As a clinical and forensic Psychologist, I’ve always been interested in the causes, not correlates, of mental health, because associations, masquerading as causal mechanisms, bedevil psychology. Our profession is at a crossroads between science-based causal reasoning and knowledge versus politically biased narratives, where scientific evidence is irrelevant and trauma, poverty and power, are all that matter. Why is this important? Because real damage could be done to patients where an understanding of their needs is far removed from actual causal drivers. As Steven Pinker states in his recent book Rationality: ‘Epistemic rationality’ concerns how well our beliefs map onto the real world. Pinker says: ‘In order to take actions that fulfil our goals, we need to base those actions on beliefs that reflect reality.’ If you tackle trauma in someone with a severe mental health problem and the real-world causes lie elsewhere, this spells real trouble for patients who desperately need effective help.
Take Ann, for example. She was in a dire psychological situation. She was 16 and experienced explosive rage after being ejected from school after school. Her family were at the end of their tether. Ann told me she was plagued with violent and suicidal thoughts. Her parents were increasingly rejecting and hostile towards her. Social services (in effect) threw in the towel on her family. They wanted Ann in a ‘trauma-informed’ residential care unit and attending specialist education provision where the teachers were trained in ‘attachment‘ and ‘trauma-informed’. Child and Adolescent Mental Health Services (CAHMS) insisted that because of emerging parental dismissive attachment, ‘something’ must have happened to Ann in the past to cause her immense pain. A harsh spotlight fell on the parents. Sessions probed for trauma or adversity; these were blind alleys, leading to failed interventions. Professionals were single-minded and driven to look for trauma. They were trained in the Power Threat Meaning Framework (PTMF); a relatively new framework as a whole system approach to well-being. Some, yet to be revealed significant childhood trauma, was in the formulation for Ann, CAHMS assured me. The effect on the parents and Ann was devastating, worsening their relationships and extreme parental anxiety. Her problems would resolve once adversity and trauma were revealed, then discussed and ‘attachment repair’ could take place. Who could argue with this formulation?
Psychologists talk a great deal about formulation, a way of understanding a young person’s difficulties, as in Ann’s case. Psychologists gather information from young people directly, parents and teachers then produce some ideas, based on their training, about what might have led to Ann’s difficulties. Formulations are based on psychological training and knowledge. But here’s the problem, a dozen psychologists could produce a dozen different formulations on Ann. But that’s OK, so the idea goes, as long as the formulation story makes sense to Ann and her family. Formulations are not causes. They are stories, but in Ann’s case, psychologist’s biases filled up their formulation (attachment ruptures in the past, powerless with her teachers, major unspoken trauma).
If you think a lot about adversity, trauma, power and attachment, your formulations will be populated with these concepts, even if they are irrelevant or non-causal. For the avoidance of all doubt, I’m not saying these factors are not important; they are, but shoehorning trauma, attachment, and poverty into your causal theory is something I’m increasingly witnessing, then being asked to mop up the damage. Studies have demonstrated when clinicians express a strong interest in attachment, they correspondingly reference an attachment disruption focus when discussing their clients. For Ann, it meant a formulation consisting of her ‘years of disrupted attachments from early childhood, parents who “struggled to connect with her”: dismissive-avoidant attachments all round, keep up the therapy, more trauma-informed care was needed, and ‘we need to you co-regulate and become trauma informed’ was the mantra to her parents. Professionals told me: ‘We are trying to embed a trauma-informed approach in the family.’ Thankfully a family court intervened, and a judge asked me to take a whole fresh look at Ann’s case before she agreed to place her in residential care. Our courts are a bastion of deliberation for opposing ideas but Courts side with science. They are not ‘privileging’ science; they value approaches based on firmer ground, more likely to correspond with epistemic reality. I thoroughly assessed Ann; she was on the autism spectrum. The road to hell is paved with good (PTMF clinician) intentions.
