PTSD and the Forensic Psychiatrist

 
This blog post is aimed at anyone considering a career in forensic psychiatry. Please read this interview in the Ottawa Citizen entitled 'Tough forensic guy' John Bradford opens up about his PTSD'.

I'm going to preface this post by saying that I know the man featured in this interview. He is an extremely accomplished and internationally recognized authority on the evaluation and treatment of sex offenders. To think that we could have lost him is a devastating idea to me. He has always been respected within the forensic community, but I respect him even more after this interview.

In this article Dr. Bradford talks about the recent stress a pretrial evaluation placed upon him when he had to work overtime, under a deadline, to evaluate a sexually sadistic murderer. He was required to watch actual videos of the crimes, to witness the killings and to hear the pleas of the women he knew were doomed. The experience brought back recollections of other serious crimes and cases he had been involved with in the past. In the interview he discusses the effects this had upon him over time and the challenges he faced when he finally needed to get help dealing with it. Getting treatment was particularly difficult for him, both because of his prominence but also because forensic psychiatrists are just supposed to be able to handle this stuff. In his own words:

“It’s complicated,” he says. “In my case it was macho. I’m a top forensic psychiatrist and I saw it as a weakness. I don’t talk about the treatment much because it’s difficult for me but getting to it early is important.”

I understand completely what Dr. Bradford is talking about here. Over the years, forensic psychiatrists end up hearing and seeing information about crimes that are pretty terrible. We see digital photographs of crime scenes, autopsy photographs, surveillance videos of murders, suspect interrogations, phone call tapes, written letters and other pieces of evidence that relate detailed information about violent crimes. A single case can require weeks and hundreds of hours of study with repeated exposure to horrible events.

Even without developing PTSD this can change your view of the world a bit. At times I joke that when I give directions now I don't use street names anymore, I give directions in terms of crime scenes: "Take a left and drive south a few blocks until you get to the church that was the scene of the ice pick murder, then take a right until you get to the samurai sword decapitation..."

Yeah, it makes life a little weird.

There are prohibitions about talking about active cases, for legal reasons, but there are also good clinical reasons why you don't talk about your cases with friends and family. Once you get these images in your head they don't go away, and it's not fair to place them into the heads of other people. I warn my program applicants about this too.

To a certain extent, medical training weeds out people who aren't able to handle this. I think there's a reason why my medical school put anatomy class as the first class on the training agenda. After four months hanging over a formaldehyde soaked body, it took me a while before I could eat chicken again. The muscle fibers and tendons just didn't look the same after anatomy class.

Some people complete forensic training and never touch a forensic case again and never do forensic work. I've often wondered about that, and wondered what we could do ahead of time to help people decide if they're really cut out for the work. Given Dr. Bradford's interview, we should probably also think about what we should be doing to look after the people who stay in the work.

The Trauma Recovery Movement: Where Did It Come From?

For anybody who's interested, you can follow along with me as I learn about this stuff. I put the tape measure pic up because I'm learning about trauma treatment and outcome measures.

I was curious about SAMSHA's National Center for Trauma-Informed Care so I did a little background reading based on material I found on their web site. (And if there's anybody reading involved in this who would like to jump in and provide more information, please do. Shrink Rap also allows guest posts!)

It appears that this arose out of a SAMSHA initiative to encourage study of innovative program delivery systems. It was recognized that certain groups of people had severe and overlapping treatment issues. In other words, there were women with high levels of childhood abuse, adult violence, mental health issues and substance abuse. They wanted to figure out how to best provide treatment to these folks and they theorized that the key link or ingredient, a "cause" if you will, was the trauma history.

A two-phase, multisite study was designed to look at this problem. (1) In the second phase, nine cities were selected to participate. They enrolled thousands of women in a variety of treatment settings. The women all had one or more of the three issues: trauma history, substance abuse and mental health problems. One key fault is that there was a non-random assignment of the patients: they were allowed to self-select the "intervention" versus "usual care" condition. Both the trauma and usual care groups provided mental health and substance abuse counselling. The trauma group was additionally provided a women-only therapy group that employed one of four trauma treatment recovery models. The usual care group provided some additional not clearly specified intervention (I didn't have time to read in detail, it sounded like a generic social skills group).

