. Recovery entails three phases that are best worked through sequentially: first, "establishing safety"; second, a process of remembrance and mourning for what was lost; and third, "reconnecting with community and, more broadly, society".

Critiques

Critics of the model, such as August Piper, argue that the logic that childhood trauma causes insanity has a serious flaw: If the claim was true, the abuse of millions of children over the years should have caused higher prevalence rates of mental disorders than the literature reveals.{{cite journal |last=Piper |first=August |title= Multiple Personality Disorder: Witchcraft Survives in the Twentieth century |journal=Skeptical Inquirer |volume=May/June |year=1998}} However, this critique disregards the possibility of underdiagnosis and the fact that not every instance of abuse causes lasting trauma. Other critics, particularly proponents of behavior family therapy, have seen trauma models as parent blaming and have emphasized the fact that families are usually the main, and often only, source of support for people diagnosed with severe mental illness. Lucy Johnstone has pointed out that some critics advocate family interventions for adult psychiatric patients whilst at the same time maintaining that childhood experiences are not causal as regards mental illness – as if family members can only have a helpful or damaging impact on their adult children.{{Cite book|title=Users and Abusers of Psychiatry|last=Johnstone, L.|publisher=Routledge|year=2000}}

In response to Piper's assertion, it has been noted that Arieti stated in Interpretation of Schizophrenia that trauma is more significant when committed by people to whom young human beings are emotionally bonded, and abuse is often interwoven with other forms of neglect and confusing behaviours from caregivers:

{{Cquote|First of all we have to repeat here what we already mentioned..., that conditions of obvious external danger, as in the case of wars, disasters, or other adversities that affect the collectivity, do not produce the type of anxiety that hurts the inner self and do not themselves favor schizophrenia. Even extreme poverty, physical illness, or personal tragedies do not necessarily lead to schizophrenia unless they have psychological ramifications that hurt the sense of self. Even homes broken by death, divorce or desertion may be less destructive than homes where both parents are alive, live together, and always undermine the child's conception of himself.{{cite book |last=Arieti |first=Silvano |title=Interpretation of Schizophrenia |publisher=Aronson |year=1994 |page=197}}}}

Recent approaches

A 2005 meta-analysis of schizophrenia revealed that the prevalence of physical and sexual abuse in the histories of people diagnosed with psychotic disorders is very high and has been understudied. This literature review revealed prevalence rates of childhood sexual abuse in studies of people diagnosed with schizophrenia ranging from 45% to 65%.{{cite journal|vauthors=Read J, van Os J, Morrison AP, Ross CA|date=November 2005|title=Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications|journal= Acta Psychiatr Scand |volume=112|issue=5|pages=330–50|doi=10.1111/j.1600-0447.2005.00634.x|pmid=16223421|s2cid=5324960 |doi-access=free}} An analysis of the American National Comorbidity Study revealed that people who have endured three kinds of abuse (e.g., sexual, physical, bullying) are at an 18-fold higher risk of psychosis, whereas those experiencing five types are 193 times more likely to become psychotic.{{Cite journal|last=Shevlin, M, Dorahy, M & Adamson, G.|date=2007|title=Trauma and psychosis: An analysis of the National Comorbidity Survey.|journal=American Journal of Psychiatry|volume=164 |issue=1|pages=166–169|doi=10.1176/ajp.2007.164.1.166|pmid=17202562|citeseerx=10.1.1.557.8867}} A 2012 review article supported the hypothesis that current or recent trauma may affect an individual's assessment of the more distant past, changing the experience of the past and resulting in dissociative states.{{cite journal|author=Stern DB|date=January 2012|title=Witnessing across time: accessing the present from the past and the past from the present|journal=The Psychoanalytic Quarterly|volume=81|issue=1|pages=53–81|doi=10.1002/j.2167-4086.2012.tb00485.x|pmid=22423434|s2cid=5728941 }} Several reviews of risk factors for common mental disorders have emphasised trauma.{{cite journal|author1=Ormel J.|author2=Jeronimus, B.F.|author3=Kotov, M.|author4=Riese, H.|author5=Bos, E.H.|author6=Hankin, B.|year=2013|title=Neuroticism and common mental disorders: Meaning and utility of a complex relationship|journal=Clinical Psychology Review|volume=33|issue=5|pages=686–697|doi=10.1016/j.cpr.2013.04.003|pmc=4382368|pmid=23702592}}{{cite journal|author=Malouff, J.M., Thorsteinsson, E.B., & Schutte N.S.|year=2005|title=The relationship between the five factor model of personality and symptoms of clinical disorders|journal=Journal of Psychopathology and Behavioral Assessment|volume=27|issue=2|pages=101–114|doi=10.1007/s10862-005-5384-y|s2cid=145806896 }} Such research has rejuvenated interest in this field, both from clinicians, researchers and service user organisations such as the Hearing Voices Movement.

