Psychopathology and Abuse

Everyone is quite familiar with the ideology these days that mental illness is a biochemical malfunction due to shitty brains and genes. Of course, the only ‘real’ answer is to take medication to re-balance what went off-centered (despite the fact that anti-depressants only work on the severely depressed, see the UK). I’m not interested in blaming Big Pharma and the biologzation of psychopathology because it is undeniable that genes and neurotransmitters can certainly leads to bizarre behavior, thinking, and emotions. For instance, one of my scholarly interests is schizophrenia and the psychotherapy of psychotic disorder (dissertation focuses on the treatment and model for schizotypal personality disorder). I am well aware of the genetic component and the finding that monozygotic twins have a 40% chance of developing the disorder if the other twin likewise suffers from schizophrenia (general population has a 1% chance). That’s all well and good, and I have no problem with the findings. However, what is getting lost in this conversation is the prominent role that trauma and childhood sexual abuse have on the development of schizophrenia. For example, Colin Ross has proposed adding a dissociative subtype (akin to paranoia) to DSM definition of schizophrenia to account for the large percentage (~25%) of people of schizophrenia who suffered from chronic abuse. The folks tend to have more positive symptoms (hallucinations/delusions) and less negative symptoms (withdrawal, avolition, etc). They tend not to respond to anti-psychotics and benefit more from psychotherapy. Another recent study conducted by Heins et al. (2011) in the American Journal of Psychiatry confirmed that different levels of positive psychotic symptoms are correlated to the exposure/severity of trauma the person endured in childhood. The study was designed to avoid reporting error/bias by interviewing non-psychotic siblings of the psychotic individuals. This really should not come as a surprise, although many in the establishment continue to pretend that environment plays little to no role. We might recall the derision that academic psychologists regularly heap on Fromm-Reichmann’s notion of the schizophrogenic mother, which despite its manifest flaws, does implicitly recognize that shitty childhoods can actually drive people crazy.

In my graduate work over the last couple of years what never ceases to amaze me is the prominence of abuse (and childhood sexual abuse, in particular) in my work with patients. Freud likewise discovered this in his early clinical work although he abandoned the seduction theory (i.e. sexual abuse) as the underlying cause of hysterical symptoms. Given the overwhelming influence that childhood sexual abuse has on psychopathology (and not merely schizophrenia, e.g. depression, dissociative disorders, personality disorders, eating disorders, etc.), one might wonder why we never hear about this in public discourse. Mental health coverage in this country is notoriously awful, and since the passage of the Community Mental Health Act of 1963 the severely mentally ill have become more invisible, homeless, and incarcerated. Here’s a terrifying fact: more folks with schizophrenia tonight will spend the night in jails than in hospitals. One wonders how these people who not only have experienced more traumas, but are also rendered more vulnerable to abuse given their difficulties, are ever going to get help. It seems the first place to start is to tell the truth about childhood sexual abuse and how it is responsible for so many of our problems. Perhaps nobody has been bolder than Louis Farrakhan in calling out men to stop abusing children at the Million Man March in 1995 in Washington, D.C. Farrakhan, “I, say your name, pledge from this day forward I will never abuse my wife by striking here, disrespecting her for she is the mother of my children and the producer of my future. I, say your name, pledge that from this day forward I will never engage in the abuse of children, little boys, or little girls for sexual gratification. But I will let them grow in peace to be strong men and women for the future of our people.” Twenty bucks says neither Romney nor Obama will once address the problem of childhood sexual abuse on the campaign trail this election year.

We need more public figures to call out this major problem because no progress will be made as long as silence continues. Despite the fact that childhood sexual abuse is revolting, it is surprisingly common (statistics are difficult to estimate, but I don’t think it’s a stretch to think it’s around 30% for men & women, if not higher). As a psychologist in training, nothing is more painful and liberating than hearing someone talk about such issues and attempting to come to terms with what happened to him/her. People spend decades running away from the trauma, and parents, siblings, and friends often collude in the silence because of the terror/guilt it stirs up in them. This takes me back to my beginning discussion of schizophrenia. So many folks are intent on biologizing the disorder and ignoring the social factors. “We, parents, aren’t to blame for this psychotic disorder. We’re victims too”. Sure, maybe you are. But I want to also be vigilant to the fact that psychotic disorders often have historical and traumatic origins (see Davoine and Gaudilliere’s History Beyond Trauma, 2004 for a Lacanian take). We have to hold individuals accountable as well as call into question certain social structures that do nothing but encourage abuse (i.e. the nuclear family).

