THE TRAUMATIC CONSEQUENCES OF PTSD: SAMPLE PSYCHIATRY REASONING IN A SEXUALLY ABUSED YOUTH
Brief Introduction: after my relocation to Florida, Pennsylvania attorneys requested repeat forensic service in the area of sexual abuse. I had worked primarily for plaintiff attorneys seeking restitution from pedophiles and other sexual abusers for injured youth.
They made me think it might be of use to revise a report conclusion for others wishing to defend the abused.
One concern I have is that youth who are "troubled" do not always engender empathy because of substance use or illegal acts. And the opposite concern is that some youth become energetic and successful, but are largely disconnected from their assault. Stress will eventually allow their damage to manifest after the statue of limitations.
Case Context: A child who was repeatedly sexually abused in a facility. Child will be named "Kevin," which is a false name. The facility will be named "Martin Residential," which is a false name. All references to professionals, such as Dr H., are false initials.
Forensic Evaluation of Trauma and its Effects:
- Was the victim able to discuss the sexual assault with their therapist?
Kevin clearly was uncomfortable and unsettled by his sexual assault, because he was unable to discuss it with his therapist(s). For example, in 6/24/9x, the evaluator, aware of the sexual abuse possibility, quotes Kevin as saying that he does not "think about" the events. Kevin also said that it did not "bother" him or cause "major worry." This shows the child was in a state of profound dissociation, describing the events as if a mere bruise that would promptly heal. Dissociation is not a sign of successful treatment or that the events were incidental. It is a sign that the youth has yet to begin treatment.
- Does the victim try to please the interviewer?
Since Kevin was dependent on Martin Residential for a place to live, during the 6/24/9x Intake Exam, he was merely trying to please the interviewer.
- Does the victim prevent adults from being troubled?
During this same evaluation when he was a mere early adolescent, he showed the common behavior of sexually abused boys of not sharing any material that may make any caregiver troubled. The caregiver might be troubled to hear what was happening at Martin Residential.
- Was there a link between abuser and location, which prevented attachment?
The definitive treatment for Post Traumatic Stress Disorder is entirely dependant on a relationship and a safe place where you can attach to the staff. This was largely unavailable at Martin Residential, since the perpetrator was associated with the facility.
- Was the child actually younger emotionally than chronological age? Making abuse more profound to him?
- Did the abuse push developmental goals out of reach?
Kevin had a baseline state of poor frustration. Likely this was due to ADHD and/or a mood disorder, which would mean that it was critical for him to receive quality, comprehensive and safe treatment. I believe that the abuse in the context of a therapeutic environment puts treatment goals far out of reach. Meaning, what would be possible in three years, and would be hard to achieve in 12-15 years.
- Sexual assault in an advertised "safe" environment makes PTSD worse and creates a hopeless attachment paradigm. What is the core belief about people that emerges?
Sexual abuse in the context of a "so-called safe, monitored, caring, attentive" therapy environment has unique catastrophic features. By analogy, psychiatric literature is filled with material on the trauma of an adult psychotherapist having sexual relations with an adult patient--grounds for severe civil and criminal penalties. If it is universally regarded as catastrophic in an adult-to-adult therapist relationship, it is much more so in a child to powerful adult relationship.
- What was the child's coping strategies? Will these serve him in coping in mature demanding adult relationships in romance and with a boss?
During the 10/92 psychological evaluations, Mr. D. reports that Kevin's coping strategies involve withdrawal--both internal and external forms. Meaning, Kevin shows internal withdrawal by not listening to his Mother, and he shows external withdrawal by running away.
Such comments are important. Simply, Kevin's repeated chronic sexual abuse in a closed residence would intensify these primitive and developing coping strategies. He would then become more profoundly dissociated and then "zone-out" or act like everything was "ok." He would also act out by different forms of "running away." Examples of withdrawal that are worsened include drug use, school and vocational avoidance, and relational attachment problems.
- What are other core beliefs that are fused to the youth's perceptions about the World? Justice? Order? Himself? Others?
An abusive environment creates specific core paradigms about the world and self. These would include believing: "The world is a hopeless place.... The world is an unjust place.... People and places that are presented as "safe," are, in fact, the most dangerous places of all...
- What Perception of Justice and Order has Developed? Did the Assault and Its Consequences have Any Effects on Motivation?
Is the reality for Kevin that: "My wrongs are punished but the severe dangerous wrongs of authorities are ignored."
Specifically, Martin Residential employed a wide variety of behavior treatment. Basic to such treatments is the belief that one is responsible for one's actions. Kevin was treated under this system of accountability, and had consequences for inappropriate minor actions. Yet, requiring Kevin to take ownership for oppositional behaviors is obscene in the context of chronic residential sexual assault of a pre-adolescent child. In other words, when a child is expected to apologize for cursing, while the powerful adult does not apologize for chronic sexual abuse, it creates the belief that "there is no order in the world" and motivation dissolves.
- Can't We Just Get a Good Therapist and Get Kevin Quickly Back on Track?
Fundamental to all treatment in child and adolescent psychiatry is typically attachment to a psychiatric or psychological caregiver. Based on Kevin's experience, he would develop a belief, "the trustable are in fact the most untrustworthy." In other words, when one has a broken leg, the Orthopedist will break the other leg. When you call the police during a robbery, they will come and beat you during their investigation. We cannot erase such memories with a wave. And think that the next Orthopedist or Police Officer can be easily plugged in with a fresh start.
When a prime "safe person and healer" is the abuser, prognosis falls markedly. The belief that the "trustable are the most untrustworthy" makes for a very poor prognosis. Individuals can lose decades before being able to receive the care and treatment they could have reasonably received as a child or early adolescent.
- Was there Evidence of Scapegoating or Blame shifting by Adults? Such Behaviors Further Traumatize the Child.
Kevin was partially scapegoated by Martin Residential. During his one and a half page re-evaluation report, Dr. H. reports that the child was having no problems with Martin. Simply, the problem was that Kevin was not acting well at home, and so he had to be brought back to the environment in which he was sexually assaulted. In his evaluation, the Psychiatrist explains that all is "ok" and that Kevin had a "bright affect."
We are led to believe the problem is with Kevin. The point of the re-evaluation, which shows an awareness of the sexual abuse allegations, was to show that Kevin had no damage. If Kevin has no damage, and his zoned out trauma state is called "bright," then the only problem is that Kevin is not acting well at home, i.e. a scapegoating of the child.
- Is There Hatred of Abuser Manifested as Homosexual Hatred as PTSD/Trauma Evidence?
In Kevin's deposition, page xx ff., we see that Kevin has very hostile and strong feelings towards homosexual people, and yet he is someone who has had same-sex sexual assault at Martin Residential. It is very common for victims of sexual abuse, particularly boys, to assert themselves belatedly and to feel hatred and hostility towards those with a homosexual orientation. It is another example of his perception that the world is a dangerous place, i.e., homosexual men are perceived as potentially violent pedophiles. It also shows that he has not processed his severe assault.
- Does the Youth Meet Any Criteria for PTSD?
If DSM-IV TR partial PTSD criteria are met in a victim, but not enough for a formal diagnosis of PTSD, that does not mean less psychological damage. Partial criteria could by profound and impair Kevin's life. Some criteria could be present at "80" intensity, while other individuals may meet full criteria at a mere "20%" intensity and be less troubled.
The boy meets criteria of PTSD, or severe dissociative disorder for many reasons. For example, he has "here and now" recollections of the events. On page xxx (deposition) he states of the repeated abuse, "that is intimidating, it is a scary thing," as if it were a very active present memory.
He describes dreams that were not a problem prior to his chronic sexual abuse. He is overwhelmed by sharing the details of his abuse and by describing any details (deposition page xxx and page xxx. Specifically he says, "Oh it is hard" when he is describing the events, and also states "I can't believe I am telling two lawyers exactly what happened to me." Such comments are consistent with a child who is dissociating or "zoning-out" because of an inability to handle the titanic chronic abuse.
Kevin's distress is highly believable and consistent with Vietnam Vet trauma survivors' or severe rape survivors. He explains very clearly that he "can't talk to people," and that he also holds "a lot of resentment towards gay guys" Š page xxx deposition. Here are strong examples of PTSD's avoidance of people, or things that are symbols of the past experience.
- Untreated PTSD Can Expand And Become More Diffuse
One of the problems with untreated PTSD is that it slowly expands. For example, if untreated, a person who is attacked by a specific moderate sized brown dog, later can become afraid of all dogs of similar color or size, and eventually perhaps all dogs. One sees clearly this expansion of fear and dysphoria in Kevin's deposition, page xxx. He says, "I feel weird around men, like real weird when it comes to talking to a man alone." He is not merely afraid of his abuser. He is not merely afraid of men who look approximately like his abuser. He is "weird" around [all] men."