For Ann, imaginal play was missing throughout childhood or highly circumscribed; she had rigid but essential routines. People with autism tend to have insomnia: it takes them, on average, far longer than neurotypical people to fall asleep, and many wake up frequently during the night. Some people with Autism have sleep apnoea, guaranteed to keep you awake. Some are highly active, even hyperactive, restless, or more alive at night, but sluggish and slower in the morning. Ann was baffled by people, school, social scenarios, and conversations. She was overloaded with sensory bombardment, leading to frustration and anger. As I explained this, her parents were in tears; Ann was relieved. Melatonin helped her sleep and her school day started later, preventing school attendance battles in the morning. Her mood improved, and parenting became more positive as a result. Her school managed her sensory issues, her attendance increased, and she began to flourish. A healthy obsession with helping in an animal refuge emerged.
Even when it comes to the adversity to trauma pipeline, the position is unclear. In outpatient psychiatric clinics in New York, a review of newly admitted patients found 82% with at least 1 adverse childhood experience (ACE), 68% with 2, and a staggering 42% with four or more ACEs; these are correlational studies, telling us nothing about what causes what. In discussions about ACE’s leading to trauma then later mental health problems, I find that there is a reluctance to talk about high levels of ACE’s in healthy people with no mental health issues. In a Welsh survey, half of the population had one ACE, and 14% had four or more Aces’, including different forms of abuse and living with mental illness and substance abuse. 65% of Scottish children have at least one ACE. ACES are ubiquitous, but mental health problems and trauma are not. By all means, let’s dramatically reduce ACE’s but don’t be surprised if mental health problem prevalence remains stubbornly high.
I can hear psychologists’ voices: ‘But formulations are not causal, they are hypotheses.’ However, they are read by other professionals as fundamental drivers, and if they are not based on developmental etiological science – what’s the point? If they are hypotheses, how come there is usually one formulation for a person and not many options? If it’s a story, then call it a story or an interpretation. And anyway, how arrogant to presume one possesses the power to identify the key factors driving a person’s problems. And if it is collaborative, how come the clinician writes it? In PTMF speak, who has the power? The famous Dunedin research on violence followed up infants until their 30’s. Glue ear or otitis media as a toddler was a predictor of violence as an adult. Imagine the knock-on effects: problematic hearing, developmental language disorder, frustration, and violence. How many psychologists have included glue ear in a formulation, compared to references to attachment? If you’re going to use formulation, consider developmental causal research.
What do I mean by causal research? Lisa Dinkler from Gillberg Neuropsychiatry Centre, University of Gothenburg, led a study on how maltreatment contributes to a range of neurodevelopmental disorders such as ADHD. They used an elegant design to control for genetic and environmental factors and gene by environmental interactions – the co-twin control design. To the authors’ surprise, they found that maltreatment did not confer a significant load toward NDD’s. They found maltreatment was non-causal and could never be in their modelling – for NDD’s. The causal direction was a genetic link to the NDD’s and maltreatment, perhaps because parents themselves had NDD’s and there was a feedback loop to their parenting evoking greater harshness. This is a different way to think about maltreatment and opens up various possibilities of earlier, more focused intervention. Genetic studies tell us far more about the environment and recursive feedback loops.
One study, which I co-led, along with Swedish and UK colleagues, found no link between maltreatment and psychopathic traits among twin children at different ages. Adoption from birth studies of callous-unemotional features shows that birth parent traits are still highly predictive far into the adoption. I meet adoptive parents at the end of the road, being told to keep showing love and be present to form attachments, and all will be well in the future with their child with callous-unemotional temperament, rather than grasping the real problems and appropriately intervening with targeted therapies. Blank slatism runs riot among many PTMF psychologists, to the detriment of many adopted or fostered children.