25 thoughts on “Psychopathology and Abuse

  1. “[S]ince the passage of the Community Mental Health Act of 1963 the severely mentally ill have become more invisible, homeless, and incarcerated. Here’s a terrifying fact: more folks with schizophrenia tonight will spend the night in jails than in hospitals.”

    Do you have any (other) pointers as to where I could begin reading on social factors in psychotic disorder as well as the history of the criminalization of those with mental illness, maybe in addition to the book by Davoine and Gaudillieres? As an amateuer I can at best say that I sense and am somewhat aware of the ideology that says “that mental illness is a biochemical malfunction due to shitty brains and genes” and would much appreciate further recommendation.

  2. Thank-you for this Jeremy. I think it is fair to say that many of us are formally and informally ‘on the ground’ when it comes to dealing with these realities. It does indeed seem like one of the larger factors is helping people to accept responsibility without having them go directly to complete denial or crippling guilt. I am more familiar with systems therapy and there is still a tendency to view it as ‘solving the origins of a problem’ (i.e. it was the mother’s fault) instead of a helpful tool to identify consistent patterns and influences so that there can be a better understanding and intervention.
    How would you comment on the initial movement that identified social and familial factors in the development of mental illness? Was there really bad PR in how it was communicated to families? Were some of the fundamental insights misguided or over-zealous?
    I also think it is not helpful to have the pendulum swing completely to other side when it comes to the ‘nuclear familiy’. Systems are systems and a healthy nuclear family can be an absolute god-send to someone struggling with mental illness. We all always have to be vigilent against certain systemic patterns. Although as you say ‘nuclear’ family are you already assuming a certain structure and not just immediate familiy as such?

  3. I don’t know as much about the criminalization of mental illness. In terms of social factors and psychological treatments: http://www.isps-us.org/

    Here’s a course I created more on the psychoanalytic tradition with schizophrenia: https://itself.wordpress.com/2011/11/24/the-psychoanalytic-psychotherapy-of-schizophrenia-and-psychosis-syllabus/

    A book my friend recommends: http://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing/dp/0307452425/ref=sr_1_1?ie=UTF8&qid=1334267854&sr=8-1

    Another useful list: http://www.isps.org/books.shtml

  4. When you say origins of the problem (i.e. mother), I’m not sure what you’re talking about. Are you referring to schizophrenia or sexual abuse?

    Yes, I think my post points out to social and familial factors that facilitate mental illness, as I hope my post recognized. The history of schizophrenia and psychoanalysis is complicated, but yes there was a tendency to scapegoat the parents. To be fair, sometimes parents weren’t great, and abuse tends to be high in the background of folks with psychotic disorders.

    My point was that family members tend to abuse one another. I didn’t intend to offer any sort of systemic analysis of psychopathology but rather open up a conversation about the impact that childhood abuse has on families and later expressions of psychopathology. Society’s not great, but as we say symptoms are political and intrapsychic conflicts are timeless. There’s no society I can envision in which psychopathology is erased. As a Freudian, I can never forget the existence of the death drive and the destructiveness, aggression, masochism, and sadism of mankind.

  5. I was more interested in whether you were aware about why initial communication about our implication in each other’s mental health was so drastically rejected. I am thinking more of how the parent (mother often) was said to put their children in a ‘double-bind’ which affected the child’s mental health.
    Regardless of the various ‘theories’ I was curious about the extent to which these earlier theories were simply wrong or fundamentally misguided, was how they were communicated to family’s unhelpful, or was there some other factor that had us as a society almost completely reject our implication in each other’s mental health.
    Does make my question any clearer?

  6. Right, I’m aware of the double-bind theory. It was rejected because it scapegoated mothers, and it is simply untrue. As I tried to illustrate there are two major pathways to schizophrenia: biological (genetic/prenatal) and traumatic.

