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Addiction, while a mental health disorder in its own right, often covers deeper wounds. Treating addiction often requires a willingness to delve deep into a patient’s psyche and find the traumatic experiences that are motiving the substance abuse.

In this Mental Health Minute, Gray talks about her efforts to treat the traumas that often lurk behind addictions. She offers tips for building strong therapeutic alliances and recommends using eye movement desensitization and reprocessing to help patients with comorbid substance abuse disorders and trauma.

is a licensed therapist and recovery coach at Hand in Hand Counseling in Greenwich, CT.

The potential role of eye movement desensitization and reprocessing.

Treating Comorbid Substance Abuse and Trauma

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Janice Haaken, PhD, is professor emeritus of psychology at Portland State University, a clinical psychologist, and a documentary filmmaker. Dr Haaken has published extensively on psychoanalysis and feminism, the history of psychiatric diagnoses, interpersonal violence, the social psychology of remembering and storytelling, and documentary methods. Her books include

 Pillar of Salt: Gender, Memory and the Perils of Looking Back

Hard Knocks: Psychology and the Dynamics of Storytelling

Psychiatry, Politics, and PTSD: Breaking Down

 (Routledge, 2020). She has directed 6 feature films: 

Queens of Heart: Community Therapists in Drag

Mind Zone: Therapists Behind the Front Lines

Milk Men: The Life and Times of Dairy Farmers

Necessity: Oil, Water and Climate Resistance

. Dr Haaken has received numerous awards for her filmmaking, most recently the Lena Sharpe Persistence of Vision award at the 2019 Seattle International Film Festival.

 is a fascinating critical analysis of posttraumatic stress disorder (PTSD) as a diagnosis, the turbulent debates surrounding the role of trauma in psychiatry that led to its creation, and the institutional and sociopolitical functions it serves in a wide variety of settings such as the military, veterans’ affairs, war zones, refugee camps, and criminal justice system. I was impressed by the adeptness with which Dr Haaken tackles the ambiguity, uncertainty, and the internal contradictions present in the subject matter while resisting the temptation for simplistic answers. This interview delves into some of the broader conceptual and sociopolitical issues surrounding PTSD and psychiatric diagnoses discussed in the book.

: You wear many different hats (psychoanalytic clinician, critical psychologist, documentarian, and field researcher), which offers you a unique advantage in being able to approach psychiatry from a variety of different perspectives. Can you tell us more about your background and how that has influenced your critical inquiries?

: My first professional career was in psychiatric nursing, beginning in the early 1970s as a staff nurse in a treatment program for children, and later in medical training centers in California and Oregon. My nursing background was formative to my identity as a professional, even in the course of pursuing a PhD in clinical psychology. Nursing is a traditionally female job, but one that is very hands-on and close to bodily experienced suffering. I value that. As a clinician, I was influenced early on by the women’s movement and its rejection of a lot of the old diagnoses, with hysteria the prototypical example. I have always approached the diagnostic process as a form of storytelling that requires attentiveness to social contexts of mental suffering and to the language available for communicating distressed states. In addition to feminism, I was influenced by the radical psychiatry, critical psychiatry, and the antipsychiatry theories of the 1960s and 70s, all of which shared a critique of the medical model that underpins psychiatry.

When I joined the faculty at Portland State University, my research methods—grounded in critical theory, psychoanalytic-feminism, discourse analysis, and qualitative field research—were considered quite radical, although the department moved to incorporate more qualitative methods over time. I joined the faculty in the era when academic psychology was moving in a more applied direction. During the year that I joined the faculty, the animal lab (which took up an entire floor of our building) was in the process of shutting down. My department was migrating to field studies and taking up messy data and real-world problems that were central to my own program of research. My documentary films grew out of my field studies where initially I used cameras to capture more of the communicative language of participants than audio recordings permitted.

. What did you set out to do and where do you think you ended up in terms of your analysis?

: This new book extends a line of analysis pursued in 

Pillar of Salt: Gender, Memory, and the Perils of Looking Back

, a book that focuses on narrative aspects of psychiatry and how social movements shape diagnostic thinking. In the later decades of the 20th century, trauma disorders, from multiple personality disorder, dissociative identity disorder, to posttraumatic stress conditions, gained enormous currency in the mental health field. There were intensely heated debates over a widening array of symptoms thought to be disguised symptoms of trauma.