- Do Aspects of His PTSD Prevent Treatment?
This discomfort with men in a one-to-one situation is very serious for his future functioning and outcome. A youth at his age would typically be identifying with male mentors and might do well with a therapist as a mentor. As a boy until now, Kevin would be identifying with men in the male community as both "safe" and non-erotic intimate supports. For Kevin, however, one-on-one time with a man is "weird." I doubt it will become comfortable without major and long-term intervention.
- If He Believes Male Rape is Impossible for Males--Worse Prognosis
In his deposition, on page xxx to xxx, Kevin explains that he perceives rape as a crime against women, and that while a woman can say that she has been raped, it is not something he or any male can do, even though he believes he was raped. He perceives himself as being repeatedly sexually assaulted by a powerful man, and this is impossible for a male to experience.
- Is He Incapable of Relating Meaningfully with Safe Male Caretakers?
The idea of discussing with a mental health professional that he has "been raped" is impossible. Kevin states, "it is not like I can go out to them and say 'yeah, I've been raped. I've been put on a dudes lap and had him but his hand down my pants.'" His ability to relate with _ the people in his world, the male gender, is hindered. He is more alone. He is more vulnerable due to his isolation.
- Does He Show Signs of Resilience Under Stress? Is He Acting "As If" He Is Recovered to Reduce Stigma?
His comments and easy shame shows an assault on the fragile emerging identity of a boy that was unable to develop from early adolescence to his current age. It has been undermined.
- Is He Able to Identify with The Male Gender?
An adolescent boy is separating from the feminine and identifying with the masculine in his identity development. His connection to men will be complicated because he sees what was done to him as a feminine experience.
- Developmental Derailments Undermine School and Vocation For Some Victims
A boy and early adolescent must have a safe environment to develop functionally in school, interact with men and women and explore vocational areas. The timing of his assaults was particularly dangerous to his development in all these areas, due to his age and his shame and isolation. My experience with boys that are abused in this manner is that they functionally lose large years developmentally in all the areas.
- PTSD is Out of Realm of Reasonable Experience. Do Not Let Your Habituation from Going Over the Case Repeatedly Calm Down the Facts. Was this and "excessive experience.
A young boy is fragile. Having the young boy chronically and repeatedly sexually abused by a powerful, large environment controller, like Mr. X has a serious effect on personality development. Bluntly, Kevin was like a partially cracked and fragile walnut under Mr. X's heel. Kevin's immature personality was crushed under the weight of this large adult male.
- Are the Victim's Coping Methods Damaging Him?
It takes psychological maturity to use advanced coping methods like humor to handle severe emotional brutalization. Unfortunately, many unhealthy coping methods offer short-term relief from pain which is strongly reinforcing - worsening prognosis.
They may act out intensely, with drugs, sex, automobiles, fighting and substance abuse. Any area of poor coping for example, a bad temper, may actually become far worse - a rage or fighting or reckless driving. They may use a dangerous coping method to avoid feeling.
Some victim's mention their "shameful," serious abuse, and often decompensate.
- Are They Able to Discuss the Event Fully?
Boys are much less likely to share any experience of sexual abuse, because they see it as defining them--a worse prognosis if unable to speak about it.
- If They Believe They Have Been "Defiled" - Worse Prognosis.
In the same way as many people see themselves as belonging to a certain race or ethnicity, a sexually abused boy sees himself as a defiled object. It is common in my experience working as a Child and Adolescent Psychiatrist, to see adolescents and young men take over a decade to make a minimal 20% improvement in their acting out and problem behavior, which is primarily rooted in their victimization from sexual assault.
- Do They Decompensate If They Talk About The Subject?
Part of treatment is addressing the abuse. But the victim can suffer further damage by exploring treatment and then drinking to complete intoxication to not feel the pain. Serious acting out is very common throughout the treatment of PTSD. This means treatment, even from newer progressive Cognitive-Behavior treatments, could take a very long time--often years.
- Trigger Acting Out?
If the youth was abused in a place(s) that still exists or is like places he sees then he may act out or be overwhelmed. Again, requiring slower treatment.
- Does the Victim Suddenly Blow up or Take off When Under Stress?
In trauma, one's defenses can become thinned and common stress may lead to incidents of yelling, reactivity in excess of the problem and inappropriate distancing.
