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 is all that matters. 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.’ Over the last 10 years there have been enormous movements in the US and UK focused on trauma and attachment as assumed causal mechanism for a range of mental disorders. However, 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 placed 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. 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 along with extreme parental anxiety. Her problems would resolve once adversity and trauma were revealed, then discussed and ‘attachment repair’ could occur. Who could argue with this appealing formulation?
Psychologists talk a great deal about formulation, which is a way of understanding a young person’s difficulties. Formulation is where Psychologists gather information from young people directly, their parents and teachers, then produce some ideas, based on their training, about what might have led to Ann’s difficulties. Formulations are founded on psychological training and knowledge. But here’s the problem, a dozen psychologists could produce a plethora of 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 significant risk 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”: the damming label dismissive-avoidant attachments were applied, 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.’ Sounds good. 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 intentions. Many clinicians have told me that they find children not being diagnostically assessed for neurodevelopmental disorders because trauma narratives are prioritised instead.
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, 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 flourished. A healthy obsession with helping in an animal refuge emerged.
Clinical culture is creaking under the weight of a blank slate trauma assumption. 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. This notion of healthy people with high ACE’s comes as a surprise to many clinicians. 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. Two-dimensional thinking will never solve multifactorial problems.
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 only 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? 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 in adulthood. Imagine the knock-on effects of chronic glue ear: problematic hearing, developmental language disorder, frustration, and violence. How many psychologists have included glue ear in a formulation, compared to references about attachment? If you’re going to use formulation, consider developmental causal research.
What do I mean by causal research? Lisa Dinkler from the Gillberg Neuropsychiatry Centre, University of Gothenburg, led a study on asking how maltreatment contributes to a range of neurodevelopmental disorders such as ADHD. They used an elegant design to control for genetic and environmental factors or genes by environmental interactions – the co-twin control design. To the authors’ surprise, they found that maltreatment did not confer any significant load toward NDD’s. They found maltreatment was non-causal and could never be causal 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 far earlier, more focused interventions around parenting with an NDD. Genetic studies tell us far more about the environment through recursive feedback loops.
In one study I co-led, along with Swedish and UK colleagues, we found no link between maltreatment and psychopathic traits among twin children at different ages. Adoption from birth studies of callous-unemotional features (a good predictor of conduct problems and psychopathy) shows that birth parent traits are still highly predictive far into the adoption. I meet adoptive parents at the end of their tether caring for a child with a callous-unemotional temperament, being told by Social Workers to keep showing love and be present to form attachments, and all will be well in the future. Grasping the reality of their temperamental challenges, carefully intervening with targeted family therapies, and helping the parent cope with their child seems too blaming and ‘othering’. Blank slatism runs riot, to the detriment of many, adopted or fostered children.
Another person, another stage of development and another formulation assuming trauma causes. This time, a man in his 30’s committed persistent violent offences. Again, another psychologist, another trauma and attachment disruption formulation. You could have transplanted Ann’s formulation directly into Joe’s life. After carefully and sensitively engaging this man’s family, his mother told me she 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 the 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 or 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, professionals who are captured by trauma and attachment disruptions rightly emphasise social causes and the risk of discrimination. However, clearly, people can develop psychosis with no trauma or threat in their lives. 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 any therapy. The heritability of schizophrenia spectrum 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. Built-in neuropsychological problems impacting working memory, processing of information and attention, loads a person to more significant adversity in the first place, and to mental disorder. Some psychologists dangerously state that psychosis is synonymous with complex trauma. If that’s the case, let’s stop all etiological research into psychosis, we have the answer.