, I revisit some of those debates and the historical and cultural dynamics that shaped the way trauma models took hold late in the 20th century. With the rise of neoliberalism, and the push to marketize everything in sight and the dismantling of public services, the dramatic and morally charged accounts associated with trauma represented an effort to break through the high threshold for responding to more mundane forms of suffering. With PTSD narratives, I was interested in how this diagnosis migrated through this same era and how the scientific disputes over the diagnosis seemed to be symptomatic of a deeper problem in the field. I came to think of PTSD as a forensic diagnosis as it was used in settings where clinicians were enlisted in adjudicating the fates of individuals. There is some consensus that PTSD is a redemptive diagnosis in the sense that it assigns causality to an external force and does not implicate the sufferer. Many progressive clinicians embraced the expanded use of the diagnosis because it seemed to offer a form of sanctuary or protection from more damning labels. I was interested in what was excluded in the differential diagnostic process as clinicians were using this diagnosis, and particularly in the military and the Department of Veterans Affairs (VA), the courts, and other institutional settings.

: It was fascinating for me to read in your book about how the diagnosis of PTSD emerged from a union of research studies in stress and trauma, and how different the cultures of these traditions were. Stress research had adopted a very mechanical view of psychology, as you point out in your book: “People, like machines, are subject to breakdown under conditions that exceed their operational capacities.” While on the other hand, “To speak of psychic trauma is to position the problem within a moral community of responsibility as well… Whereas stress speaks to the machinery of mind, trauma evokes images of the ghosts in those machines” (p. 8-9).

 How do you think this tension has played out in subsequent research on PTSD?

: Early in my career, I was highly critical of machine metaphors, associating them with masculinist assumptions in science and dehumanizing modes of intervention. My own field of feminist psychoanalysis holds some affinity with the trauma models in their focus on storytelling, and the ghosts in the machine! Trauma therapists often speak of hauntings, which can be a meaningful way of representing the ineffable or elusive aspects of mental disturbances. But I do think it is a mistake to align metaphors too readily with conventional gender dichotomies, or good vs bad metaphors. The Yerkes-Dobson law, for example, developed by military psychologists during the First World War, is based on what could be described as a machine-model of stress and it remains the closest thing we have to a natural law in psychology. It still explains some aspects of the relationship between increased stress plotted against performance and breakdown. But military psychologists soon realized that the model failed to account for the complex dynamics and factors that mediate stress responses.

You also asked about how the tensions between stress research and trauma studies have played out over time. Until recently, stress has lost ground to the more mesmerizing stories associated with trauma. For a very long time, child sexual abuse, deserving of our attention as it is, has stirred far more public outrage and clinical interest than do the much bigger and prevalent problems of child poverty and neglect.

There have been a number of campaigns since the entry of PTSD into DSM III in 1980 to expand the diagnosis to include chronic or what came to be termed complex traumatic stress disorders. These campaigns failed in my opinion because PTSD has become such a marker of the societal boundary separating the deserving and the undeserving, good individuals who are victimized through no fault of their own from the willfully deviant, and complex trauma attempts to expand and redraw that boundary. PTSD retains its taxonomic legitimacy and forensic status by keeping the diagnosis pretty closely tied to a discrete event or set of events that depart from some demarcated expected realm of normal experience.

: Your critique is one that is sympathetic to the practicing clinicians, appreciative of the demands and the pressures under which they work, and the bureaucratic systems they are forced to navigate to help the patient in front of them. You write about “how practitioners were enlisting the PTSD category as a way of managing seemingly impossible clinical tasks – situations where they were negotiating various institutional, political, and psychological demands.” (p. 3).

Another example of this sort of dynamic that comes from your book is that of personality disorders. You discuss how prior to the official acceptance of PTSD as a diagnosis, military psychiatrists were pressured to diagnose traumatized veterans with personality disorders because the traumatic reactions could then be dismissed as deeply rooted character problems. You write, “Some of these troubles were indeed likely influenced by personality factors. But the political context made this avenue of exploration more of a tool for the military than a means of understanding the struggles of soldiers” (p. 9).