    I don’t know if they were wrong in their own times because the definition of schizophrenia has changed rather drastically in the US from the 1940 to 2012. So some folks they called ‘schizophrenic’ might better qualify for other disorders (dissociative disorders, borderline personality disorder, etc), and those disorders tend to be thought of as having a more traumatic etiology.

  7. I think David is asking the question “why aren’t people receptive to the theory that our interpersonal relationships have a powerful impact on mental health?” I would answer by saying the truth itself is basically traumatic. If I remember correctly, Judith Hermann suggested that Freud rejected the seduction theory because it was simply to horrible to imagine. If Jeremy’s estimation is correct, alot of people are doing pretty horrible things to each other. And we know this usually happens in families. The social silence about sexual abuse, the avoidance and denial, all fit pretty well with how individuals are affected by trauma.

  8. Two thoughts:

    1) I don’t think people in general aren’t
    receptive to the idea. It’s simply that the discourse surrounding severe mental illness (particularly schizophrenia) disavows this knowledge for various politico-ideological and economic reasons. It’s not very hard to convince the layman that death, abuse, abandonment, neglect, etc. impact people’s psyche. You’re right that the collective silence is a response to cover over the trauma. After all, it’s fucking terrifying/depressing. Notice I only discussed childhood sexual abuse while avoiding childhood neglect and other forms of adult-adult abuse (rape, domestic violence, etc) suggesting the problem is really massive.

    2) I disagree with this psychologization of Freud you introduce here, although it’s a quite common explanation. There are multiple reasons why he moved away from the seduction theory, including its inconsistency in clinical data. Not all hysteria (a term that lacks a clear parallel in modern diagnostic systems) has sexually traumatic origins. One has to assume that he was responding to the clinical data that he encountered. Second, although he moved from seduction to fantasy (Oedipus), it’s a complete fabrication to act as if Freud did not believe his patients. He continued to hold out that some patients suffered from real abuse while others did not.

  9. A couple of disorganized but related thoughts:

    The legal definitions of abuse do not jive with the popular or psychological definitions of abuse. Most people would say I was sexually abused, but because the law does not, no authorities could do anything about it. Perhaps this is where some political action needs to come in?

    The way abuse is addressed in mental health care can be just as traumatic, sometimes more so, as the abuse itself. Mine was on the lighter side of the sexual abuse spectrum. Presumably because I was so severely depressed, they assumed the abuse was much more severe than it really was. They tried to get me to “confess” more extreme abuse (a la false memory syndrome), so I wasn’t able to address the abuse at all. Eventually, I found a decent psychologist who was able to understand the abuse as it was and help me address the abuse as it was. If abuse is so misunderstood by mental health care professionals, I think we have a very long way to go before politicians and the general public will have an accurate picture of its impact on society.

    In mental health care, I have seen two attitudes simultaneously: 1. 100% biology, and 2. 100% situational. 90% of the treating professionals I have seen have used both of these views, only one at a time, based on whichever was most useful at the time. (I have seen more nuanced, combined views in discussion, as here.) If treating professionals are so bad at this, I don’t think there is much hope for the rest of society understanding how the two work together any time soon.

  10. Sorry to hear that your mental health practitioner was worthless. I don’t doubt that many clinicians aren’t sensitive/empathic. The whole false memory syndrome fad in the 90s was particularly weird, and it was likely iatrogenic. I won’t apologize for mental health practitioners, and the field certainly has problem. As someone coming from the psychoanalytic tradition, I am confident our tradition and my program trains adequate, competent psychologists, although I realize some psychologists certainly have problems.

  11. I’m sorry this post got buried so quickly, because I think this is a really important issue. It seems to me that part of the explanation for the clinical establishment’s defiance of clear common sense (i.e., that childhood abuse contributes to mental health problems) is that the more “individualistic” answer keeps the establishment from having to raise really serious systemic issues. If it was publicly stated that child abuse of various kinds was rampant and contributed to all kinds of individual and social dysfunctions and that it was obvious that the system of the “nuclear family” (i.e., the principle that each autonomous unit is shut up in its own little space into which others mostly have no right to pry — NOT, contra David Drieger, identical to the concept of kinship as such) enabled and even encouraged that, what would that imply? I daresay it would require an even more fundamental shift in our social norms than the abolition of capitalism would.