Often where there is a focus on trauma or attachment, no references to behavioural genetics or temperament are made. Temperament is the bedrock of resilience. Attachment authorities make little mention of cognitive intelligence, critical to coping or functioning in life. In behavioural genetics, the likes of Steven Pinker highlights how genetic drivers are regarded as a scientific law in behavioural science. Many advocates of trauma and attachment 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 the tiny (but cumulative) effects of thousands of individual genes. These ‘small’ effects are more significant than the effects of poverty on mental health outcomes. Any mention of behavioural genetics must mean you are on the right-wing of politics. Far from it in my case with years of dedication to centre-left/liberal causes. 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 how predispositions to schizophrenia, bipolar disorder and seemingly unrelated disorders, such as autistic spectrum, intellectual disability, and epilepsy, overlap. Behavioural genetics can highlight how neurodevelopmental disorders and temperament interact with adversity. If we Think Wide, clinicians will consider complex interactions of biologically or genetically driven neurodevelopmental disorders (ASD, FASD, ADHD), along with temperament and their interactions with adversity. If you are poor, suffer maltreatment and have a neurodevelopmental disorder, this could spell trouble for your life outcomes. My experience, and that of others, particularly of child mental health service, is constant reference to trauma and attachment which in turn can leave the impression that this is all that matters. 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. The over-focus on adversity then attachment/trauma, whilst well intended, can lead to 2-dimensional contaminated mindware, over-applied to every person’s emotional struggles.
Where clinicians over prioritise trauma and attachment, psychiatric diagnosis can be viewed as dominant and reductionist based on some malfunction in the brain, meaning medical illness. Most psychiatrists a multifactorial in their causal assumptions. Diagnosis (with the various limitations to each diagnosis) can lead to meaning and 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. Still, from the grand sweep of enlightenment knowledge, we categorise 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 and organised our world. A symphony emerges from a single note.
Critical Psychiatry approaches can highlight the presumed damaging effects of diagnosis. 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. An ideal diagnostic assessment can view issues on a spectrum and blur the line between normative and pain. What’s the alternative? Well-being descriptions based on poverty, attachment and trauma for profoundly psychotic or seriously depressed people? The risk is that clinicians who overapply trauma/attachment models could explain autism, fetal alcohol spectrum, ADHD, and a raft of neurodevelopmental disorders from this blank slate standpoint.
Clinicians should be pro-choice when it comes to diagnosis. A young person recently told me why they don’t want a diagnosis of FASD, but a formulation. I backed him 100% despite other agencies pushing a label for him. However, suppose you find meaning from a diagnostic term, research or in examining possible causal complex interplays between gene and neurodevelopmental disorders using a diagnosis. In that case, an anti-diagnostic stance implies you’re thinking is flawed because of the adverse consequence of a diagnosis. If the focus is only on narrative, then only stories relating to adversity, and trauma (formulation) restore real meaning. The implication is that people desperately seeking diagnostic assessments or labels are engaging in folly or are not clever enough to understand how the diagnosis will fail them, due to the adverse impacts, and your poverty could be masked behind a label. Some patients might perceive a double bind with support of diagnostic choice and at the same time pointing out the adverse impacts of making that choice. A story that denies science and aspects of truth that might be challenging can be ultimately vague and could deny patients access to a raft of medical and psychiatric choices.
For anti-diagnosis groups, an implicit false choice is being offered up between diagnosis and formulation, whilst stating it’s imperative to find meaning in a narrative formulation, not a diagnosis, but the two are not mutually exclusive – you have a choice, but your (diagnostic) choice is flawed – because of the negative consequence flowing from your diagnosis. This perceived stance could engender mistrust and censorship. You can have a diagnosis, but it’s risky and obsolete, and you might be a fool to accept a label. Diagnosis is a choice for you, but the weight of the medical model will crush you; a patronising double-bind stance could create confusion and distress.
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.
By Dr John Marshall, a consultant clinical and forensic psychologist. Dr Marshall has previously headed child and adolescent forensic services, therapeutic fostering services, clinical psychology services in the adult forensic field, is an expert witness and published research in child psychopathic traits, family therapy and evidence based therapies for children.
This article is based on the author’s experience and that of other clinicians who have increasingly found that professionals informed by a range of international approaches emphasising trauma and attachment can lead to over-focus on these issues to the detriment of receiving a mental disorder diagnosis.
This article is a revised version (21/2/22) of the original article published on Psychreg.