 The identification of maladaptive personality styles coming from an empathetic psychoanalytic clinician could be immensely psychotherapeutic in the right setting, but the same identification of personality dysfunctions in a different setting could be wielded as a weapon to silence, stigmatize, or discriminate. This suggests to me that the fundamental problem may really be these institutional, political, and psychological demands. Do you think that critical inquiry in psychiatry sometimes gets sidetracked by focusing too much on these diagnoses rather than on the institutional structures in which they are employed?

: Yes, I think the enormous investment of resources and campaigning to expand PTSD research has more to do with pressures on the field and professional marketing than it has to do with addressing the sources of mental suffering. One of the interesting boundaries that I take up in a chapter of the book is the line between PTSD and personality disorders. I trace the history of efforts to widen trauma diagnoses as a corrective to over-diagnosing personality disorders, including in the military. One of the reasons that psychiatric casualties were so low during the Vietnam War was that so many service members were dishonorably discharged under the character disorder labels. Doctors were seen by many veterans as complicit in the disciplining of rebellious soldiers through these diagnoses, just as they had during World War I. But PTSD depends very heavily on the concept of normalcy, the claim that this is a normal response to an abnormal situation. This leaves many other individuals and problems outside of the protective fold of the diagnosis.

: You write, “For those suffering harms more diffusely located in history or based on more systematic forms of violence or neglect, for example, polluted neighborhoods or poorly run schools, the diagnosis failed as a register of their claims” (p. 7).

 I do not know if any diagnosis can register these sorts of claims in a manner that is also adequate for clinical and scientific tasks. Perhaps our collective mistake is to think that we should look to diagnosis as a tool for the purpose of acknowledging systemic oppression?

: Yes, I do think that the over-expansion of DSM and its burgeoning taxonomy is part of the problem. But PTSD carries a unique history as a disorder in that it was specifically thought to be caused by societal conditions. Progressive clinicians largely embraced the category as a corrective to the systemic problem in psychiatry of over-pathologizing, as well as sexism and racism. Because the diagnosis carries a long history of morally charged campaigns, its expansion has had this inadvertent effect of reproducing some of the moralizing tendencies in psychiatry. PTSD was not simply discovered through some enlightened path of medical progress. It emerged as a kind of compromise formation (like an individual neurosis) at the frontlines where progressive clinicians used the tools of their profession to intervene in what are basically social problems.

The situational stress reactions of prior eras carried expectancies that normal individuals are able to move on quickly from disturbing events. For me, the question is not whether PTSD or any other diagnosis can adequately address societal forms of violence or oppression, but rather why these problems get so loaded onto this category and its exclusionary criteria. Proponents tend to focus on what PTSD includes and exposes in terms of societally produced suffering. I was interested in what this diagnosis tends to exclude.

: Your discussion of the antipsychiatry movement was quite interesting. You describe it as “a loose collection of intellectual and political projects focused on challenging the societal basis of psychiatric authority” (p. 10).

 You go on to comment with reference to Michel Foucault, PhD, “From a Foucauldian perspective, a critical psychiatry works to decenter the authority of psychiatric discourse by exposing its own historical contingencies” (p. 177).

 It seems to me that any framework that is utilized to deal with the realm of human distress, disability, and deviation will have historical contingencies and will be susceptible to having the societal basis of its authority challenged. Would you agree that even if the authority of psychiatric discourse is given to some other kind of discourse, an ongoing critique of a critical and Foucauldian nature would continue to be necessary?

: The legacy of Foucault in psychiatry and the social sciences most decisively includes rejection of master narratives of all sorts, whether in Marxism, psychoanalysis, psychology, or other human sciences. There is some recognition, written into ethical guidelines, that mental health professionals must attend to cultural differences and societal factors, and are required to recognize misuse of professional authority. These caveats are included in the preface to recent editions of the DSM. But the traditions of critique that I draw on require a more sustained and deeper engagement with both the ideological side of our professions, the ideas that take hold, and the material conditions of our work, which include things like how services are provided and paid for.

I also draw on critical traditions to recognize how social justice movements have profoundly shaped, even transformed, and how we think about boundaries between normal and abnormal, for example the issue of homosexuality. The APA was pushed by the gay rights movement to remove homosexuality in 1973 from DSM II. I also try to recover some of the ethos of the early antipsychiatry movement that has been marginalized in the mental health field; for example, the idea that patients suffering from delusions or hallucinations have something to say worth hearing.

