Therapy Gem- Diagnosis By Event: We Do Not Diagnose By What Has Happened

“My 13 year-old son, Carlos James, has reactive attachment disorder,” reported an anxious mother to start the first interview.

The therapist asked, “What makes you come to that conclusion?”

“He was adopted from Columbia.  He never felt bonded to me.  He always seemed to keep a distance from me.”  As she said this, her husband sat quietly at the far end of the couch shifting his jaw in a gesture of doubt.

“Adopted at what age?  From what kind of situation?”

“He was two months old. From an orphanage.  I think it was an okay place, but didn’t have a lot of staff or resources, from what I heard.”

“How was he when you met him for the first time?”

“He seemed okay.  He was well-fed.” [Further inquiry regarded early attachment signs, eye contact, comfort, consolability, timing of milestones.  From the description given, nothing seemed unusual.]

The therapist then asked, “What does he do or not do that makes you think it’s RAD now?”

“He isn’t truthful.  He talks to anyone.  When he doesn’t get his way, he has a tantrum and is hard to calm down.  He never liked being separate from us to go to school – he was always clingy.”  The therapist thought these behaviors could reflect an attachment problem or even conditions other than RAD, such as Separation Anxiety.

“When he is not truthful, as you say, is it to cover up things he doesn’t want you to find out or pin on him, or more things that are really made up or even things there isn’t any need to lie about at all?”

“When you put it that way, probably the first one.”

Father stepped in here. “Definitely it’s to weasel out of stuff, you know, not to get caught or blamed for things he did.  Mostly hiding he didn’t do homework, things like that.”

“Well, let me meet him and then I’ll bring you back so I can get his developmental history.”

The therapist had the parents go to the waiting room and the 13 year-old son came into the room.  He was a well-dressed and well-groomed adolescent.

“What did your parents say about coming here today?”

“They think there’s something wrong with me.  They always do.  It’s annoying. Well, mostly my mother.  Did she tell you the story of how she was raised by her aunt because her mother was psychotic?  She will. I try very hard in school and do my chores, but Mom is always picking on something.  Perfectionist!”

“So then what is your idea or feeling about that?”

“I am always in therapy.  I don’t know why.  It’s always the same.  They think I care about being adopted, which I don’t.  I’m lucky.  I know that.  I don’t think I am different.  Yes, I have a temper sometimes, but nothing different from what I see my friends do with their parents.  Really.”

“What sets you off?”

“I don’t like being criticized.  Mostly that.”

The boy reported he has two close friends.  His grades have always been in the B range.  His relatedness seemed surprisingly comfortable, even warm.  He did not seem to have an insecure attachment style.

When the parents returned to the consulting room, Father answered a question about his son’s behavior and relatedness over the years, “I remember feeling so thrilled when we got him.  I felt pretty close to him since then.  We played catch and, when he was in Little League, I went to all his games.”  Father thought Carlos was extroverted, but saw no problems with that.

“Where did the idea of RAD first come up?”

The parents explained a therapist who saw him briefly when he was six and was having problems in first grade gave him the diagnosis.

Nothing in the presentation seemed consistent with a RAD diagnosis.  This could be because of previous effective therapeutic work or the diagnosis had never been accurate.  Perhaps it was mother more than son who was having problems with the adoption?

*********************

Sally Ann, 36, and her daughter, Gina, 14, were referred by a protective service worker. Sally Ann spoke up saying, “She has PTSD. The worker is Jane; she agrees.”  Gina and the family were in a safety program run by protective services because, during a visitation with her father, the girl suffered a minor injury in a car accident in which her father had gotten an OWI.  In the course of the interview with Sally Ann and Gina, the therapist asked, “Jane ____, the worker from protective services, said something about sexual abuse. Can you explain more about that?”

She was indeed subject to a sexual relationship with an uncle involving oral sex four times from around age 9 through age 10.  At that point, she threatened to tell her parents and the abuse stopped. She never talked about it before now.  At family gatherings, she kept her eyes on the man and she did not talk to him.

“When he is there, what do you feel?”

“I’d make sure he doesn’t go anywhere near me or my cousins,” Gina reported.  “He doesn’t have a daughter and neither does my aunt [Mother’s sister].  My cousins are boys.  He knew I was so onto him.  I think he is a wuss.”

“Your feelings?  What emotions do you have around him?

“Disgust a little, mostly nothing,” asserted Gina.

Sally Ann then said, “I feel sorry for him, being that weak a jerk that he would have done that.”

Gina added, “I developed early and he took advantage of me. I don’t think he would do it to anyone else because I told him if I found out about it I’d make sure he was in jail.”  Gina seems to have remarkable perspective, good boundaries, and an effective strategy for managing the current situation.