Psychiatrist Colin Ross calls his model the "trauma model of mental disorders" and emphasises that, unlike biological models, this addresses the literature on comorbidity of trauma with mental disorders. Ross describes the theoretical basis of his trauma model: "The problem faced by many patients is that they did not grow up in a reasonably healthy, normal family. They grew up in an inconsistent, abusive and traumatic family. The very people to whom the child had to attach for survival were also abuse perpetrators and hurt him or her badly.... The basic conflict, the deepest pain, and the deepest source of symptoms, is the fact that mom and dad's behavior hurts, did not fit together, and did not make sense."{{Cite web|url=https://www.rossinst.com/|title=The Colin A. Ross Institute for Psychological Trauma - Research, Education, and Clinical Treatment of Trauma Based Disorders|website=www.rossinst.com}}

In terms of psychoses, most researchers and clinicians believe that genetics remains a causative risk factor, but "genes alone do not cause the illness".{{cite web|url=http://www.scienceagogo.com/news/20060514024158data_trunc_sys.shtml|title=Media report of sexual abuse as cause of schizophrenia|accessdate=2009-04-15|date=2006-06-14}}{{cite web|url=http://www.iop.kcl.ac.uk/podcast/?id=208&type=item|title=Maudsley debate on sexual abuse as a cause of schizophrenia|accessdate=2009-04-15}} Modern views of genetics see genes more like dimmer switches, with environmental factors switching the genes on; the more severe the environmental stress, the more effect genes have.{{Cite book|title=Madness Explained: Psychosis and Human Nature.|last=Bentall|first=Richard|publisher=Penguin|year=2003}}

In the field of criminology, Lonnie Athens developed a theory of how a process of brutalization by parents or peers that usually occurs in childhood results in violent crimes in adulthood. Richard Rhodes's Why They Kill describes Athens's observations about domestic and societal violence in the criminals' backgrounds. Both Athens and Rhodes reject the genetic inheritance theories.{{cite book|last=Rhodes|first=Richard|title=Why They Kill: The Discoveries of a Maverick Criminologist|url=https://archive.org/details/whytheykill00rich|url-access=registration|publisher=Vintage|year=2000|isbn=978-0-375-40249-4}}

Criminologists Jonathan Pincus and Dorothy Otnow Lewis believe that although it is the interaction of childhood abuse and neurological disturbances that explains murder, virtually all of the 150 murderers they studied over a 25-year period had suffered severe abuse as children. Pincus believes that the only feasible remedy for crime would be the prevention of child abuse.{{cite book|last=Pincus|first=Jonathan|title=Base Instincts: What Makes Killers Kill|publisher=W.W. Norton & Company|year=2002|isbn=978-0-393-05022-6|url-access=registration|url=https://archive.org/details/isbn_9780393050226}}

References

External links

[http://www.alice-miller.com/ Alice-Miller.com] – According to Miller, the "forbidden issue" is the parental role in mental disorders
[http://www.psychologyintherealworld.co.uk/resources/special_edition_JCPCP_on_complex_reactions_severe_trauma.pdf Special edition of JCPCP on complex reactions to severe trauma]
[https://web.archive.org/web/20060715191020/http://www.laingsociety.org/ LaingSociety.org] – The Society for Laingian Studies, R.D. Laing (1927–1989)
[http://www.moshersoteria.com/ MosherSoteria.com] – Loren Mosher, MD, (1933–2004)
[https://web.archive.org/web/20100706231018/http://dynamic.uoregon.edu/~jjf/defineBT.html Prof J.J. Freyd's Betrayal Trauma Theory Home Page at the University of Oregon]
[http://www.psychohistory.com/ Psychohistory.com] – The Institute for Psychohistory
[http://www.rossinst.com/ Rossinst.com] – Home page of the Ross Institute for Psychological Trauma
[http://www.sfhelp.org/ sfhelp.org] – Home page of the "Break the Cycle! (of inherited psychological wounds + unawareness)" Web site

Category:Aftermath of war

Category:Anti-psychiatry

Category:Attachment theory

Category:Child abuse

Category:Mental disorders

Category:Psychiatric models