Another person, another stage of development and another formulation assuming causes. This time, a man in his 30’s committed persistent violent offences. Again, another PTMF trained psychologist, another trauma, attachment, and power formulation. You could have transplanted Ann’s formulation into Joe’s life. After carefully and sensitively engaging this man’s family, his mother heavily drank alcohol throughout her pregnancy with Joe. Joe, in turn, had all the hallmarks of the developmental cluster of persistent lifelong language difficulties, impulsivity, hyperactivity, callous traits, and a lack of learning. He had (some) dysmorphic features. Fetal alcohol spectrum was the new formulation driving his offending. And so, it goes on: trauma, trauma, trauma, and attachment disruption, in formulation after formulation. What are the dangers of trauma bias? In a study by Matt Woolgar and Emma Baldock, published in Child and Adolescent Mental Health in 2014, 100 foster care and looked after and accommodated children described as having attachment disruptions linked to trauma as the cause of their problems were reviewed by experts in the field. The researchers reported on the ‘allure’ of generic terms like attachment but that ‘although more common diagnoses, such as ADHD, conduct disorder, PTSD, or adjustment disorder, may be less exciting, they should be considered as first-line diagnoses before contemplating any rare conditions, such as Reactive Attachment Disorder or an unspecified attachment disorder.’ The stakes are enormous: children are not receiving the appropriate interventions for the difficulties they are actually facing in life due to the imagined formulations of the Psychologist. These researchers concluded that ‘victims of this confusion (over-focus on attachment / trauma-related disruptions) are likely to be the looked after and adopted children who miss out on access to the evidence-based treatments and educational support that could help them. It is unhelpful thinking of these as front-line problems.’
When it comes to psychosis, PTMF rightly emphasises social causes and discrimination. However, with psychosis PTMF also states: ‘ask what happened to you’ not ‘what’s wrong’ and orient the approach to one of trauma. In reading PTMF documents and ‘research’ (there is no empirical evidence such as Randomised control trials in PTMF), the lack of experience with people with florid psychosis or described as having schizophrenia is apparent. Examples PTMF advocates include are people who reflect on their voices or link them to trauma. I’d love to see patients like this. Where are they! Patients with psychosis, often admitted or detained in hospitals, can be wholly lost from reality on admission. Only after anti-psychotic medications for a lengthy period might someone with psychosis be ready even to tolerate the presence of a psychologist, let alone begin therapy. The heritability of schizophrenia in twin study after twin study and adoptions studies is estimated to be over 80%. Even when these studies become dramatically modified to take account of methodological criticisms, high heritability estimates just won’t go away. This built-in neuropsychological problem impact working memory, processing of information, attention, loading a person to more significant adversity in the first place. Some psychologists dangerously state that psychosis is complex trauma. If that’s the case, let’s stop research into psychosis, we have an answer.
It is neither wonder Power Threat Meaning advocates over egg trauma, power, and attachment because, in one main PTMF document, 414 pages long, trauma is referred to 489 times. There are no references to temperament, the bedrock of resilience, and little mention of cognitive intelligence, critical to coping in life. Hugely important Neurodevelopmental problems are referred to 14 times and finally genetic factors 70 times. Genetic references are part of a lengthy diatribe dismissing genetics. Yet, their criticisms mainly involve deeply flawed ideas about ‘weak polygenetic effects’. PTMF advocates ignore the consensus in behavioural genetics from the likes of Steven Pinker, who highlights how genetic drivers are regarded as a scientific law in behavioural science. They fail to understand how polygenetic effects are reported as ‘small’ yet don’t grasp how they grow year on year, in study after study, because increasingly massive samples are needed to detect tiny effects on thousands of individual genes. They ignore that these ‘small’ effects are more significant than the effects of poverty on mental health outcomes. They assume that you must be on the right of politics if you mention genetics. Far from it in my case. Ironically, behavioural genetic findings are increasingly leading to spectrum and syndrome understandings of mental health problems. Behavioural genetics knowledge leads to novel findings such as overlapping genetic predisposition to schizophrenia and bipolar disorder and seemingly unrelated disorders, such as autistic spectrum, intellectual disability, and epilepsy. Or how neurodevelopment and temperament interact with adversity. But PTMF ignores this; their training constantly refers to power relationships, trauma, and adversity. Imagine any other field of study or science that paints a two-dimensional picture of causal mechanisms in human well-being, ignoring decades of science on other factors? Physics without gravity, Biology without natural selection. PTMF is contaminated mindware, over-applied to every person’s emotional struggles.