: You acknowledge the influence of Peter Sedgwick on your views, referencing his contention that the antipsychiatry theorists often approach mental suffering from too much distance “rather than from the hard seat of the waiting room or the casualty department’s stretcher.”

 The impression I seem to get in this regard is that you are saying: yes, we need to problematize the role of psychiatric and psychological explanations with reference to what we consider to be abnormal, disordered, or dysfunctional, but we should not use this problematization to argue against the rights of individuals to have their distress and disability be registered and the right to receive adequate care within some framework of health or social welfare. Is this an accurate characterization?

: I do try to hold these complexities in mind and to draw out both the insights and blind spots of those early movements. This is a very interesting time we are living in now, and in many respects, a very hopeful one. After a long era of meager resources for public health agencies (the poor stepsister of medicine and private health insurance), public health and calls for investment in social welfare have gained enormous public support after this horrifying pandemic. The Black Lives Matter movement has pushed for a different vision of society than we have been fed over the past 50 years, particularly in the area of policing. There are calls around the country to move away from policing to a greater focus on crisis services and interventions outside of the criminal justice system. But I also think that a progressive vision of psychiatry requires more in terms of attitudes and thinking about patients suffering from mental illness. As mental health professionals, we should be working to build more receptive spaces in the community for individuals who may seem odd or who process reality differently.

: You write, “the obsessive tendency in psychiatry to ‘pin down’ PTSD within a stable, trans-historical taxonomy is itself symptomatic of the anxiety associated with this diagnosis” (p. 6).

 Subsequently you write regarding psychoanalysis, “psychoanalysis departs from medical psychiatry in widening the interpretive lens for diagnostic storytelling. It allows for ambiguity, for dynamic shifts in the meaning of events over time, and for the symbolic and metaphorical registers of symptoms” (p. 179).

 I can think of at least 2 sources of the sort of obsessive tendency that you describe, 1) the need for operationalization of constructs for the purposes of scientific inquiry, and 2) the categorical needs of the health care and legal system (such as, to reimburse or not to reimburse, to declare criminally sane or insane). Psychoanalysis has been able to allow for ambiguity, perhaps by distancing itself from these needs and restricting itself to a more clinical role. What do you think mental health systems can do differently to allow for the sort of ambiguity that you value?

: That is a fair critique of tendencies in clinical psychoanalysis—that its attentiveness to ambiguity and to the layers of meaning and the overdetermined aspects of mental life can feel like a luxury or privilege available to professionals who are remote from the hard decisions and demands of those living precarious lives. My book does include a critique of psychoanalytic interventions, noting that the diagnostic process for PTSD runs counter to many psychoanalytic principles. PTSD tends to focus on single causal factors, an emphasis that also runs counter to much of the scientific literature. But there also are rich traditions of social psychoanalysis and psychoanalytically informed community practices that I draw on.

Some of the problems you describe are bound up in the market economy and how deeply capitalist logic shapes medical training and its ledgers of value. I do think socializing mental health services and moving away from our dependency on private insurance and fees-for-service would be a good thing. Many of the storefront clinics that were part of the anti-psychiatry movement included treatment approaches that were quite nuanced in recognizing the complexity of patients and their problems. It was understood that individuals could be self-defeating and destructive, both victims and perpetrators. I also think there are some wonderful programs carried out in Vet centers and the VA by staff clinicians, programs that I describe in the book. The Hearing Voices movement is also an example of groups drawing on some of that same ethos and working outside of the medical model.

: At one point you comment, “Disorders can be both socially constructed… and at the same time valid ways of understanding mental functioning” (p. 13).

 I think that is an important point because there is a tendency to think that if something is socially constructed then it cannot be valid. Can you elaborate more on this?

: I am not anti-diagnosis, but I do generally view them as provisional and contingent on a community of shared meanings, rather than as entities readily objectified and operationalized through the tools of science. But diagnoses also hold currencies, both material and ideological, that are important to recognize. Much of my work focuses on the history of psychiatric diagnoses and forces that shape the migration of categories across some moral divide. I have also written about folk maladies such as codependence and love addiction, as well as syndromes bridging feminism and clinical research, such as the battered woman syndrome. PTSD grew out of the anti-war and feminist movements, and so it interested me as a category bridging social movements, popular culture, and DSM taxonomy. I like working at the messy borders between diagnostic categories. PTSD has this messy etymological and social history, with its collapsing of stress and trauma, present and past.

