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International Conference on Trauma, Attachment and
Dissociation
Transforming Trauma: Critical, controversial and core issues
Melbourne
September 12-14 2003
Keynote address:
Sunday 14 September 2003, 12.30
Child Abuse, Hallucinations & Delusions:
A Post-Traumatic Dissociative Psychosis?
by Dr John Read
(A transcript)
Introduction: It
gives us great pleasure to introduce the next speaker who will give the final
keynote address of this conference, Dr John Read, who is the Director of
Clinical Psychology at the University of Auckland. John's had a long-standing
interest in psychotic disorders and has spent a lot of time working in the
USA and the UK. Judging by what John said about the state of Australian
rugby, however, last night, I assume that he's now well acculturated to kiwi
culture and today he will be addressing us with a paper titled ‘Child Abuse,
Hallucinations & Delusions: A Post-Traumatic Psychosis?' Thank you John.
[scattered applause]
John Read: I
think it befalls to me as the last keynote speaker, although this will happen
again later on the day, but some of you might not be here, so I just think we
should acknowledge the enormous amount of work that has gone into gathering
us all together.
I'm not going to name individual people because I'm sure that there's more
than Susan [Henry], Naomi [Halpern] and Warwick [Middleton] - oh I just did
name three people then - and all the others who helped, so can we do that
first of all please. And to Yuichi [Hattori] I'd just like to say you have now
been added to my long list of people never to speak afterwards. And you have
certainly added a new twist to family therapy. [laughter].
I'd like to acknowledge some of the other speakers. It's been an amazing
three days. I'd like to thank Colin Ross first of all for only giving 2/3 of
my talk [laughter]. Normally he gives between 3/4 and 100%, so thank you
Colin. But don't worry. I am actually well prepared. I'm used to speaking
after Colin and I always prepare a 3 hour talk, so I just have to throw out the
bits that Colin has covered already. So that's no problem.
I'd like to acknowledge, especially, the psychiatrists who have spoken. I
don't count Colin as a psychiatrist - I mean, let's be real.
I'd like to acknowledge Russell [Meares]'s quite moving talk yesterday, and I
thought that was a lovely synchronicity at the end of that when that slide
just would not work, because I don't think that treatment actually would have
gone quite as smoothly as a smooth presentation of the slides would have
actually represented. So the fact that it took a long time to get to that
last slide seemed somehow - it must have been carefully planned Russell
actually. You stood there looking non-plussed but I'm sure you planned that.
It was a very moving talk.
I especially want to acknowledge Carolyn [Quadrio] also for the bravery
yesterday of holding up her own profession [applause] in terms of what
[drowned out by applause]. It's not common for me to say anything to protect
psychiatry, so I won't. What I will do is put my own profession right
alongside what Carolyn was saying and just to acknowledge that there is just
as much sexual abuse by clinical psychologists of their patients as there is
of psychiatrists, and that just needed to be said.
I have a number of biases - unlike all the objective scientists in the world
- and I like to just like to tell a few stories of how I got to those biases.
Most of my real training took place in one year, in 1974, when I was working
in a psychiatric hospital in New York. I was 20 years old and knew nothing. I
had not been trained not to talk to schizophrenics. As I was later to be
trained, because you can upset them and they regress and decompensate, or
decompose or all those things that happen when you actually ask schizophrenics
what's happened to them. So I didn't know that you weren't supposed to do
that.
So there I was, as a nursing attendant in Bronx, New York, with a guy who'd
been on the ward now for 4 days, and he hadn't opened his eyes for four days.
Which is quite a feat actually. He was now black and blue from walking into
the doors and the walls.
We had all been looking up in our DSMs - eye's closed behaviour - and
astonishingly we couldn't find it. And somewhere about 3 o'clock in the
morning, probably more out of boredom than clinical acumen, I said - Bob, why
are you keeping your eyes closed? And he put his face about this close to
mine, and said: It's about fucking time someone asked me that. [laughter]
And he went on to explain to me that he was very cross because he had been
put into the hospital to get insight, and that's what he was fucking well
doing, arseholes. [laughter]
I learnt the importance of asking people what's going on, early on.
A more serious, or more frightening, story occurred on that same ward. Away
from the main area of the ward there was the laundry area, which was a very
small area where nobody could hear you. And a huge guy of about 25 and I were
in there, and he said to me: You know, John, I really like you, so what's
going to happen next is really distressing to me. I thought: Right. But I am
going to have to kill you.[nervous laughter] It's funny now. In between
trying to control my sphincter and from somewhere I said - and I didn't know
my mid-brain could think - from somewhere the words came out: It's ok, I
haven't got you here to kill you. I have no idea to this day where those
words came from. But he collapsed on the floor in absolute tears.
And I think what I learnt from that is that behind a lot of weird stuff is
absolute terror.
After a few months working on this ward, the psychiatrist there used to tell
me I seemed to have a natural ability to connect to people who were freaked
out. Unfortunately I was so screwed up at that point, and so paranoid, that I
was absolutely 100% convinced that this was a condescending way of trying to
make me feel better because I was so terrible at it.
And I discovered years later the real reason I liked working with psychotic
people at that age was because at least there were so people on earth more
screwed up than I was. And that's not a joke.