Power Threat Meaning advocates also critique a caricature of psychiatry, seen as the dominant model, although in CAHMS meetings, discussions are dominated by discussions about trauma, attachment, and adversity. PTMF advocates describe how psychiatrists believe that the cause of a person’s difficulties is based on something that has gone wrong with the functioning of the body or brain, a medical illness. I’ve still to meet these psychiatrists in 25 years of service work and leadership. They describe the damaging effect of psychiatric diagnosis as a ‘loss of meaning’, but psychiatrists are not as reductionist, and diagnosis (with the various limitations to each diagnosis) is the starting point of a conversation positioned in a person’s grand narrative, which often gives meaning. Of course, diagnosis can be misused or unhelpful, but from the enlightenment, we categorised the world (accurately and inaccurately) as a starting point to develop a complex system view. Steven Pinker in Rationality describes how humans have always naturally categorised our world. A symphony emerges from a single note.
PTMF advocates state diagnosis is discriminating, and deprivation is sealed off behind a label. The problem is that deprived people are desperately seeking diagnoses for themselves, their children and relatives, in their droves. When a person can label pain and distressing emotions, this can alter positively such experiences and is relieving. An excellent diagnostic process should be collaborative and include a causal formulation. A diagnostic process should describe and classify problems, not the person. A good diagnostic assessment can view issues on a spectrum and blur the line between normative and pain. What’s the alternative, vague well-being descriptions based on poverty, power, and trauma for profoundly psychotic or seriously depressed people? If that’s the case, be prepared for services to miss autism and fetal alcohol spectrum, ADHD, and a raft of neurodevelopmental disorders, for it is the life span interaction of these NDD’s and poverty/adversity which should be the real focus.
PTMF advocates cleverly state they are not against diagnosis; they are pro-choice, not wishing to remove someone’s ‘labels‘. They are saying that if you find meaning from a diagnostic term or are researching or examining possible causal complex interplays between gene and neurodevelopmental disorder, you’re thinking is flawed. Because only stories relating to power, adversity, and trauma (formulation) restore real meaning. People desperately seeking diagnostic assessments must be engaging in folly or are not clever enough to understand how the diagnosis will fail them and hide their poverty behind a label. PTMF is patronising to patients, implicitly telling them what they need without the guts to say what they are openly against. A story that denies science and aspects of truth that might be challenging is ultimately vague and could deny patients access to a raft of medical and psychiatric choices.
An implicit false choice is being offered up between diagnosis and formulation, whilst stating it’s imperative to find meaning in formulation, not a diagnosis, but the two are not mutually exclusive. PTMF says you have a choice, but your (diagnostic) choice is flawed. Their stance engenders mistrust and censorship. You can have a diagnosis, but it’s dangerous and obsolete, and you are a fool to accept a diagnosis. Diagnosis is a choice for you, but the weight of the medical model will crush you, a patronising double-bind stance, creating confusion.
The philosopher Wittgenstein remarked that clouds might have fuzzy boundaries, merge imperceptibly, and drift, being carried by invisible air currents, have inner physical and chemical structures hidden to the naked eye. Still, nevertheless, we classify them regarding their shape and properties, observe and measure, to make predictions, despite the errors in weather prediction. We can’t communicate about clouds, nature, or mental health without using (imperfect) classifications.
Dr John Marshall is a consultant clinical and forensic psychologist.
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