This is the sixth in a series of blogs devoted to examining the barriers that block persons presumed to have major mental illnesses from living longer and more effective lives. This time, I thought it might be more useful for those of you who have been reading this series of blogs to write a follow-up to my last blog, where I first introduced the notion of replacing the disease model with one rooted in trauma and that utilizes ACEs for explanatory purposes. The “jobs” blog will wait.
I explained in "Replacing the Disease/Biological Model with ACEs" why I thought the disease model had to be replaced: it is underpinned by suppositions about biological or genetic causes for serious mental illnesses that have little data to support them; and it relies principally for treatment on neuroleptic and other psychoactive medications, which dramatically shorten life expectancy. Finally, I explained that I viewed serious mental illnesses as existential in nature, i.e., problems in living, that required psychosocial solutions, principally the teaching of social skills and skills of emotion regulation. Accordingly, the model I was proposing was not concerned with etiology or cause but primarily with treatment, as well as with questions of epistemology—why do certain individuals experience psychotic episodes—and ontology—how are these individuals to be in the world and what is their individual self-identity to be?
On further reflection, however, I believe the real starting point for this discussion is even more basic: why do we need a model at all?
Persons who undergo psychotic episodes, and their family members, usually want some sort of explanation as to why they’ve gone through what they have. It’s probably less counter-intuitive to acknowledge that traumatic experiences could well cause individuals to have psychotic symptoms now that mental health practitioners and the general public have acquired some familiarity with PTSD and the persons who suffer its consequences, particularly combat veterans, 9/11 survivors and witnesses and other terrorist attacks, survivors of natural disasters and victims of sexual assault and domestic violence. Yet, very few Americans, including mental health professionals, have much awareness of the centrality of trauma in the lives of persons considered to suffer from serious mental illnesses.
In a survey published in 2002 by Maxine Harris and colleagues of the trauma histories of men and women treated at Community Connections, the treatment program Dr. Harris directs in Washington, D.C., the prevalence of lifetime exposure to sexual or physical violence was as follows:
- For men and women diagnosed with serious mental illnesses: 43-81%, depending on treatment setting and trauma definitions;
- For women addicted to substances: 55-99%;
- For homeless women diagnosed with serious mental illness and substance abuse disorders: 97%;
- For all homeless women: 43%
… of childhood sexual abuse:
- For women hospitalized in in-patient psychiatric units: 55-63%;
- For women treated in out-patient settings: 40%;
- For men, depending on population sampled and definitions: 4-76%
… of violence and physical abuse: