Paula Joan Caplan (July 7, 1947 - July 21, 2021)

First published October 7, 2020, in

https://www.madinamerica.com/2020/10/ptsd-labels-harm-exposed

A recent Wall Street Journal (WSJ) article and a recent American Psychiatric Association (APA) press release reveal the power the APA has wielded through its various DSM editions in pathologizing the effects of trauma.

What's Wrong With the "PTSD" label?
Before I examine the problems with the article and press release, it is important that readers not assume that if "PTSD" ("Post-traumatic Stress Disorder") is a harmful label, "PTS" (just removing the "D") is fine. There is little difference, because "PTSD" is so widely used—even by people who rightly criticize the use of other psychiatric labels—that it will be generations before people stop thinking "Disorder" when they hear "PTS." Instead of using either term, what is accurate and useful is to call the trauma what it is—war trauma, rape trauma, hurricane trauma, etc.—and to call trauma's effects what they are, such as terror, grief, fragmentation, moral injury, loss of ability to trust, total exhaustion, etc.

As with any psychiatric label, its application subjects the labeled person to a vast array of kinds of harm, ranging from plummeting self-confidence to loss of child custody, employment, respect, all possible human rights, and even death.

Neither the WSJ article's author, Andrea Petersen, nor the unknown author of the APA press release ever questions what "PTSD" means in the DSM, what people will assume it means, and whether there is any scientific validity to it at all.

As I found when on two DSM-IV committees, there is no scientific validity to it. Still worse, when it first went in a DSM edition as a description of (some) reactions to trauma, there was a sentence noting that these were normal responses to abnormal situations. That meant it was weird to include it in a manual of mental disorders, but the DSM authors have rarely worried about consistency in their rush to include as many labels as possible. But that sentence was useful for traumatized people to see, because sometimes it made them feel less like they were overreacting and "crazy." However, even that little bit of help vanished when Allen Frances headed DSM-IV's Task Force, for that sentence was removed.

Not only is "PTSD" not scientifically derived, but even caring therapists apply the diagnosis without ensuring that their patients even meet all the DSM's required criteria, as researcher Meadow Linder wrote in a chapter in Bias in Psychiatric Diagnosis.

In a way, that is irrelevant, because what good does it do to stick scrupulously to arbitrarily chosen criteria? But this means that, as I have written elsewhere, "PTSD" now consists of shifting sands on shifting sands—an unscientific label, unscientifically and unsystematically applied.

When a Label Has No Validity, It's Absurd to Study What Helps "It"…and Other Problems
The Wall Street Journal author starts by referring to the pandemic, wrongly assumingthat it is creating skyrocketing rates of "PTSD"—rather than NONpathological suffering, and reviewing what she says therapists have described as "new" and needed treatments for the "disorder." It is especially troubling that she mentions that the most common reports of "PTSD" during the covid-19 pandemic in a large study were about loneliness and worries about the virus. Does it make sense to call loneliness and worries about the virus signs of mental illness?

And she mentions another study, this one of frontline healthcare workers during the pandemic, in which 16.7% are said to have "PTSD." Does it make sense to claim that it is a mental illness for people constantly exposed to a mysterious, dangerous, contagious illness to be traumatized? What is the point of all that, other than to alarm people and provide more money, power, and territory for therapists?

What the author mentions only briefly in her lengthy article is how helpful self-help groups for traumatized people can be. Instead, she writes endlessly about one drug after another after another and various forms of traditional talk therapy.

The author then zooms ahead, naming the psychiatric drugs (she calls them "medications") Zoloft, Paxil, MDMA (called "Ecstasy" on the street), and ketamine, all of which have negative effects ranging from upsetting (e.g., sexual problems) to dangerous (e.g., increased violence against self or others). Acknowledging that only small percentages of people who take these drugs are helped, she asserts that "Scientists" (who?) are seeing (based on high-quality research…or not?) "early" (oops) "positive studies combining psychotherapy with certain drugs." Even so, she does note that "About 40% of people who received the MDMA treatment reported side effects including anxiety, headaches and nausea." She might also have cited this report of even more serious kinds of harm.

Petersen also reports that an unspecified "growing body of research shows that transcranial magnetic stimulation, which uses a high-powered magnet placed on the scalp to stimulate neurons in certain parts of the brain, can ease PTSD symptoms." To begin with, I know from direct experience with one of the top marketers of such devices that they often fail to warn of negative effects and fail to disclose that these devices cannot be targeted to particular neurons, so little is known about what effects they will have—good or bad—in any given individual.

Further food for thought is that leaders in the movement challenging the traditional mental health system have asked the rhetorical question, "Why should we assume that when these marketers say that their devices are safe because they send LESS current through people's brains than traditional electroshock, we should believe them?"