Some things I wasn't very good at on the ward - the first that - I was a
nursing attendant - you have to do a lot of jumping on people and holding
them down and things. The first time that happened, I thought I'd done a
really good job. There was five of us on top of this poor guy, holding him
down while he had his depo injection. Until it was time of get up and I had
hold of the ankle of one of the other nursing attendants, and the wrist of
the psychiatrist. So there were some skills I still had to learn.
Anyway - what is my talk? Child abuse, hallucination and delusions: a
post-traumatic dissociative psychosis?
This is the advantage of Colin having talking first, you see, I can just
twitter on about anything now. I obviously have some ambivalence it seems
about the word dissociative because in the title it's there but in my
abstract - when I wrote the abstract I took it out. Anybody spot that? My
abstract is a post-traumatic psychosis. I do have some ambivalence about -
well a lot of diagnosis as you will see. And I think the proper title for my
talk would actually be: Moving in diagnostic circles, and I'll try and make
clear what I mean by that as we go along.
I'll certainly conclude with more questions than I have answers. I am very
sceptical about all diagnosis. I'm sceptical about getting too excited about
the concept of dissociation as if it explains everything, as I am about
anything else explaining everything.
But I am also - I like to think as a strategist - so when I'm asked, as I was
a couple of months ago, to write a chapter for one of the books that will
inform the next DSM - the lobbying starts a long time - this is a whole
political process. I don't know if you understand this. The next DSM is due
out in 2010, and one of the dissociation organisations asked me to write a
chapter about post-traumatic dissociative psychosis. Not knowing anything
about dissociation, I immediately ran off and said to my colleague Andrew,
and to Tom and Suzie at the back there - see, some of my friends are
psychiatrists - could you please write this chapter with me. And we will do
that, of course. Because the DSM is a very powerful thing, and it needs to be
influenced.
Before I actually move on to the talk itself, we heard about our roots this
morning, which is very important to remember our roots. And I just want to
acknowledge that we have some darker and deeper roots, the whole field of
trying to assist people in distress, or people who are mad.
The very first use of the word hysteria was a long, long time ago in ancient
Greece when a very, very patriarchy was beginning to crumble. This was a
patriarchy that was so powerful that baby children - ah, baby girls would be
left to die if there wasn't enough food. But it was beginning to crumble and
women were acting out in all sorts of strange ways. They were marrying later.
Or, God forbid, refusing to marry at all. And the experts of the time, the
priest physicians, who just happened to be male, came up the theory
completely unlike the theories that we have today, much less sophisticated
[said with irony].
But what was wrong with all these women who were acting strangely was that
their uterus was wandering around their body, looking for something. What
from a male perspective would a uterus be looking for? Yes, absolutely right.
This was the theory of the day. The uterus was wandering about looking for a
penis. If it found a penis everything would be alright. Sadly the first
treatment of choice was marriage. If the woman absolutely refused to marry
the next treatment was forced fumigation of the vagina, which is essentially
mechanical.
I raise this partly to remind us that we have centuries of tradition of
coming up with theories for people's good. Very often men coming up with
theories for women, but not always. So when we point, when Colin and I and
others point the finger at biological psychiatry today, we have to remind
ourselves we have always had these problems with us.
I just want to quickly acknowledge the other people involved in the research
that I'm going to present to you. And there's two taboos. I like to make life
difficult for myself. There's two taboos involved in research in this area.
The first one is very, very familiar to all of you. Child abuse is common and
can have severe and long lasting effects. Now we still have to combat, do we
not, people who say: No it's not common, and is it that harmful after all?
And I have to remind you, as Jeffrey [Masson] has done I think, it's only
1975 that the leading psychiatric textbook that trained that generation of
psychiatrist and psychologists in America put the figure of incest at one per
million. The fight continues.
In New Zealand currently we have a bizarre case where, I would call in
hysteria in the other way in fact, hysteria around a particular case that has
been to trial, appeal court, two reviews, and still we have people all over
New Zealand jumping up and down signing petitions asking for a third review.
We have a book by Lynley Hood which is the core of this campaign which has
received book awards, which just two weeks ago received a doctorate of
literature from Dunedin University. This is a woman that writes that
Christchurch where this all happened is a particularly likely place for a
prosecution like this to happen because it's so flat. [long pause, scattered
titters from audience] Takes a while to sink in. What she meant was that
social movements and hysteria are whipped up easily in places that are flat
because you can get to the meetings more easily, and her evidence for this
was that the suffragettes in New Zealand started there also.
I shant dwell on that I shall move on to the - Here's another taboo which
Colin of course has debunked very nicely. He does some superb work in this
area. The idea - schizophrenia is not an illness, and that hallucinations and
delusions have a social and psychological aetiology. Or perhaps, more
accurately, I think I should say that schizophrenia simply doesn't exist. And
I'll say what I mean by that in a minute.
A lovely example of the way these two taboos link up for me personally. The
hate pages on New Zealand's equivalent of recovered memory website in New
Zealand, just generally goes for me sort of about the fact that I criticise
the goddess Professor Loftus from time to time and so forth.
