Underrecognition of PTSD II: Clinicians Are Taught Wrong
Unfortunately, you can be confident that your therapist is poorly trained.
Posted Mar 16, 2018
Jude was a 53 year-old male whose posttraumatic stress disorder (PTSD) had been misdiagnosed for over 40 years. He came to our clinic at Tulane University for depression and anxiety. He had been feeling more tired, withdrawn, useless, and lonely. During our intake assessment, our clinician asked about possible traumatic events as she always does in new intakes, and followed this with questions about PTSD symptoms. She immediately recognized that he had PTSD since childhood following sexual abuse and witnessing domestic violence. Jude had seen multiple therapists over the years, starting from childhood, but he reported that he had never been diagnosed with or treated for PTSD. We had recognized his PTSD in about 60 minutes. Why had Jude’s PTSD apparently been missed for over 40 years?
This is the second of a three-part series explaining why the diagnosis of PTSD is missed in approximately 90% of patients, and what you can do about it. In Part I, I described seven reasons why the diagnosis is missed so frequently.
Understanding reason #7 - the “frame of reference” problem – can help you come to accurate diagnoses, whether you’re a patient or clinician. The frame of reference problem is where the patient has a condition, namely PTSD, and the individuals conducting the assessments have never experienced PTSD themselves. If the individuals conducting the assessments have never experienced PTSD themselves, they do not understand how to ask the right types of questions.
“Don’t Lead the Witness” Training is the Wrong Way to Train Clinicians
Psychiatrists, psychologists, and other professional counselors are taught in graduate schools to not “lead the witness” when they interview patients. These young clinicians are taught that if they do not provide suggestions to patients about how patients should answer questions this will be a truer path to diagnoses, prevent clinicians from jumping to the wrong diagnoses, keep clinicians from missing rare diseases, or create a more patient-centered atmosphere. In addition, the don’t-lead-the-witness approach feels comfortable for doctors if they suspect patients are trying to get pills that they don’t need, or to qualify for a disability check from the government.
Here is an example of the wrong way to conduct an assessment, and likely explains what happened to Jude. In this example, the clinician wanted to know if the patient has the PTSD symptom of psychological distress to reminders of past trauma events. The clinician asked the question, “Do you get upset when exposed to reminders of the event? “ Simple and straightforward, right? Wrong.
Because most patients with PTSD actively try to avoid remembering reminders of their traumatic events, the answer to that question is buried under a few layers of avoidance. It can take patients several seconds to get through the layers of avoidance in their minds to those memories that they have been trying to forget. Even if they do get through the layers to those memories, patients often choose to stay quiet about them out of shame or anxiety. When clinicians lack a frame of reference of what it’s like to have PTSD, they are likely to fire off impatiently the next question.
The Right Way: Educational Interviewing
The frame of reference problem can be overcome with good training. Here is the right way to conduct an assessment. After asking the patient the generic question, follow it immediately with an example that is specific to each patients’ traumatic experiences. In the following example, the clinician wanted to know if the patient has the same PTSD symptom as in the previous example - psychological distress to reminders of past trauma events. This time a mother is being interviewed about her young daughter who was trapped in their home from the flood during Hurricane Katrina.
Counselor: Do many things or places remind her of the trauma and do these reminders make her upset?
Mom: (pauses to think for five seconds) No.
If the counselor had stopped there, as the vast majority of clinicians would have done, the answer would have been recorded in the patient’s chart as a no. This clinician however thought of examples based on this child’s unique experience and “led the witness” with the educational interviewing technique.
Counselor: So if she goes through a damaged neighborhood or she sees pictures of a flooded house does that remind her of seeing her house destroyed?
Mom: Yeah, that’s a good example. I didn’t think of it like that. Yeah because I took pictures of the house and when she sees those pictures it’s kind of a reminder.
Counselor: Does it make her upset?
Mom: You know children. She’s upset for a little while and then after about 5 to 10 minutes she’s back to doing what she was doing.
Counselor: Do you think she’s more upset than the average child that age?
Counselor: OK, can you give me an example?
Mom: She just saw some picture that I had and she asked, “Is that our house?” She just kind of freaks out.
Counselor: OK, when she does that, she kind of freaks out, what does it look like?
Mom: Just kind of angry. Not throwing food, but she’ll have to talk about it, what the water did to our house, and it’s all messed up.
Psychological distress at reminders is not the only difficult symptom. Other symptoms that can be confusing are avoidance of reminders, dissociation, hypervigilance (often confused with exaggerated startle response), and nightmares (often confused with night terrors).
It is unfortunate that those who are most interested in helping patients are too poorly trained to actually help them. If it were funny, it would be irony.
The good news is that it doesn’t have to be this way. It is quite possible to diagnosis PTSD accurately 100% of the time. I think you can even diagnose yourself or your loved ones with a self-administered questionnaire most of the time without the help of clinicians.
(Dr. Scheeringa will be signing his new book, They’ll Never Be the Same, on April 27, 2018 at the American Counseling Association annual meeting in Atlanta. Please stop by the Central Recovery Press publisher table.)