“I have a few questions about the memories.  How often does it come into your head?”

“Not much. When I got an invite to a family event and before I went.  That’s about it.”

“Is it vivid like it’s a fresh memory or more like an old memory like going to first grade or something?”

“No.  It’s like anything in the past.”

“Tell me the feelings you get remembering what he did.”

“Like I said, nothing much.  Just disgust about him now.”

“If you picture yourself in the experience, what emotions does that stir up?”

“Now?  I don’t see it that way.  It’s like I am watching it over in another room.”

“What situations do you avoid so they don’t remind you of it?”

“Sometimes I would rather not go to a family party.  But I still went.  Really, it’s not a problem.”

“If zero means it has no impact on you today, it’s neutral, no feelings about it, and 10 is the most distressing thing you can think of, how would you rate those memories?”

“Maybe 1 or 2,” she said.

To Sally Ann, the therapist asked, “Do you think you are paying attention to the possibility of something like this happening again?

“Actually, yes.  I think about that.  But I try hard not to let her know it.  It’s hard to let her wait on the corner for the city bus to take her to school, so I stand on the porch and watch.  But you can’t be everywhere.”

Further questions inquired about Gina’s relationship with boys, her view of future dating relationships, her view of her body, and her acceptance of her sexuality.   Her responses seemed age-appropriate.  They reported the uncle was being prosecuted by the DA.  So the therapist asked Gina how she felt about being questioned and perhaps having to testify.

“You know, I feel real bad for my family.  This is such a mess.   One of my cousins wanted me to back off.  But it’s out of my hands.  I guess it will be easier on me if he isn’t at family events.  I don’t really want him in jail all that much though.”

The therapist reported to the worker that Sally Ann had no PTSD and her level of vigilance appeared to be normal. The family had responded to the revelation of the abuse with acceptance of Gina and with reasonable protectiveness.

Comment: Many therapists would induce guilt in the client by asking why she took so long to report it since that put other children at risk.  Gina took it upon herself to be a protector of children.  But I once had a patient who had a reasonable adjustment to a college rape that she had not reported.  When a therapist scolded her a decade later for not protecting other women from that man, her reaction to that accusatory remark demonstrated significant trauma, which was very difficult to resolve.

*********************

The Referral Department asked me urgently to interview a man who said he was “traumatized.”  It was a referral from an EAP and the referral form, in the problems box, had these words: “Probable PTSD.”

As a widower raising girls 12 and 16, Scotty had been unemployed for two years and the family was receiving state aid.   He had been in construction before that.  Finally, he found a job and he was proud of his work.  After three months, the company had some financial problems.  Since he was the last hired, he was the first person laid off.  But he dressed each morning as if he was going to work, and he went out looking for jobs.   He didn’t want his two teenagers to learn he was unemployed again.  His wife had died at age 40 of ovarian cancer.  He did not think he was more sad or pained about that than anyone else would be after two years of mourning.  He did feel he owed it to her memory to be outstanding with his daughters.  He viewed his work problem as a failure.

The original unemployment came about because he put his kids’ needs ahead of his job.  He had no trauma or seriously unresolved conflicts.  He had an uncomplicated childhood.  We observed some early stress inoculation because his grandmother lived with the family during her last years and final illness, and Scotty had helped a lot with her.  He had effective coping skills for managing illness and loss.

Scotty is a man who had lost his wife and two jobs.  But there was no evidence of trauma.  The driving force was his need to be a good father and his fear his daughters would be disappointed in him.  This related to his fear of disappointing his deceased wife, her memory.  Yes, he had some symptoms of Reactive Depression, namely impaired sleep, reduced appetite, guilt feelings, self-doubt, and irritability.  But he had no intrusive thoughts related to any of the events.  He talked about them factually without anxiety.  He did not report being jumpy or hypervigilant.  He reported no nightmares.  He was in an emotional crisis with a clear precipitating event. PTSD should not be “diagnosed.”

*********************

In these three cases, trauma had been presumed from the events in the person’s life.  In each case, the presumption turned out to be incorrect.