Petersen asserts that the best psychotherapies for "PTSD" are cognitive processing and prolonged exposure therapy. In my decade of listening to military veterans, as well as to other traumatized people, I have learned that sometimes the former—examining one's beliefs that cause them suffering—helps and sometimes not, because often the moral injury and powerful emotions caused by trauma and the painful isolation are never addressed. And I have learned from them that exposure therapy—going over and over the trauma—helps some people but is horribly retraumatizing for others, and it, too, does not in and of itself include working on the moral injury, the isolation, or the other strong emotions.

Toward the end of the article, Petersen does mention the potential effectiveness of aerobic exercise, though only combined with prolonged exposure.

In summarizing concerns about the WSJ article, it is important to note that it is always a good thing to allow people to try anything that has helped some people who are similarly suffering, but it is essential for those people to be told in advance and fully what the potential benefits and the known kinds of harm are.

APA Wants Exclusive Control Over Prescribing Drugs for Veterans with "PTSD"
In a September 24, 2020, news release, the APA's headline came across as gloating: "Successful APA Advocacy Assures Veteran Patient Safety Regarding MH Care." The piece was about the House of Representatives' Veterans' Affairs Committee removing a proposal from suicide prevention legislation that would have given psychologists the right to prescribe drugs to veterans. A major problem in the release is that they automatically assume that the veterans who killed themselves had "PTSD."

Unsurprisingly, after a lengthy description of its lobby efforts about this matter, the release included this quotation:

"We will continue our work with the VA, Congress, and partner organizations to improve the mental health and substance use care available to our veterans through the VHA and beyond," said APA CEO and Medical Director Saul Levin, M.D., M.P.A.  "We must work with policymakers on genuine solutions that promote the recruitment and retention of critically needed psychiatrists, psychologists, and other mental health providers who are in short supply within the VA system. Meanwhile, with the help of our members, we have avoided the enactment of a false solution that could have put many veterans at risk, without any improvement in access to the care they truly need."

Note that Levin acknowledges that psychologists can help veterans but that allowing them to prescribe drugs would be "a false solution that could have put many veterans at risk," as though psychiatrists prescribing drugs does not put veterans at risk. This is reprehensible in light of the well-established fact that so many psychiatric drugs increase rates of suicide. My own view is not that it is worse for psychologists than psychiatrists to prescribe these drugs but that the fewer people of any discipline who are prescribing them, the better.

What would be amusing if it were not so frightening is that Levin is also quoted as saying:

"We believe that nothing is more important than ensuring that veterans are given high quality mental and physical health care by qualified, appropriately educated, and trained medical clinicians, not more prescribers and more prescriptions…."

Nowhere in the news release is there mention of any attempts to prevent suicide except through psychiatric drugs, and all the gloating is about how impressively the APA prevented psychologists from doing this. Wouldn't it have been great if he had:

surprised everyone by saying that psychiatrists should be prescribing fewer such drugs;
said that traumatized vets should be told they are having deeply human, understandable reactions to trauma instead of pathologizing them by saying they have "PTSD," and pointed out that labeling people as "mentally ill" increases the chance they will be put on drugs;
mentioned any of the many nonpathologizing approaches to helping traumatized people (such as the many at this website: http://www.youtube.com/playlist?list=PL51E99E866B9D735E)?
 

Initially published on December 30, 2019, at https://www.madinamerica.com/2019/12/invisible-children-foster-care/

For people who have recently lost a loved one, holidays that others seem to be happily celebrating are hard. For the uncountable thousands of children of refugees whom the United States government has taken from their parents and put in cages, isolation from their families must be excruciating. But what about the nearly half a million foster children in this country, who are even less visible than refugee children, rarely the subjects of media reports except in the case of a death or a lawsuit? How are the holidays for current and former foster children? To be sure, some foster parents are loving and supportive, but far too often, being a foster child means something terrifyingly different.

I learned this 40 years ago when I was working as a psychologist at the Toronto Family Court Clinic in Canada. Some of the people we were asked to evaluate were children or youth deemed neglected or abused by Children's Aid Society (CAS) workers. Each time one of us clinicians was asked to recommend whether to leave the person in their home or send them to foster care, it pained us to know that there might be pros and cons for each option. We couldn't be sure whether or not a child who was living in a home where there were difficulties had a strong love or need for their parent(s), and we knew that, while some foster parents were wonderful, others were cruel (and some that had seemed wonderful turned out to be terrible). In still other cases, the foster parents were just a bad match for a particular child.