But as evidence of how bonkers this man is, they immediately put, before I
can get it on my webpage, because I'm pretty slow at these things, every
study I ever do on abuse and schizophrenia, just to show how completely
screwed up I am. So it's just more evidence, you see. These two things are
sort of linked for me quite personally. I'm quite grateful to them because
they're quite good at getting my research out there. Not in a particularly
positive context.
Now there are different explanations for why we went off the tracks about -
coming back to our more recent roots - Jeffrey blames Freud - you know, we
hear about trauma and dissociation at the end of the 19th century being quite
a focus for a lot of people. Jeffrey quite rightly points at Freud. Russell
quite rightly identifies behaviourism, positivism, that sort of just wasn't
interested in things like this, and that's accurate too in my opinion.
I focus more on the invention of schizophrenia. And I use the word
‘invention' purposely of course. Some of the symptoms of this so-called
biological illness - I have to do a deconstruction job - I think it's the in
word, isn't it? - for when you're describing something you don't like, you
deconstruct it. Which means you say mean things about it.
So here's some of the symptoms - there are several - by the end there are
about 200 pages of symptoms. So I want to read some of them to you, of the
original definition of schizophrenia by Emil Kraepelin and Eugen Bleuler.
‘Schizophrenics do not adjust their behaviour according to the situation in
which they find themselves, whether they are addressing someone of superior
station, or someone more humbly placed, whether a man or a woman. They fail
to respect their superiors, challenging them to duels. They decorate
themselves with gaily coloured ribbons and they go with a lighted cigar into
church. For some patients, homosexuality is evident in all aspects of their
demeanor. They fall in love with other patients regardless of their ugliness
or even repulsiveness. Their loss of judgement exhibits itself in a
preference for extraordinary combination of colours. One haberphrenic
schizophrenic held a cigar for another patient for hour after hour showing an
indefatigable kindness of which no normal person would be capable.' There are
200 pages of that.
Now for me that's a wonderful historic social document about broken social
norms of this particular time and place. But for Kraepelin and Bleuler and
for biological psychiatrists of the whole of the 20th century, and
unfortunately for some still holding on to this deluded idea today, these are
symptoms of some illness.
At the time they said, ‘Well, we will discover the physiological basis
later.' The ‘to be discovered' argument. It's a wonderful argument. You can
never defeat that one. And researchers all over the world are constantly on
the verge of discovering the cause of schizophrenia. In fact I calculated
once that it is indeed the most discovered cause in the history of
psychiatry, or even medicine. It's discovered on average every 2.3 years, the
physiological cause of schizophrenia.
I should mention the last symptom - not the last one - one of the defining
characteristics for Eugen Bleuler, when asked ‘What are the really core
symptoms?' Actually interestingly he talked, as you will know, a lot about
the splitting of psychic functions - does that found familiar to anyone? -
splitting of psychic functions. Almost - very very close to modern-day
definitions of dissociation. But he highlighted a fascinating key symptom
which was the peculiar incomprehensibility of schizophrenics. So to avoid a
diagnosis of schizophrenia, apparently, you had to be respectful to
superiors, not challenging them to duels, not going into church with a
lighted cigar, be heterosexual, fall in love with the right people, choose
ordinary combinations of colours, don't hold a cigar for somebody for far too
long, and even communicate in a way that psychiatrists can understand. Fairly
impossible task, I think.
So schizophrenia has a long history of ignoring social context, I think.
That's the main point I'm trying to make. And just to get that across even
more, I'd like to show you - this is my version of the thematic aperception
test - you know, where you show a funny picture and say, ‘What might this
be?' Some of you will know this. This is a picture of schizophrenics showing
what is called waxy flexibility, which is a symptom of catatonic
schizophrenia which Andrew is very interested in - Andrew Moskowitz, one of
my colleagues.
Now they don't look two together, do they? I mean, this is not your average
sort of group of people. Something odd is going on here. What's left out of
the picture, quite literally, is why they were doing it. It would be nice,
wouldn't it, if we could've gone up to them, ‘Why are you doing this? This is
weird.' And in fact Kraepelin did ask them, to his credit, and I don't know
if you can read that. ‘I have to do it,' said a patient when he was asked
about the cause of his cataleptic behaviour. Another said, ‘It happens to
order.' And all through here what's actually happening is that they are doing
it because the psychiatrist told them to do it. Why would a psychiatrist tell
them to do it? Because they wanted to find out if they had the symptom called
waxy flexibility.
In a context like this, where your likelihood of getting out of a psychiatric
hospital lifetime was roughly 50%, do you do what the doctor tells you to do?
I would. So you can actually see the wry grin there. I think that's a nice
example of how people can be made to look quite bonkers if you ignore the
social situation.
Schizophrenia genetically based - this is the bit we can put in the bin
because Colin has covered it, except I'll highlight a couple of things. I'm
more generous than Colin, I say the [inaudible] is a little higher than that.
But either way the point remains that it's primarily environmental. Twin
studies of course are quite meaningless because twins grow up in the same
environment as well as having shared genes, so you can ignore them. So you
move on to adoption studies which are just hopelessly methodologically flawed
except for the more sophisticated ones which actually look at the families of
the people to whom the adoptees go. And we only have one or two studies like
that, and the best study of all is Tienari and his group who showed that the
effect of the role of the adopting family - the family that the adoptees go
into - is several times greater than any genetic explanation.