: One of my favorite sentences from your book is, “like many religious texts, the DSM is rife with contradictions. Practitioners bring their own interpretations of its arcane truths to the messy world of human experience” (p. 5).

 That is a rich analogy. I would add that like many religious texts, practitioners not only take it more or less literally, but also take it more or less seriously! (I have also observed how there is substantial disagreement when it comes to the philosophical foundations of the DSM, what sort of notion of mental disorder does it have, what it means by 

, and so on.) One of my dissatisfactions with a lot of popular critiques of the DSM is that they take the manual way too literally and way too seriously, perhaps because our system does too in some ways, but I feel any robust critique has to take into account these contradictions and the varying interpretations they provoke. Your thoughts?

: Yes, amen to that! After leaving the fundamentalist Christian fold of my youth when I entered adulthood, I developed a deep allergy to religious zeal, including in those fields where I hold allegiances and attachments. But the over-investment in the DSM seems more tied to its use in institutional settings and how decisions are made about patients’ lives when there is some consideration of mental states. There is a great deal at stake. Clinicians working with the courts, military, and in VA settings, including disability evaluations, are required to have considerable fluency in the DSM and its obsessive logic. Clinicians in private practice are required to enter a code on an insurance form, but can remain pretty agnostic about the taxonomy itself. They can bypass the disciplinary side of this manual.

In the last chapter of my book, I tell a story from interviews I carried out with both patients and clinicians at the Oregon State Hospital for my film, 

. One patient, sentenced to the state hospital for 20 years under the insanity plea, had killed his boss after falling from the roof on a construction site. He was diagnosed with a psychotic disorder, based on his preoccupation with numbers and codes. His psychiatrist, a compassionate clinician who frequently spoke on the patient’s behalf before the Psychiatric Security Review Board, was also preoccupied with numbers and codes. At hearings, he cited the canonical DSM criteria and the elaborate codes associated with Oregon Statutes in describing this case. I could not help but see the psychiatrist and patient as each registering some of the madness of the world they both inhabited, a psychiatric hospital that was also a prison. Of course, a crucial difference between the psychiatrist and the patient was in how many of their signifiers were legible to others. That difference decidedly favored the normalcy of the doctor.

: You comment in the book that the critique of the medical model in the 1960s was complemented by an embrace of alternative states of mind. There is an on-going revival of interest in the use of psychedelics, this time largely within a medical model, with PTSD being one of the conditions of interest. You discuss that the development of the therapeutic use of psychedelics invites us to revisit the work of Timothy Leary, PhD. What is your assessment of current investigations into the therapeutic use of psychedelics for PTSD and what insights do you think Leary has to offer?

: Campaigns to decriminalize psychedelics and other Schedule I drugs have been vital to the racial justice movement in the United States. In my own State of Oregon, a pair of ballot measures were passed last fall to decriminalize possession of small quantities of Schedule I drugs that have been a leading gateway into the criminal justice system. Many young people of color get arrested on minor drug charges. In my book, I take up some of the history of how drugs migrate across the good drug/bad drug boundary, often through the medical model. In the late 20th century, the trauma movement emerged as a site of rebellion against what many viewed as the excessive use of pharmaceuticals in the mental health field. Trauma required intensive, long-term listening. Perhaps inevitably, PTSD emerged as the modern-day poster condition in this new effort to bridge that divide, partly through its redemptive association with normalcy. It was interesting to me that a small group of multidisciplinary psychiatrists, founded in the 1980s to champion therapeutic use of psychedelics, moved quite quickly from the margins to the mainstream of public policy, if not to the mainstream of the field of psychiatry itself. It is a fascinating story that still unfolds—one that I would love to follow as a documentary filmmaker. There are many cultural dynamics operating here, including widespread interest in alternatives to the mind-numbing and anti-libidinal drugs so often dispensed by the medical profession.

