Saturday, November 03, 2012

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.


Anonymous said...

Hmm, shouldn't each person get to define recovery for themselves which is what Ms. Cain has done?

"In her interview in the National Council Magazine, Tonier Cain said, “Someone finally asked me ‘What happened to you?’ instead of ‘What’s wrong with you?’”

This question led to a breakthrough in her recovery. It was the first time someone focused on what brought her to this point, not what she did to come to this point, which for her was jail."

By the way Clink, Ms. Cain, hits on a real shortcoming with your colleagues as everything is seen through the DSM and no one seems to ask about trauma in someone's past. This is common sense and shouldn't take pubmed research for this to change in practices, particularly in mental hospitals where so many people with trauma are retraumautized due to what I feel are extremely brutal practices like restraints.

sard said...

I have not seen the film about Ms Cain but this is from the blurb below the trailer to which you linked: "The transcendent story of Tonier “Neen” Cain’s emergence from drug addiction, multiple incarcerations and two decades of homelessness to become a tireless advocate and educator on the devastating impact of childhood abuse . . .".
To me, it seems that she meets your definition of recovery because she has emerged from a state of putting herself into situation of reliving her trauma. Now, she has taken control and harnesses the lessons and power of her past to advocate for others.This is a journey to health and reframing or reshaping the trauma for a positive purpose is healthy. If you have ever sent patients to AA of NA and they have not touched drugs or alcohol since but continue to attend meetings to receive and give support, call themselves recovering addicts even if they have not touched the stuff in years, is that not success? I believe that it is.
Is Ms. Cain a positive role model? Yes. She has proven that one can overcome trauma and it is not necessary to distance herself from it by becoming an air traffic controller. A number of people deal with their own traumas by entering the helping professions. I am sure you can find quite a bit on Pubmed about that topic. If they function well, why is it a problem?

ClinkShrink said...

I think if I reframe the situation slightly it might make my concerns more clear.

What if a patient came to me who was very sick. I treat him, he gets better, he stops coming for treatment.

Then he travels around the country speaking to thousands of people about how wonderful my treatment was.

What would you think if you later found out I had hired him to go on the lecture circuit?

And then later you found out that the treatment I gave was completely experimental?

That the experimental treatment was being sponsored by a government agency---and the government is now mandating people be trained in the experimental treatment?

Doesn't that all seem a bit weird?

People are appropriately concerned about undue influence on psychiatrists, mainly by the pharmaceutical industry. But at least the pharmaceutical industry is held to minimum criteria for safety and efficacy. I think the government should be held to the same standard.

sard said...

I don't think the pharma industry is held to the standards you claim. I'd rather have an experimental treatment that did not cause diabetes or kidney failure. It is time govt got behind something that actually respects individual experience as opposed to a pure focus on medical model of mi and addictions.

Anonymous said...

Clink, I wouldn't be thrilled about the hypothetical situation you raised but I agree with Shard that better that treatment then drug treatments that cause diabetes and kidney failure.

And addressing trauma has been neglected as an issue for years. It is criminal that people are retraumatized in hospitals with brutality when they have this history. So if takes the government to mandate that this should grbe addressed, you only have yourselves to blame when you should have been doing it years ago.

On an topic note - the characters for verification are very hard to read. It shouldn't take several attempts to get it right.

ClinkShrink said...

Saard and Anon: The trauma recovery model doesn't bar the use of medications, or hospitalization. I'm reviewing a couple of the studies to see where this came from now. More to follow.

I agree about the word verification issue, I've had the same problem myself even after enlarging the text in my browser. The Blogger designers obviously are younger and have better eyes than me!

Anonymous said...


Sorry I wasn't clear.

The issue is that a tremendous amount of people who were hospitalized and forcibly medicated and restrained did not have their trauma issues addressed. They would try to bring it up and it was ignored by professionals.

Will Hall, a mental health advocate, who has schizophrenia and does not take meds, spoke about this in his talk before a recent meeting of the APA.

It is an extreme failing of your profession which you cannot continue to overlook.

Anonymous said...

I'm kind of all over the map on this one. Not sure exactly what they mean by trauma recovery movement. I was in a treatment center and they did trauma work. I felt it was abusive, having patients get on the floor, relive the experience, beating pillows, screaming, etc. I hear the words get in touch with your inner child, and I'm heading for the door. So, i think it depends upon what the trauma work looks like. I think it can be abusive. Any treatment that makes me feel like a helpless little child doesn't feel safe to me.

On the other hand, when i look at people who have been through horrendous trauma and use these experiences to help other people, I see recovery. I have spoken to classes about sexual abuse and i found it empowering. But, i know my limits and there's a fine line for me for where talking about it is helpful, and when it can become a real downer.

i agree with the anon who said that trauma does need to be addressed in psychiatric hospitals. People who have been abused don't need to be put in a position where they are once again begging not to have their clothing removed, etc. Recreating past abuse is harmful. Patients need to have their voices heard and respected. They need to be given power, not have power taken away.

sard said...

No, the model does not bar meds or hospitals but the starting point is not the person as disease it is person who has been through hell and needs to find a way back. The person who referred to the reliving business brings up a good point. That used to be standard in trauma therapy--to have the patient "deal" will all the aspects of the trauma-- but it became apparent that for many patients that is a more harmful than helpful. I do not know of many programs that force anyone to relive anything. The point in the Cain story is that someone cared to ask about what she had been through and to listen and help her and that is respectful. Meds will not be barred because some people find them helpful and some people have co-morbid problems. Hospitals will be used as last resorts if a person cannot be safe in the community but it would be great if we had money to fund alternatives that are less traumatic and more respectful of human needs for care, especially when the human in question may never have received real care before.

Anonymous said...

Sard, i really hope you're right that trauma work today doesn't look anything like what i saw in a well known, JCAHO approved eating disorder treatment facility where i was patient in the late 90's.

The problem is that "trauma work" can mean whatever the heck the therapist wants it to mean. Does it mean having a patient screaming at an empty chair pretending it's their abusor while the therapist chants at them, completely breaking down the patient? Does it mean having the patient pretend like i'm a little victimized girl again? Or does it simply mean two adults talking, where the therapist is sensitive to the impact of these events on the patient's life and helps them work through them?

The problem is there is no standard of care, and there really needs to be. I believe that JCAHO needs to look really closely at some of the things that pass for therapy in treatment centers, particularly the eating disorder treatment centers. There's some really messed up stuff going on.

I can't help but cringe when i hear the words trauma work, because i saw how weird some of that stuff could get.

Anonymous said...

If someone had bothered to ask what happened to me, I don't know if I would have said.If instead of drugging me up they kept asking, maybe I would have said. It took decades until someone asked and it took years to get bits of it out and I still do take pills but they don't call me crazy anymore and it is freeing in a big way. If someone wants to pay me to say that, I would so I can't see why Ms Cain would agree to tell her story or why she should not be paid for telling it.

Anonymous said...

If a doctor has had an awful past and overcomes it and writes a memoir and it gets published and he gets press in the papers and on blogs, would you say that he is not well or is mired in the past and should get over it?
Your link to the legislation shows that you get training for use in specified cases, including reporting rules around abuse but I do not see that everything else you do that is supposedly more evidence based has been banned.