The results were difficult to interpret because it turned out that two of the nine sites had significantly different study subjects. They had to break out certain sites from the rest to analyze the data. However, when pooled two interesting findings came out: the first was that a program that integrated all services (mental health, substance abuse and trauma/generic) was better than a program that offered disjunctive services. The second finding was that the more core services the patient used, there was a slight but significantly worse outcome. (2)

Outcomes were measured at six and twelve months. Overall mental health scores were measured using the Global Severity Index (GSI) and the Brief Symptom Inventory (BSI). Mental health status was improved more when services where combined, even when there was no change in addiction severity. Traumatic symptoms also improved.

What I take away from this is: integrated treatment is better.

That doesn't surprise me. Maryland is reorganizing it's public health services to reflect this, and the Affordable Care Act also recognizes this. There's also been at least one study (I've got it pinned on my pInterest board) which showed that integrated care post-release can decrease felony recidivism.

But improvement with integrated care does not prove that the treatment effect comes from treating the trauma. I think that's the mistake. This model can be useful for anyone with complicated co-occurring conditions, male or female, traumatized or not.

OK, I'll shut up now. What's new with you, Dinah?



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1. McHugo, et al. Women, Co-occurring disorders, and Violence Study: Evaluation design and study population. Journal of Substance Abuse Treatment 28: 91-107, 2005

2. Morrissey et. al. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services 56: 1213-1222, 2005

Am I Recovered Yet?

Today on our local public radio station I heard an interview with Tonier Cain, a team leader for the National Center for Trauma Informed Care. Ms. Cain is a renown speaker who has appeared at multiple national venues to talk about her horrific childhood history of sexual and physical abuse, multiple adult arrests, history of prostitution and drug abuse, and incarceration in our own Maryland prison system. Her story is remarkable for her 180 degree transformation to become an accomplished organizer and advocate. She has repeated her narrative many times online, on the radio, and even in local theater. She frequently speaks to women prisoners to talk about the importance of trauma recovery therapy.

I was familiar with her story because the state of Maryland passed a law last year which mandated that anyone working in a state facility must be given training in trauma-informed care. I went through this training myself where I saw a shortened version of the documentary "Healing Neen," about Ms. Cain. Following the presentation the instructor asked what we thought about the film. Everyone in the room thought that it was wonderful, that Ms. Cain's story was amazing, that the trauma recovery treatment she had had was miraculous.

"Isn't it amazing how she has overcome her trauma?" the instructor asked.

I should have kept my mouth shut. I really should have.

But I couldn't help myself.

"But she hasn't recovered!" I blurted out. "She just reshaped it. She has recreated her personal and professional identity around her trauma narrative." And that's true---she is now a professional trauma victim/survivor. How is this overcoming her past? How is this recovery?

The room fell silent. People looked at me, a bit aghast and shocked. Some people tried to explain: "Well, you don't ever really COMPLETELY overcome the past, you just learn to live with it."

Well OK, that sounded reasonable. But wasn't the point of the trauma recovery movement that you actually are supposed to recover? That at some point, you stop being a patient? I mean, when I treat someone my goal is complete recovery----zero symptoms----that's what I call recovery. My goal is to free someone from being my patient, as much as possible.  Isn't that the goal of the trauma-recovery movement?

Maybe I just was uninformed. Maybe I needed to read more about it.

I did a PubMed search using the terms "outcome" and "trauma-informed care." This search produced all of four articles. One focussed solely on trauma-informed interventions to reduce seclusion and restraints in the hospital. Another paper discussed the dirth of outcome-based evidence for trauma informed care for people with schizophrenia. There were no controlled trials, nothing in the way of any standard study of anything related to trauma informed care.

Yet education about this recovery movement and treatment approach is being mandated by our state government. There's something seriously wrong here. An intervention with no evidence base is being required and weighed on the same level as a requirement for CPR certification.

The trauma recovery and prevention movement also has moved into the domain of disaster psychiatry. This is the idea that prompt mental health intervention can prevent longterm psychiatric complications for people who experience traumatic events. I've written about this before on the blog in my posts "I Don't Need to Talk" and "I Still Don't Need to Talk", including a review of studies to suggest that for some people these interventions may actually be harmful. In his Mental Illness Policy blog, DJ Jaffe expressed similar concerns in his post "NYS Office of Mental Health: Wrong Response to Hurricane Sandy," where he discussed the diversion of mental health workers to crisis counseling and away from services for the seriously mentally ill.

Government money for mental health services is limited, and should be directed toward people with serious mental illnesses and evidence based practices.