A recent episode of the TV show Criminal Minds told of a woman in her 20s, the eldest of three daughters, who accused her father of sexual abuse.  The mother at first dismissed these complaints.  Workers interrogated her youngest and her middle daughter, but they had no sexual abuse experiences to report.  A trained assessor, applying appropriate techniques for evaluating abused children, concurred; he found no evidence of sexual abuse in the youngest.  The therapist for the eldest daughter was convinced she had been sexually abused and the memory arose from repression after a lot of therapy including a Pentothal interview. The therapist had seen a variety of symptoms – depression, anxiety, hostility towards her father, feeling alienated – and concluded she must have been sexually abused.  Eventually, the young woman produced the memories that “corroborated” the suspicion.  In this episode, the presumption was that the symptoms meant a trauma had occurred.  But there had been no trauma.  The therapist inferred the trauma.  Then the therapist suggested it.  Eventually, the client complied.  This type of inference of trauma from symptoms went to the heart of the Repressed Memory debate.  An event should not be inferred or even suggested from the symptom presentation.

Steve and Sybil Wolin, in The Resilient Self (1993), found a significant percentage of people who had grown up in an alcoholic household had no serious impairment.  They were not without some impacts, but they were not traumatized or psychologically dysfunctional.  Wolin would ask clients, “When did you decide to be different from how you were raised?”  Clients were able to remember making such a decision.

Wolin’s work, along with that of E. James Anthony and other resilience researchers, is consistent with the general notion that about 1/3 of those experiencing a supposedly traumatizing event were not experiencing trauma symptoms.  About 1/3 were traumatized.   The remainders had some impact, but were not suffering traumatic stress per se.

In summary, Carlos James, Sally Ann, and Scotty were assumed to have PTSD because of the events they experienced.  But in fact they did not have PTSD.  This illustrates the error of diagnosis by event.

The TV episode showed reasoning from symptoms back to a presumed trauma, a pattern followed in the “repressed memory” camp of therapists and still all too common a logical error.

It turns out that events, such as growing up in an alcoholic home, but also any number of possibly traumatic events, produce PTSD symptoms or severe symptoms in a minority of those who experienced the event.

We are not going to consider the question which troubled Freud and the ego psychologists, namely, why is it some people experience events as traumata and some do not.  The main point here is that the event does not tell us whether the person has PTSD or any other condition.  The event is just a pre-requisite; it is necessary, but not sufficient.  The diagnosis is made by looking into the symptoms themselves.

We do not assume the diagnosis from the event or assume the event from the symptoms.  It would be statistically more often accurate to assume the person experiencing an event does NOT have PTSD until proven otherwise.

The converse is also true.  The failure to have florid or obvious symptoms does not signify the absence of PTSD.  For instance, William came in after he was arrested for an OWI.  He had been drinking and using cocaine.  While his assessment revealed dependency upon those chemicals, a well-hidden set of symptoms came to light when he was asked a routine question about trauma.  “Have you experienced any events in life which still bother you so much today it’s as if they had just happened?”  He reported watching a mortician taking away the body of his older brother who died of an overdose.  He said it is so vivid, he sees it and reacts to it as if it had just happened now.  It is an intrusive memory; he experiences it many times a day.  The other event he reported was the death of his mother from a stroke.  All he could see was his mother in the ICU with various tubes and wires, struggling to breathe and unable to speak.  He felt he let her down because of his failure to complete school.  He also felt their relationship was very “unfinished” when she died.  Diagnostically, in depth assessment showed he met the criteria for PTSD for both of these events.  Nothing in his clinical presentation had pointed to the presence of PTSD.

In fact, this is not uncommon.  My impression is that PTSD is one of a few diagnoses which is often both a) over-diagnosed because of the error of reasoning from the event or b) most frequently overlooked because of the failure to investigate sufficiently.  The former is the case when therapists reason from symptoms or events to the assumption of trauma.  The latter is true when we do not inquire sufficiently.

Because the treatment of trauma is specific, the diagnosis of PTSD must be correct.

The problem of reasoning from an assessment to an event is also a hazard when the problem is separation in childhood, avoidant attachment in an adult, or any other attachment anxiety or conflict.  The tendency is to assume an event.

The problem is also present when a client is not in a state of trauma, but in a state of emotional crisis.  We tend to think of the event as producing a trauma.  But following the crisis psychotherapy model (Hoffman and Remmel, Uncovering the precipant in crisis psychotherapy, Social Work, 1975), we experience repeatedly that clients feel better after one or two interviews.  No PTSD was present.  Often, the Precipitating Event for therapy seems to be a minor and not particularly traumatic experience.

In summary, assigning an explanation and including a diagnosis flows from detailed assessment following established criteria.  Sticking to the facts is crucial.  For reasons not yet fully understood, most people who experience a particular event do not develop a diagnosable condition.  Inferring an event by reasoning backwards from symptoms or inferring a condition by reasoning forward from an event are two logical errors which can be damaging to clients.  These errors lead to inappropriate or ineffective treatment recommendations.  First do no harm.

© Don D Rosenberg, 2012

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