  12. Yes, it discourages people from raising uncomfortable questions. There are also lobbying groups that have a major influence on policy and perpetuating the biological reductionism that often dis-empowers people and makes them feel ‘cursed’ for having faulty hardware. Of course, inventing a problem (abuse) does not help either, especially if it wasn’t there to begin with.

    Also, I agree that the ‘hunker down’ approach of nuclear family to avoid the external abusers likely contributes to the high rates of domestic violence and child abuse. It becomes a sin to even question that something might be awry in the home, which makes the situation THAT much more hopeless. The whole head of the household perpetuated by conservatives also makes the word of the father beyond reproach. Also, when I used to work with survivors of domestic violence, the church does a pretty good job of turning women away and back into the abusive home life.

    I wonder why the question isn’t discussed in any serious way – politically or in pop culture. Instead, we get shows like “Catch a Predator” which makes pedophiles look like some sick or crazy Boo Radley who are perverse and alien. I suppose it would be much more difficult to have TV shows in which 1/3 of the children are being abused by, you know, seemingly nice and normal people (who are also closet child abusers). We might understand this location (projection) of the abuser’s badness onto the stranger in psychoanalytic terms. The other/stranger (boy scout leader, baseball coach, school teacher) is the bad persecutory object which allows the abuser to disavow his guilt and ensure that his family is safe and full of love (life drive) and void of abuse/destructiveness (death drive).

    That’s why I like Farrakhan’s exhortation. Men, stop being assholes and hurting boys, girls, and women. It seriously fucks things up. Quit it.

  13. B. van der Kolk is not shy in suggesting there are much more nefarious reasons for the lobbying; enabling the powerful to continue their abuse. Thanks for the post – it is rampant.

  14. I’d be curious for a reference. Van der Kolk has been on my reading list for awhile. I don’t doubt this, but I just don’t want to speculate considering I haven’t studied this question thoroughly.

  15. Yes, I did not account for how ‘nuclear family’ specifically was being referenced in its social/political/religious context.
    One gets the impression as a regular reader here that the blogger’s are not overally fond of their families!

  16. I’m sorry I didn’t express adequate gratitude for your assessment of my clarification as “helpful.” I was too busy responding to a joke that (a) wasn’t funny and (b) represented a continuation of the misunderstanding that you had supposedly just overcome.

  17. We’re talking about really serious abuse and how actual-existing family structures allow and even encourage it, and you’re joking about how we don’t like to visit our families for holidays. Awesome. Thanks for your amazing contribution to our discussion.

  18. Adam, do you think I don’t know what we are talking about? That is my point. My initial concern was that just maybe there is a general sense here at AUFS that families are just plain shitty (and I think we can all bring plenty of shit to the table on that conversation). So I wanted to be clear that there wasn’t an unecessary swing in that direction (in Jeremy’s initial post) because the context of immediate and extended families can be a tremendous site of resiliency for those struggling with pyschosis and other traumatic mental illnesses (and not just potential sources for it). So the joke exposed why I might have some initial concerns . . . which you clarified . . . as opposed to the joke being a continuation of my ignorance.
    So yes my initial observation was misguided and corrected and my later joke was in bad taste. Is there anything else you need to push on Adam?

  19. Yeah, so the problem as I see it is trivializing my critique by chalking up my opinion to some adolescent resentment. You apologized for that. However, nothing gets under my skin more than lay or wild psychoanalysis, i.e. your argument is simply a working through of some childhood conflict. Even if that were true, I have no idea why people go there, considering it does nothing to challenge the actual argument.

  20. Sorry not to have caught all the rich nuances of your interventions! Including such nuances as apologizing for something you’ve said while simultaneously insisting that you were, at bottom, right to say it!

    I like my family members just fine. I actually had the privilege of growing up in a more robust extended-family setting than most people, and I’m deeply grateful for it. Kinship-based loyalties are obviously very valuable in a lot of ways. And yet the family structure of the nucelar family is a really dangerous one that has virtually no safeguards against abuse, regardless of how excited I am about visiting home for Christmas. It’s the structure that’s the issue — the notion that society should be built around autonomous, isolated “mommy-daddy-me” units with as little outside interference as possible. Get it through your thick skull!

  21. Incidentally, I spent the morning at work buying plane tickets to visit my parents and my sister’s family for a weekend vacation. Should be fun.

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