And anyway, as all my clients (as we now say) have told me whenever I've
raised this issue with them, ‘John we're really not interested. This bloody
debate about whether it's genetic or not - actually, could you get me a
home or an income, please? Or stop twittering on about what percentage is
genetic because we really don't give a damn.' Actually, more academically,
it's a meaningless debate because of course everything is partly genetic and
everything is partly environmental.
It is interesting of course how biological psychiatry pretends that it's
genetic. So Colin's absolutely right.
Now the other reason it's important is - an over-emphasis on genetics has led
to some unpleasant circumstances, including the murder of 1/4 of a million
mental patients - not all diagnosed schizophrenics - in Germany. And the
astonishing thing - well, it's all astonishing and all horribly sad - but
Jews were actually excluded from that programme. And if you think about it
the reason is quite clear. This preceded the genocide attempt on the Jews. It
was like a trial, if you like. But the reason the Jews were excluded from
that was that the whole idea was to allow degeneration of that race but
purify the Aryan race. 1/4 million people, before the 6 million Jews who
died, were killed in the name of genetic theories and psychiatrists were
right there with the theories, and right there killing people. Of course that
isn't happening today. Of course.
What is happening today around the world is genetic counselling still goes
on. Genetic counselling is nicely and carefully informing people that there's
a fairly high chance that if you have kids they'll be mad. So it might be,
you know, perhaps you should consider that.
Now, one of the things that all researchers agree whether they come from a
biological or a social perspective on schizophrenia is that there is
something going on around heightened sensitivity to stress. We have different
explanations, most of us in the room, to the biological explanations which is
all genetic predisposition. But let's assume that's true, most people do,
regardless of where it comes from. Let's assume we could narrow the gene pool
through genetic counselling. It that something we ought to be doing because
we are actually still doing it around the world. I just raise this as a
worrying thing about genetic theories.
Another piece of evidence that the genetic component of schizophrenia is not
very high is - I can't remember now where I read it a couple of weeks ago -
it had never struck me before in 30 years of looking at this - having wiped
out most of the schizophrenics in Germany, was there a lowered rate of
schizophrenia in Germany in the next generation. No. Rather crude sort of
analysis but it's a kind of important piece of the picture.
Now Jeffrey and I have written a chapter for a forthcoming book I'm editing
on schizophrenia on this issue because Jeffrey knows heaps about this, and
one day Jeffrey you will get that book out, and you must get that book out
that documents this awful series of events and the implications for today.
You must get that book out.
But there's a very sad end to that chapter which shocked even me, and
documents the power, the generally awful power of the medical model to make
people stupid and do mean things, just appalling things. When the survivors
of the concentration camps got back to Israel you would assume that the
response they got there was a full acknowledgement of what they'd been
through, and all sorts of - what would you call it - trauma therapy - I don't
really care - a lot of human support.
The Time article in 2002 - and it took me a while to take this in - it was
documented that the majority of people in Israel psychiatric hospitals were
Holocaust survivors, and the majority of them had been diagnosed schizophrenic
on return from Germany and Austria, and had been living in back wards doped
up to the eyeballs with Haldol and Thorazine for 30, 40 years. Now that is
one of the saddest things I have ever read. It is really quite astonishing.
To the credit of a small number of psychiatrists in Israel they are now in
the process - of course it's too late for many - but they are now in the
process of getting them out of those places and giving them something of what
they might need. But that's the power of the biological model, and that's why
I hate it so much. The simplistic, reductionist, stupid biological model.
It's dangerous.
Here's some figures. I am going to talk about what I'm supposed to talk about
eventually. But it's important - see in this - in two weeks time I come back
to Melbourne for a psychosis conference with the same number of people again
from all over the world. At that conference I will talk of nothing but
trauma. At this conference I have to talk about psychosis to get those of you
who are either still wondering is there something over here.
We do still have this idea that, yes, trauma causes everything - [mumbles]
eating disorders, Post Traumatic Stress Disorder, dissociation, da di da di
da, sexual dysfunction. Then at the other side of this iron curtain are the
real biogenetic illnesses, and it's just rubbish. So that's why I talk about
that here.
And even if you're convinced you need some ammunition because there's an
awful lot of people out there not convinced.
The general public are convinced, by the way. Studies all over the world,
public opinion studies all over the world - Germany, Britain, United States,
Ireland, Australia, New Zealand and two or three others - when you ask people
what causes schizophrenia, at the top of the list are two things: stressful
events and bad things happening in childhood. The destigmatisation programmes
around the world call that ‘mental health illiteracy'.
The health of the drug companies, which we'll come onto shortly - the drug
companies are very happy to fund programmes trying to help people understand
that mad people have biological illnesses, which our research in NZ shows
actually increases people's fears.
But now I'm not even talking about the slide in front of me which isn't even
about what I'm supposed to be talking about. The definition of tangential
thinking, by the way, as whether you're psychotic, is whether you can find
your way back to where you started. And on this occasion I can. But I have
been known to - I may need some help later - so Jeffrey steer me back if -
This is an example - it's not surprising, given I told you there are 200
pages of symptoms of schizophrenia, that the experts cannot agree on who has
got it and who hasn't. It's an absolute nonsense scientifically. The whole word
should have been thrown out at the beginning. Possibly with any other
discipline, or any scientific discipline, it would have been.
