Psychiatry has a duty to be trauma-informed, given that 50 to 60 percent of the general population, and around 90 percent of people with severe mental illness, have a lifetime history of at least one traumatic event. Yet the mental health system often falls short.
Consider involuntary hospitalization in a psychiatric unit. Losing one’s freedom can be traumatic for anyone and triggering for those with past trauma of nonconsensual experiences. Sometimes, patients are unwillingly restrained through chemical restraints like sedatives or through physical restraints that tie them down to a hospital bed. Occasionally, patients may be placed in “therapeutic quiet” or isolation, spending several hours or days in a small locked room with no windows or objects besides a mattress. The defense is that they are unwell, and their behavior could lead to harming themselves or others. What else can we do besides confine them, sedate or physically restrain them, and isolate them? Imagine you’re the patient being stripped of dignity during that devastating experience. When examining psychiatry’s controversial history of patient mistreatment, we need not look far. Problems persist in the present day.
That’s why planned reforms of the U.K. mental health system suggest creating advanced choice documents to request preferred treatment plans over possible involuntary hospitalization. The goal is to modify the “paternalistic” model of psychiatry. Psychiatrists currently have excess control over independent human beings, enabling the undermining of the adults that psychiatry ought to empower toward better mental and emotional well-being. While one would hope that abusers would be unlikely to choose a compassionate helping profession, the ability to wield excess power against vulnerable people who often have insufficient mental, emotional, or tangible resources to stand up for themselves can appeal to the most power-hungry in society.
That power extends outside hospitalization, given that diagnostic choices can discredit anyone who displeases a psychiatrist. The framework of personality disorders is pathologizing and stigmatizing, perpetuating marginalization and social exclusion while failing to address the underlying trauma that often drives rigid and maladaptive behavior patterns. Of those with personality disorders, 80 percent have a history of childhood adversity, and 91 to 92 percent of those with borderline personality disorder (BPD) report a history of abuse or neglect. Health care providers largely do not approach “personality disordered” patients with an empathetic goal to understand and collaborate with the trauma survivor. The label “personality disorder” connotes “difficult” or “bad,” stereotypes leading to bias and diminished empathetic responses. If a patient expresses dissatisfaction with a health care provider or the system, casual use of “personality disorder” behind the patient’s back serves to soothe the bruised egos of health care providers who feel underappreciated. Psychiatrists need to abandon the egotistical hunger for paternalistic power and insincere praise, instead showing humility in accepting feedback from unhappy patients. Cultivating disdain, even in private, does not help anyone. A failure to cultivate genuine empathy can lead to blind spots, inadequate treatment, and devastating outcomes; suicide risk is highest among those with personality disorders.
Psychiatry’s struggle to effectively address trauma stems from its reliance on outdated paradigms, overlooking the complex interplay between adversity and mental health outcomes. The historic sexism of “hysteria” continues, rebranded as “histrionic” or “borderline” while labeling women as emotionally unstable. Even the language around suicidal ideation reveals stigma. Although a desire to die is merely evidence of suffering, psychiatrists are taught to use the label “suicide threats,” an archaic holdover from the days when suicide was considered immoral and a crime.
While dialectical behavioral therapy (DBT) is popular in treating personality disorders, its behaviorist approach often ignores the underlying trauma. The idea is that behaviors influence thoughts and feelings – behave better, think better, feel better! Yet by focusing primarily on modifying behaviors and teaching coping skills, DBT may inadvertently suggest that symptoms solely result from individual deficits rather than addressing the role of trauma in shaping maladaptive patterns. DBT’s emphasis on acceptance and change dialectics can inadvertently invalidate survivors’ experiences by promoting tolerance of distressing situations without addressing the traumatic impact. This may perpetuate feelings of shame and self-blame, ultimately hindering the healing process below the surface behaviors. Changing behaviors to hide, mask, or camouflage the pain may only mean living a life in secrecy while the pain continues, internalized. Patients who express dissatisfaction with DBT complain that they may function better in society, but on the inside, they still aren’t happy. They’re just too afraid to admit it, lest they get a “resistant” label.
The time has come to dismantle the fundamentally flawed construct of personality disorders in order to effectively treat trauma survivors. Rather than pathologizing individuals, diagnostic criteria should reflect the complex interplay between trauma and functioning, recognizing the heterogeneity of trauma responses and addressing the role of environmental factors in shaping outcomes. Research has shown promising results in treating personality disorders through trauma-informed approaches. Intensive trauma-focused treatment can lead patients who screened positive for BPD to experience decreases in symptoms such that up to a third no longer screen positive after only eight days. The label “narcissist” is highly overused and vilified, yet many know that narcissism is a normal developmental stage that most children outgrow – unless trauma keeps someone stuck. Most adults with narcissistic traits have unresolved trauma. Selfish, unempathetic behaviors can simply be defenses that were previously somehow adaptive, which means treatment is possible from a compassionate provider utilizing intensive trauma-focused treatment. The TEMPO study (Trauma-focused EMDR for Personality disorders among Outpatients) is the first RCT investigating the effect of intensive trauma therapy on personality disorder severity at a 1-year follow-up. If the results show significant improvement in various personality disorder symptoms as a result of trauma treatment, are they really personality disorders, or are we overdiagnosing problems with the person and underdiagnosing trauma responses?
Psychiatry must enhance understanding of heterogeneous trauma responses and widen the umbrella of trauma disorders. Only by embracing a trauma-informed approach can we truly provide compassionate, effective interventions to promote hope, healing, and resilience for individuals struggling to overcome the lasting effects of suffering adversity.
Patricia Celan is a psychiatry resident.