We also knew that in order to acquire greater certainty, we would have had to do far more observation and information-gathering than we had time for, and that in some cases, only the passage of time would reveal what mattered most, but that might be too late for the child. When what is at stake is nothing less than the security and happiness of a human being, these uncertainties and practical barriers often leave the frontline workers and clinicians feeling all at sea, helpless to find the truth but given the task of making crucial recommendations.

Forty years ago, both the children and teenagers who were in the system and their birth or adoptive parents were likely to be labeled as incorrigible, resistant, unworkable, and "mentally ill" and to be much less able to resist the system's dictates if they were poor and/or belonged to racialized groups than if they were white and wealthier. Times have changed far too little. Two major changes in recent decades have been the explosions in the use of psychiatric labels and prescription of psychiatric drugs for children — not just by psychiatrists but also by other clinicians and frontline workers (many of whom are quick to recommend the drugs even if they themselves cannot prescribe them).

Being a Foster Child
Please join me in imagining trying to live through just one of the following kinds of trauma, keeping in mind that many foster children experience more than one and often all of them:

--Being moved often — dozens of times not being rare; never knowing when one will be moved yet again; being shifted from one school — and thus one teacher and set of classmates — to another
--Never feeling loved and secure
--Being abused by foster parents or siblings
--Being diagnosed as "mentally ill" even though one is feeling utterly understandable grief, terror, and/or rage at being separated from one's original family or at never having felt secure and loved even in that original family
--Feeling overwhelmed, bewildered, unseen, and unheard as the system moves one around, often with little or no attention to what is helpful
--Having little chance to learn social and other skills for coping with everyday problems, never mind those that plague foster children
--Being put on psychiatric drugs that are more likely to harm one's body and brain than to help in any way (see Robert Whitaker's Anatomy of an Epidemic)
--Turning to illegal drugs to dull the grief, abandonment, helplessness, and/or despair
--Sliding into the juvenile justice system and later the adult prison complex because of how one expresses painful feelings or because, once turning 18, one has no way to support oneself and begins stealing food or dealing drugs just to get by
--Imagine homelessness, literal homelessness after long years of emotional rootlessness.

Jana Kaplan, a former foster child now in her sixties, summed it up well when she told me that foster children are "bromeliads, sometimes called 'air plants.' We grow without roots, without soil."

What the Numbers Show
All of this is documented in a welcome (and unusual) six-part investigative series published this month in the Kansas City Star, to which Kaplan drew my attention recently. Based on a year's worth of research by reporters Laura Bauer, Judy L. Thomas, and Eric Adler, the series, titled "Throwaway Kids," shines a spotlight on the vulnerability of foster children and on a Senate initiative to address their needs and growing numbers. The series is one every American should read and never forget.

The reporting team found that 23,000 children go into foster care each year, and in 2017, 443,000 children in the United States were in such care, an increase of 12 percent from five years earlier. They then recount the kinds of problems that send children into foster homes, including poverty and the kinds of neglect that are fairly easy and inexpensive to fix.

Part Two of the Star series includes this stunning news: Despite U.S. Congressional action in 1980 that set family preservation as a higher priority than removing children from their families, only a small fraction of all monies spent in the child welfare system is used for that purpose: "Collectively, in child welfare budgets across America, more money is spent on investigating families than on trying to keep them together — 17 percent for child protective services versus 15 percent for in-home preventive services."

As a result, "Kids who could have stayed in their homes take up beds in good foster homes that are needed for severely abused and neglected children whose safety is in jeopardy. Because of that, kids from Oregon to Florida and states in between are forced to sleep in child welfare offices or homeless shelters."

According to the Star, the National Council for Adoption estimates that the yearly foster care cost per child is about $25,000, whereas the cost of preserving a family average only $5,000-10,000 per child. But even if the cost of family supports were higher, is it fair to compare the immeasurable value of keeping children where they may be otherwise secure and loved to the monetary cost of helping their parents stay or get out of poverty? These efforts could include providing comprehensive, low-cost or no-cost health insurance, so that a family member's illness doesn't send the household spiraling into poverty, or providing practical, community-based help and moral support to a parent who is ill or coping with someone else's illness to prevent their being deemed negligent of their child, who is placed into foster care as a result. A woman who stays with an abusive partner because of a realistic fear of not being able to feed her children without the abuser's financial support would also benefit from financial help, and one who stays because she fears the abuser will implement threats of more physical violence if she leaves could certainly benefit from both moral and practical supports to help her do so rather than having her children taken away.

While politicians and other talking heads in the media describe the economy as thriving, they ignore those at the low end of the income scale, and clearly, child welfare matters more than money. Sadly, though, as a nation, the U.S. generally harshly judges rather than genuinely helps poor people. Years ago, Barbara Ehrenreich commented on this judgmental attitude's creation of a barrier to change, making the tongue-in-cheek suggestion that the government give the poor enough money to live on decently… but subject them to public shaming on a regular basis.