Here's an example of one study in 1971 where he took 194 psychiatrists in
Britain and 134 in the US. Presented them with the same description of a
client and asked them what the diagnosis was.
They didn't have 400 diagnoses to choose from, like in the DSM. They had 4:
schizophrenia, personality disorder, neurosis and depression. I don't need to
comment on those figures. These are not tiny differences are they? It's
bizarre. That meant that the entire 20 or 30 years before, when everyone was
running round trying to find the causes of schizophrenia, people in England
were researching an entirely different group of people than the people in the
US. The stupidity of biological psychiatry staggers the mind.
Here's the criteria today. We're more sophisticated today. We have DSM 4
revised. Yes. And there's a problem here. It's very scientific. Lays out all
the criteria. You have to have 2 of the following: hallucinations, delusions,
thought disorder, catatonia and negative symptoms. Ignore the bottom bit.
That means that you can have hallucinations and delusions.
All of you over there can be - nothing personal - hallucinations and
delusions. This half has not hallucinations and delusions but has thought
disorder and catatonia. Absolutely nothing in common, same diagnosis. And you
can guarantee the same treatment: anti-psychotic medication.
It gets worse because you only need one of the above five if you have voices
commenting - and we'll return to that, it's quite important - or if your
delusions are bizarre. Those of you over here who've got delusions and
hallucinations, well some of you haven't got hallucinations, it's just that
your delusions are bizarre. That well-known scientific construct: bizarre.
Science at its best. Better move on, I think.
There are a number of factors inhibiting the acknowledgement of a
relationship between abuse and schizophrenia which I will talk briefly about
- again Colin has covered a lot of them.
But I just want to stop for a second and say this is not just about abuse,
it's not just about trauma. The biological model buries so many other issues.
It buries poverty - which is a huge, huge relationship between being
diagnosed schizophrenic and being poor. Demonstrated over and over and over
again. And ignored and buried under the medical model.
It also buries ethnicity and issues around ethnicity. And I know Caroline
gave the senior male psychiatrist in Australia a really hard time yesterday.
So I'll just jump on the bandwagon and carry on.
We did a study in NZ which asked all - a very high number, 500 I think,
several hundred, I can't remember the number - NZ psychiatrists and
psychologists a simple question - why do you think there are so many Maori in
our psychiatric hospitals? The majority came up with - I was going to say -
good reasons. I suppose I mean by that reasons I agree with. Such as loss of
land, loss of culture, alienation and so forth.
And 10% were happy to write down that theory that we like to think psychiatry
abandoned a long time ago - that Maori are more genetically predisposed to
madness than Pakeha, than Europeans. And I immediately thought - oh that'll
be all the people coming in from overseas - because we've had quite an influx
of psychiatrists from overseas. We went back to look at the data and it was -
first of all they were all male. None of the women psychiatrists said that.
And to our profession's credit only psychologist, also a male, said that.
They were all male and all senior - by senior we meant having practised for
10 years or more. So when we looked at the percentage of senior male
psychiatrist in NZ who held that racist belief, it was the majority. So we need
to address these issues as well.
Of course it's important we focus on trauma but as John says, there's simply
trauma, there's complex trauma, and then there's life. Okay? That's the
poverty and ethnicity are important issues. And if you forgive me, I'll put
it as a hope for the future, rather than a criticism of the last 3 days. I
think it's important, and it's a job for all of us to do together that at
conferences like this we must, we must have a visibility from ethnic
minorities and I think next time [rendered inaudible by applause]
The last thing you need is a Kiwi coming over here and talking about that but
tough, let's do this together. There must be aboriginal people here next time
talking about their experiences. Can we see some of these - a long tradition
of people who do psychosis research ignore abuse. People who do abuse
research ignore schizophrenia. It's very sad. It's getting better as I'll
show you in a minute.
Now here's a key one for us in this issue of what should we call these people?
What diagnosis should we use? One of the things that gets in the way, and
Colin alluded to this about establishing scientifically the relationship
between trauma and schizophrenia, is that you will find time and time again
that people who have been diagnosed schizophrenic for years and years and
years and some how suddenly somehow manage to get a mental health
professional to understand they were traumatised after years and years and
years - the hallucinations that have earned them the diagnosis of schizophrenia
for the last 20 years suddenly become pseudo-hallucinations.
Dissociative-like hallucinations. And the diagnosis shifts from schizophrenia
to either PTSD or dissociation.
Now I am, and Russell I think, there was an example in Russell's talk yesterday
that Casey presented, as a matter of fact - and it's very understandable - as
a matter of fact Russell said this person obviously who had been diagnosed
schizophrenic was misdiagnosed.
And we have a real catch 22 situation here, which Colin and I identify, for
that individual person. God knows they're better off with the diagnosis of
PTSD or dissociative disorder, because somebody might start talking to them.
And they might get off a lifetime course of anti-psychotic medication, which
in most cases is a good idea.