Why does this matter? Simply, it makes every close relationship more difficult and at times impossible with key relationships. Reactivity alienates friends, romantic relationships, teachers and bosses.
- Does the Victim Seem Very High Strung and Someone Engaging in Excessive Activity?
Some youth "throw themselves into music, school or sports as a way to escape. These things can be fine. But if it is unusually intense it is not a treatment and still is a form of acting out - just a legal and positive way of acting out. Under great stress, the defenses may be overwhelmed and suddenly they cannot function - seemingly "out of nowhere."
- How Severe was the Abuse?
While meaning to the victim can be as important as the specific action, the severity of intrusion into the youth's boundaries can worsen prognosis.
- What is Full Recovery?
Psychiatrically, full recovery would be complete remission of the illness and a return to full normal function. For example, in Biological Depression, full remission is 100% return to baseline. One recalls being depressed, but the only residue is an appreciation for solid treatment and recovery. Yet some practitioners use "success markers" that set the bar of effective treatment so low, that it makes mere modest superficial progress a "success." PTSD recovery is the ability to recall the events without any other cognitive, emotional or behavioral effects.
- Have Vocations Just Barely in Reach, Now Been Moved Out of Reach?
Kevin's chronic assault has caused dissociation, which causes cognitive difficulty. Vocations that he might have been able to learn with effort, now with the dissociation and hopelessness caused by chronic sexual assault in a locked setting, will be out of reach and probably impossible for many years.
In keeping with that, vocational success is dependent on identification and cooperation with a mentor or teacher. And yet, because of this man's caretaker abuse at Martin's Residential, his ability to identify with these vocational guides and teachers will be seriously undermined. This typically lasts for decades.
- Age of Abuse? Younger is Commonly Worse
One way to estimate the duration of sexual abuse damage is to look at the age of onset of the abuse. Many children are unable to speak simply because this is a complex ability. Young children are also laying down the foundation of their body self and core self.
- The Longer the Window of Time From Abuse to "Confession" to a Supportive Caretaker - the Worse the Prognosis.
Trauma handled alone is serious. Sexual Trauma handled alone for years is very unfortunate because it means the child is adding isolation to their trauma during very critical development years serious.
Unfortunately for Kevin, he was unable to initiate the process of recovery until recently. Meaning his entire adolescence was spent avoiding and hiding his assaults. One typically finds that if taking the first step on the stairway takes so many years, the process of recovery before him will be very long.
- Was Their Other Past Trauma's or Major Stressors? If Present, They Worsen Prognosis
I child who has moved regularly with a military family is quite stressed. A child that has divorced parents is stressed. Yet many of these things with support, affection and care, can be eventually handled.
However, adding to these common serious stressors the brutality of sexual abuse may entirely change life outcome.
- Compounded Abuse?
Some children are abused by their peers, siblings, neighborhood youth, or an alcoholic parent, and then eventually the abuse finally ends. Adding the severity of sexual assault to previous abuse may cause logarithmic worsening. 1 Plus 1 Equals 8.
- Life's Future Challenges and Disappointments Will be Experienced as Much More Challenging and Stressful.
PTSD research shows that individual's with initial early abuse as pre-adolescents are much more vulnerable to losses, traumas, and disappointments in future years. For example, Vietnam Veterans were most vulnerable to severe PTSD when sexually abused as youth. Kevin's emotional foundation is very weak and therefore, the inevitable losses and disappointments he will face in future years will be harder to cope with in light of his chronic trauma.
- Is The Victim at Risk For Self-Harm?
Besides showing the immense pain of sexual abuse, suicidal actions as "coping" can ultimately make the victim unemployable, non-functional, and isolated. Simply, few businesses or people have the capacity to handle repeated suicidal gestures and/or attempts.
- If the Victim is Vulnerable Genetically to any Psychiatric Illness such as Major Depression, they are Much Harder to Treat Fully.
In PTSD there is chronic stress. The world is experienced as threatening and this stress is a direct promoter of biological depression.
- Was a Therapist or Therapeutic Figure Employed to Further Hurt or Decrease Power?
One of the goals of child and adolescent psychiatry is to intervene with troubled youth, and with sufficient resources, to successfully bring about change and healing. A child with ADHD is given medication and tutored to study better. An oppositional child is given rewards and consequences for his good and bad behavior and improves.