Possible Solutions… and Barriers to Implementing Them
To be sure, some families are dangerously neglectful or abusive. For those parents whose drug or alcohol abuse leads them to mistreat their children, stricter government oversight of doctors who hand out drug prescriptions like candy and states paying for and directing parents into proven substance-abuse programs would be far better than removing their children from an otherwise loving home. The alternative is sending them into the black hole of foster care, playing Russian roulette with the children's need to feel cherished and secure.

Regardless of the justifications offered for taking children into foster care, classism and racism plague the system today, just as they did four decades ago. "Black children enter foster care at a significantly higher rate than white children," according to the Star, and poor families and families from racialized groups are more likely than wealthier and/or white families to be punished in this way for being "dysfunctional" or having a physically messy or dirty home. Too often, child welfare workers — whether because they are overworked or for other reasons — don't see, or consider, the love between parent and child in such situations.

Furthermore, once the child welfare system connects with a family, those who are poor or from racialized groups tend to lack "the money or power to push back against government intervention," according to attorney Ira Lustbader, an attorney who represents children in class action lawsuits.

Where is the legal system in all this? In the past 40 years, nearly three dozen states have faced lawsuits citing foster care abuses, a remarkable figure in light of the powerlessness of foster children. But even in Illinois, a state that had improved its foster care system, a recent lawsuit was necessary to get it to stop transporting foster children in handcuffs and leg shackles. Alarmingly, the Star's review revealed that some states are currently being sued "for the same issues that plagued other systems 15 to 20 years ago," and a recent Rhode Island lawsuit alleged that "children in Rhode Island are more likely to suffer abuse or neglect if they are in foster care than if they are not."

Outcomes
What happens to children who go through the foster system and then age out of it at just 18 years old? More than 4,000 of them become homeless each year, thus making them subject to sex and/or drug trafficking. Former foster children are about half as likely to graduate from high school as are their peers, the Star found.

The reporters also surveyed prison inmates and found that one in four had been in foster care, some of whom reported moving more times than they had birthdays. Compare that to the mere 3 percent who graduate from college. The journalists also quoted Gerald Marshall, a 37-year-old Texas death row inmate, who observed, "The state that neglected me as a kid and allowed me to age out of its support is the same state that wants to kill me."

And consider those foster kids who, even if they have not ended up in the prison system, have been slapped with psychiatric labels and put on psychiatric drugs. These young people can suffer for the rest of their lives from the woefully mistaken belief that, because they were so labeled, they are "mentally ill," defective, or twisted. As documented in Robert Whitaker's book Anatomy of an Epidemic and countless Mad in America articles and webinars, the negative consequences of taking these drugs even briefly, and the effects of withdrawing from them, can last for many years.

Uncounted millions of former foster children remain invisible — at holiday times and throughout the year — in the loneliness and rootlessness that they feel. This is true even for many of those who have stayed out of the prison system, graduated from college, raised children, and contributed in many ways to the good of society. They deserve our attention and our care.

What's to Be Done?

What can parents do when they see that the authorities plan to take their children from them? I would say they can hire a lawyer, but that means either having enough money to do that or finding attorneys or other entities that provide legal help pro bono. And it's not as though family courts are devoid of racism and classism, as well as rampant mother-blame, so even if parents get their day in court, there's no guarantee that even deserving ones will be able to keep their children. Such parents can also assert their rights under the Adoption Assistance and Child Welfare Act, the 1980 legislation mentioned above, which mandates a focus on keeping children in their original home and trying to help and preserve the family, by contacting local and state officials. But do I have faith that that will change the system? Not much.

One useful step that any of us can take is to contact the bipartisan Senate Caucus on Foster Youth, co-founded by Republican Sen. Charles Grassley and Democratic Sen. Mary Landrieu, now chaired by Sen. Grassley and Sen. Debbie Stabenow. Their goal, they say, is to break the silence about current and former foster children and they have listened to them, leading to the passing in 2018 of the Family First Prevention Services Act, aimed at keeping as many children as possible at home… and safe. We can express appreciation for the Caucus's work and ask how we can help.

We can also urge our legislators to support the Fostering Stable Housing Opportunities Act, now making its way through the 116th Congress, which would give foster youth access to affordable housing when they reach 18.

And no matter where we live, we can contact our representatives in the U.S. Congress and our state legislatures and governors to ask them to increase expenditures to help struggling families. And we can demand they ride herd on the vast array of abuses that plague the foster care system, crushing the souls of children who deserve so much better.