However, from my position, trying to establish that you can, you can have
psychosis, full blown psychosis that is trauma-based, it's the kiss of death,
because we're moving people - Colin described it as rescuing people -
absolutely - then we're left with this chorus of people who we can't find any
trauma for.
More important theoretically, we can't establish it. There's a long tradition
of making rediagnosis when a theory doesn't fit in schizophrenia, but I won't
bore you with that.
This is a troubling one. I don't have the answer. Of course clinicians - if
you can get someone to diagnose PTSD rather than schizophrenia, go for it.
And there's enough overlap it's not difficult to do. But please don't
therefore then fall for the trap that you cannot have schizophrenia caused by
trauma. I've probably said enough about biogenetic model. I think you've got
a vague idea of how I feel about that.
Just a classic example here, people - some of the research that has been done
around trauma and psychosis you'll find amazing comments like: ‘It's a
terrible tragedy this coincidence. Not only has this person got this terrible
debilitating illness called schizophrenia, but they had such a traumatic
childhood. What a double whammy. That's really, really sad.' And I'm sitting
there pulling my hair out.
This actually shows up in research papers as well. They try and explain that.
One of the papers that's made me the most sick, I won't even name it. I can
if you want to later. Somebody who was actually trying to understand this
relationship from a biological psychiatry position. They said, ‘Well
obviously there must be a genetic predisposition to both.' I read it and I
read and I read it, and there - yes, absolutely, a genetic predisposition to
being abused as a child. The same set of genes that predisposes you to go
mad, predisposes you to be sexually abused as a child.
Beaten only by my very, very favourite one, I know if you saw it back in the
early ‘80s, when they actually found a chromosome for propensity to
adversity, and one of the examples for adversity was losing your job. Anyway,
well I think we've said enough about simplistic genetic theories.
Drug companies - Colin has covered this but obviously the people that Warwick
named on the first day who have supported this conference have done, I'm
sure, a wonderful job to make this conference possible. And I hope that one
day they rise high enough in their companies to get a sense of what those
drug companies are actually about.
And to be able to perhaps influence them because - I have to choose my words
carefully because it's being videoed and drug companies are extraordinarily
litigious. Colin doesn't seem to worry. I don't know which of us is more
healthy. So I'll choose my words carefully. I hate drug companies. They have
been an absolute disaster in the field of mental health.
They have given us the benzodiazapines that led to one in 10 women across
Europe in the 1970s being addicted to benzodiazapines, and they knew they
were addictive and they kept that information to themselves. They have given
us ritalin for our children. That diagnosis ADHD, by the way, the older ones
amongst you will know this, they used to be called Minimal Brain Disfunction,
that particular set of symptoms. It turned out so damn minimal they couldn't
find it, and therefore they had to come up with this new diagnosis.
They gave us the anti-depressants. Now we read in the Melbourne Age just this
morning that the number of prescriptions of just one anti-depressant - zoloft
[?] I think - has trebled in the past 7 years to 2.4 million prescriptions a
year. Has everybody in Australia suddenly got more depressed? Are you alright
Australia? Should we send more of our Kiwi psychologists over? No - because
it's happening in NZ and it's happening all round the world. Now either
people are getting more depressed in which case I would imagine - well I
suppose that's genetic as well, no it couldn't be, could it.
Something's going on the world, and maybe something is going on the world, or
this is just pure marketing. It is turning what used to be called ordinary
being-upset-when-bad-things - happen into an illness. Depression is now an
illness.
Just to complete the list, the rubbish that is coming out about sexual
dysfunction just to sell viagra is just astonishing - I'm sure you've had it
here as well. Forty percent of men over 40 - I'm not biased at all about this
myself - have sexual dysfunction. We know damn well and have known for
decades that the primary cause of sexual dysfunction in men is performance
anxiety. It has nothing to do with physiological problems whatsoever.
And now on to anti-psychotics which is my own area of course. For years the
old-style anti-psychotics caused tardive dyskinesia which is an irreversible
form of brain damage in somewhere between 30 & 40% of people and we heard
nothing. Now we have the new, safe, upgraded anti-psychotics, the atypical
anti-psychotics. And tardive dyskinesia which was not mentioned for years is
now a marketing tool for the new one.
And when we have the next wave we will hear all about the agranulo-cytosis,
and weight gain, and all of those things that are now somewhat minimised. I
could go on - and probably will - no I won't.
Because I'd better talk about what Naomi and Susan asked me to talk about. I
will just finish by saying that the drug industry has the largest profit
margin and has done for 30 years of any industry in the Western world.
Enough.
I've actually finished by photo drug
company story. I was at a conference not so far away from here. A different
profession. Though of course there are some psychiatrists here, which is
lovely. Whoops, I just let the cat out of the bag. Not so far from here - and
a drug company, God bless them, gave a $2000 reward if you like, or prize,
for the best presentation by a non-psychiatrist. That was sweet, wasn't it? I
so badly wanted to win it because I had already written the press release
about why I was returning it. There were only two presentations by a
non-psychiatrist. I gave both of them. It was 2 years ago and they're
obviously still deliberating. I will move on though.
I've said enough about false memories, I think. And I'll whizz past this as
well because I did that yesterday and it's not central.