In contrast, the great power of child and adolescent psychiatry was entirely reversed in Kevin's situation. The attempt at a strategic intervention for long-term life success at Martin's Residential was a violent and sadistic intervention, which I believe with a reasonable degree of medical certainty, will have long-term life implications.
- Soul Murder and Pretending Nothing Happened to the Residential Staff
Certainly Kevin had profound shame during his late child years and entire adolescence. But the facility and staff made many interventions and comments to make it seem unacceptable, a betrayal and attack of them if he raised the sexual abuse. Therefore, he had to die to his experience and be compliant with the "needs" of his adult residential caregivers. He had to die to reality and act "as if" nothing happened. He had to "act as if" he was not assaulted. He had to act "as if" he identified in a basic way with the Martin program since they fed, clothed and sustained him--he was dependant on them. Meaning, he had to identify with the program in which he was sexually abused.
This coping strategy of identifying with the aggressor, which is so common in male sexual abuse victims, makes his prognosis much worse.
Introduction: Treatment options are unique to each patient and case. This is not a complete list. My next book, 80 Solutions for Out of Control Youth, is allowing me to expand treatments from this practical research.
- Because Kevin will be unable to easily process his sexual trauma; he will most likely be drawn towards impulsive ways of coping. He should be guided towards pro-social and legal forms of "thrill seeking." These will enhance his mood, but will be merely be a band-aid. Their only goal is to prevent more serious forms of acting out and any potential illegal forms of acting out.
- Any financial support should be tied to some modest amount of pro-social behavior. His capacities are poor and so payments should not be unreachable.
Payments should be linked with having blood and urine tests, which show no substance abuse of alcohol or other illegal substances.
If he works competently in a regular job, this is a form of pro-social therapy and his paycheck could be augmented with any restitution payment. Payouts should be conditional on compliance with any suggested medication, or therapy.
Some youth find something healing in having something concrete and visible as restitution for their trauma. Examples would be a small modest home and a highly safe modest automobile with side air bags (no sports cars).
Since many abuse victims have a vulnerability to drive impulsively, he should attend 2 safe driving programs of any kind and be rewarded for his attendance.
Additionally, any training or apprenticeship that would enhance his marketability should be paid for fully and rewarded from any settlement.
Kevin should also meet with a vocational and educational consultant. I would specifically recommend J H in XXX. His lifetime consultation is approximately $2,000.
He should also meet four times a year with a highly respected budget consultant, who is experienced at working with those who have minimal capacity at budgeting and managing money. I would suggest D T located in XXXX.
Kevin should have aggressive support for any and all psychotherapeutic interventions for the rest of his life. This would include individual therapy, group therapy, couples therapy, addictions therapy and family therapy. Regretfully, it is likely he will be very slow to access this option. The linkage of restitution income to attendance at any of these forms of treatment is recommended. The therapists who could handle his complexity and who have wide psychological and abuse training, are typically those outside of most insurance networks. Yearly "out patient visit allowances" in typical insurance plans are entirely absurd for Kevin, and show a trivialization of mental health problems. In the practices of those I commonly observe, he would be seen no less than 2x/week with a possible third checkŠin by phone. Costs for seasoned broadly trained competent therapists run from 140-155/hour. I estimate he would benefit from such long term mentoring assistance and treatment for a minimum of a decade. He has lost a decade to his trauma and I believe will need at least this much to become modestly functional.
I would also recommend that he receive an evaluation by a Ph.D. Neuropsychologist to explore in greater detail his visual motor integration capacities. One option would be Dr. J C in xxxxx at the xxx Psychological Center. This may help guide future occupational options towards those that would be fulfilling. A comprehensive evaluation with follow up once a year for five years would be $3,000.
In conclusion, my comments discussed in this report on the effects of Mr. X's abuse to Kevin XXX are stated with a reasonable degree of medical certainty and in keeping with my experience of the effects and outcomes of many abused boys.
Kevin XXX is a highly fragile young man who in many ways is emotionally still stuck at the age at which he was severely abused. His prognosis is marginal, but with very aggressive intervention and concrete signs of justice and restitution, he may have a slowly evolving safe and useful future.
Respectfully submitted to the Honorable Court,
James L. Schaller, M.D., M.A.R., P.A.
Child and Adolescent Psychiatrist
Diplomate: American Board of Psychiatry & Neurology
Diplomate: Forensic Medicine & Forensic Examination
Certification: American Soc. Clinical Psychopharmacology