I will just dwell briefly here to point out that although people are not
asking very much at all - mental health professionals are not asking about
trauma, there are certain groups that are especially not asking and the key
one for this debate today is they're not asking people diagnosed psychotic or
schizophrenic.
The clinicians who especially are not asking that group of people are the
ones who most strongly believe in biogenetic causal beliefs. Not surprising.
Schizophrenics, if you excuse the term, are less likely to be referred for
abuse therapy. Now here's what we're actually supposed to be talking about,
so I better do my whole talk now in 5 minutes. But I think these sort of
contextual things are quite important.
So we now have a large number of studies, a large number of studies, that
cannot be denied. So when you look at the proportion of women in-patients, or
if you - we included out-patient samples, where 50% or more were diagnosed
psychotic, in other words, the extreme end, you find these sorts of figures:
so from 36 (that is 50% of women) when asked will tell you that they were
sexually abused, and 69% sexual or physical abuse.
It's always important to include the male figures because as John Briere will
tell you we have always been behind on researching that but we are catching
up. The figures as time goes on actually get closer and closer to the female
figures. They're not going to get all the way there. Not on sexual abuse. But
they are going to get a lot closer than we suspected.
So we now have evidence that child abuse is linked to psychosis in general,
schizophrenia - this is a quick run through. Colin's covered the positive
symptoms, and Colin's research in the mid-90s was absolutely pivotal to
breaking the silence on this issue. We owe him a huge level of gratitude, I
think.
Symptom content. I will take one minute because of course we do all this
numbers research, and we don't actually - you can lose the people in that.
You can lose what you're talking about. So here's some of the - in one of our
studies - some of the symptoms that are in the notes of people with psychotic
symptoms and no-one has made the connection. I'll just read you 2 or 3 from
our latest paper.
One person whose chart included a forensic report stating ‘was abused over
many years through anal penetration with the use of violence' that's the
quote in the medical notes. ‘Hears the perpetrator's voice telling the
patient to touch children.'
Another person who was sexually abused at age 8 to 9 years ‘has auditory
hallucinations in the form of the voice of the abuser'. It goes on. There's
many, many examples. That's just to give you a taste of our now - some of the
studies as an example.
But I must get on to this particular study, which I will now do in 2 or 3
minutes. John Briere talked about the need to look beyond simple traumas to
complex traumas.
We're just at the beginning now trying to understand which types of sexual
abuse relate to which types of schizophrenic or psychotic symptoms. So I'll
read you the study of 200 out-patients.
Here's some of the figures. Those who experienced no abuse: 18% were
hallucinating. Those who experienced sexual abuse: 55%.
I've tried to put out as many copies of this paper as I could, but I've now
run out.
So what was perhaps unique about this paper is that we did look at - we
separated sexual abuse and physical abuse, and then we did what actually John
was recommending, that we also include adult rape. Because so many people who
are abused as children for quite complex reasons - well in some ways not so
complex reasons - are also raped as adults, it's important to actually try
and control for that, or understand that.
So you can see the increase there. Someone was both sexually abused as a
child and raped as an adult: 86% of those were hallucinating or had
hallucinated in the sample compared to no abuse.
Delusions. It's not such a powerful relationship as far as we know. This is
just one study, but there is a pattern here with some of Colin's stuff. The
consistent pattern seems to be that hallucinations are the most strongly
related to childhood abuse. Thought disorder is in there, but according to
our study only if you are retraumatised as an adult. It's going to be
different for different people, so don't get too carried away with the numbers.
But again consistent with Colin, no relationship with negative symptoms. For
those of you who don't know, negative symptoms of psychosis are sort of loss
of pleasure in life, social withdrawal, sort of thing that Yuchi was talking
about. You can even get more specific and breakdown the type of the types of
hallucination. I won't bore you with all this. I'll just pick out one.
Is it surprising - it's not to you lot of course and, it shouldn't be to
anybody - that in this study people - I'm looking at the tactile line there -
people who were not abused, none of them experience tactile hallucinations,
usually in the form on insects or animals crawling over their bodies or
entering their bodies. What could that possibly be about? The genetic
predisposition to experience insects crawling over your body no doubt.
I put this in because - as I said before, you need two or more schizophrenic
symptoms to get the diagnosis - so I thought we'd just play this silly
numbers game and see if child abuse actually could predict whether people had
two or more schizophrenic symptoms, and it did.
Physical abuse did not. But then again, if you put childhood sexual abuse and
rape as an adult together the picture changes again.
Now, this is my attempt to be scientific. I understand stepwise linear
regression to be something about having a dream the night before you give a
talk to 700 people and you picture yourself at the top of the stairs and
you're feeling about age 50, and you go in a straight line down the stairs and
by the time you've gotten to the bottom you're about age 5 as you enter the
auditorium. That's my understanding of stepwise linear regression.
But fortunately I have a statistician who works with me so this is a very
early attempt to tease out some of the stuff that John Briere was talking
about. So the ones on the right, you can predict all of those - if someone
who has been abused as a child, and abused as an adult, will predict, there's
a risk factor or whatever the right word is - and some, but not all, the
child abuse alone is sufficient.
And voices commenting - which to those of you who understand dissociative
identity disorder better than I do, it might be relevant. Tactile again -
child abuse by itself.
Delusions needs both. Thought disorder needs both. Negative symptoms isn't in
the picture. Don't take too much from this. This is what - we need another 20
studies.
But the pattern is sort of beginning to become clear. It's a particularly
strong relationship with hallucinations. Now John hates when I do this one.
Well he doesn't hate me but he - Because the question is correlation or
causal.
If you're a scientist you'll know that just because two things happen
together, it doesn't mean one causes the other. A lot of the studies I've
described are correlational. What does it mean? They could both be explained
by something else. Like that - you know - they're both genetic
predispositions. But they could be other thing. John actually, possibly
without intending to, I don't know, he's never admitted it, has done the only
study that actually has tried to control for other factors. And when you
control for some factors - not all here - other variables which predict
victimisation and/or psychiatric outcome: childhood sexual abuse was not
related to anxiety disorders, not related to manic disorders, marginally
related to depression, and very powerfully related to what John described in
that study as non-manic psychotic disorders e.g. schizophrenia and psychosis.
That still doesn't prove causation, but it's another step on the way to
looking at that. We have tried to explain this in a number of ways. One of
the ways we've done it is to just document the fact that the exact same brain
dysfunction in the brains of adult schizophrenics that always used as a
biological explanation, of proof that it is a biological illness, we now know
that those same things are found in the brains of severely traumatised
children.
That might just mean something. It includes over-activity of the HBA axis
which as we heard earlier this morning. No we didn't hear earlier this
morning, sorry. Earlier in the week, perhaps. Is about controlling response
to stress. Hippocampal damage is in there as well, we did hear about that
earlier today.
This is just the little advertising part of the speech here. Those of you who
are in Melbourne and want to hear more about what Colin and I have been
talking about, there is a huge conference coming up here. You should just be
able to get back to that one after you've been off to Manly for the
conference on severe disorders, and you come back here for the conference on
severe, severe, severe disorders. Then you have a holiday. No, no. Because
then you come on to NZ where we're doing the follow up to the Melbourne
conference. This is for the Kiwis in the audience who are probably sick to
death of me plugging this particular conference.
Here's some of the books that are out, including our own. Now Colin has his
coming out. This is a growing field. People are becoming more aware of it.
It's Colin's 10th book and my first, so when they come out be nice to me. Buy
both! Buy both! Richard Bentle's [?] book is an astonishing, much far
ranging, very far ranging book. I'm going to have to stop without covering
everything I wanted to.
So there are ways we can understand these relationships. These are just
numbers. That's just grains. There are ways we can I believe actually, for
instance, the self-trauma model, or the trauma model that Colin talks about,
makes as much sense applied to psychoses as anywhere else. We need to
actually think about what it means when we start battling with one another
about: should we call this dissociative sub-type psychosis? Should be call it
psychosis - PTSD? Let's not get too caught up on all of that. I have a very simplistic
theory, I'm afraid. It might be intellectual laziness. I'm not sure. It
probably is.
I always start my depressions - um - my lectures to 800 undergraduates trying
to explain depression. I start by saying: ‘Depression is caused by depressing
things happening.' And I walk out. You have to do stupid things with
undergraduates to keep their attention. But actually that's what I believe.
It's just that you can't write a book about it. So I'm a subscriber to the
bad things happen in life and they fuck you up.
And we must of course all this thing like - how much is dissociation, how
much is PTSD - of course they're important but we can actually get lost in
all that. Repeating what John said, which you already know, it's the
relationship what counts.
My final words of wisdom to you are - do not get caught up with new fads,
whether that's dissociation-explains-everything or PTSD-explains-everything.
And do not get caught up in treatment fads. If you discover a new treatment
and you suddenly find yourself selling it to lots of people very
enthusiastically, take a holiday. Please.
And finally, and seriously, I'd like to acknowledge all of you because I get
quite stroppy with trauma people sometimes. Sometimes you seem to talk to
yourselves too much and not to the external world enough. I want what you
have to say to be out there in the external world more. There's a battle to
be fought.
I was whinging on to two Kiwis last night when I came out for cigarettes from
the dinner. I said: ‘Why aren't we out there more fighting and getting more
resources? If we had 10% of the drug company profit for last year we could
probably run child prevention programmes for the next 10 years for the whole
of Australia. [applause] Clap loud enough, they'll go native I'm sure.
Those of you who are interested in prevention, and you cannot not be
interested in prevention if you're interested in prevention if you're
interested in trauma. Emma Davies is doing a talk. In fact, interestingly the
only talk on prevention I think in the whole conference, that's something we
perhaps need more of.
But the two Kiwis I was moaning to quite rightly said: ‘John, you aint doing
any trauma therapy at the minute. That's hard work. You've got your role. You
do it well. We're proud of you. Be proud of us.'
And I want to end by saying [microphone turned off, voice becomes
faint] that I have to acknowledge, and we all have acknowledge to one
another, the extraordinary, extraordinary, work that you all do in different
ways. It's not something everybody wants to do. I don't know why you want to
do it. Well, we do, but we won't go into that. It's different for everybody,
he answered quickly. But I just want to acknowledge that, and thank you
all.
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