I am glad you asked about Timothy Leary, whose legacy as icon of the 1960s often surfaces in campaigns to promote therapeutic use of psychedelics. In my book, I use this case of psychiatry’s recent romance with psychedelics to revisit the early research of Leary and his lesser known contributions to psychology and psychiatry. Through his studies on the use of psilocybin in group treatment settings in a prison outside of Boston, Leary advanced his theory of what he termed 

, with the former referring to the attitudes of practitioners, including to the drug itself, and the latter referring to the environmental context, including the aesthetic and social context of drug administration. Prisoners were provided psilocybin in special rooms with music and group support, and encouraged to set their own goals for self-development. Many of the current protocols for therapeutic use of psilocybin similarly involve long sessions with music of one’s choice, social support, and rituals, including some associated with Indigenous practices. The important insights that grew out of Leary’s work on these contextual influences on drug effects have had little influence on psychiatric administration of drugs in general, and they typically register as confound effects, although some of the focus on social support and aesthetics have been incorporated into protocols for therapeutic use of psychedelics, including here in Oregon.

If these protocols open larger questions about cultural practices and market forces in the mental health field, I think this could be a good thing. It will also be important to attend to how debates over the therapeutic use of psychedelics shape treatment options for patients suffering from major mental illness where clinical sets and settings—to borrow the phrase again from Leary – have been so impoverished.

: We have seen a lot of discussion around mental health over the past year, especially in the context of the COVID-19 pandemic. I think there is a certain unease in a lot of these popular discussions, where the desire to acknowledge the magnitude and prevalence of suffering coexists with concerns about medicalization of this suffering. Do you have any thoughts on how we as a society can have more meaningful conversations around mental health?

: The pandemic has indeed opened space for more meaningful conversations around mental health, particularly in the renewed focus on chronic stress as a public health and mental health problem. The internet is awash now with discussions of 

, and PTSD has emerged again as a signifier for shared suffering not born of individual failures or deficits. But I view much of this as a diagnostic containment strategy and a distraction from the real issues at hand. Dispensing diagnoses as an intervention in the pandemic is not very illuminating, even with PTSD as the site where societal sources of misery are narrowly acknowledged.

More than offering just a critique of the PTSD diagnosis, psychiatric diagnoses in general or the medical model, I hope my book contributes to self-reflection in the field about how the histories of our disciplines are embedded in larger societal histories, and on our roles in reproducing the very suffering we aim to control. Following psychiatry through military history was particularly instructive in bringing into bold relief the contradictory forces we face as clinicians in keeping individuals healthy in unhealthy places. It is not a conflict we can deliver ourselves from by simply refusing to be part of the system. Those in secure private practices can opt out, but many of us are part of institutions that offer less distance from how we are implicated in the difficult lives of others. But many of these institutional sites, where psychiatry is closest to the heartache and hard problems that exceed its reach, carry potential for greater creativity in a field that has suffered its own inhibiting obsessive conditions. That is why I am so delighted to be part of your Conversations in Critical Psychiatry. Thank you for inviting me!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the 

Dr Aftab and Dr Haaken have no relevant financial disclosures or conflicts of interest.

Psychiatry, Politics and PTSD: Breaking Down

Psycho politics: Laing, Foucault, Goff man, Szasz, and the future

How should the sociopolitical nature of PTSD as a diagnosis inform our understanding of trauma?

Trauma and the Politics of Diagnosis: Janice Haaken, PhD

June is National Men’s Health Month, and of course that includes men’s mental health too. Unfortunately, men often neglect their mental health, leading to substance abuse, violence, and other harmful behaviors.

In this Mental Health Minute, Russell Kennedy, MD, talks about why men avoid seeking treatment and what psychiatrists can do to help them when they finally walk through the office door.

is a physician specializing in the treatment of 

Anxiety Rx: A New Prescription for Anxiety Relief from the Doctor Who Created It.

How do you help men with anxiety disorders and other psychiatric conditions? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

During National Men’s Health Month, take time to consider the unique mental health needs of male patients.   

What Can Be Done About Anxious and Violent Men? 

SPECIAL REPORT: SEXUAL AND GENDER MINORITIES PART 2

Sexual and gender minority (SGM) youth experience the same types of traumas as their non-SGM peers, including child maltreatment, domestic and community violence, accidents, traumatic death, and separation. SGM youth are also at elevated risk for stressors common among minorities. Furthermore, these youth experience distinct ongoing stress related to discriminatory societal, medical, educational, housing, employment and/or legal attitudes, norms and/or practices, among others. In addition, 

 are at increased risk for traumas that are specifically related to their sexual orientation, gender identity ,and/or expression. They may be bullied, sexually or physically assaulted, or rejected by their parents. Thus, these youth are at significantly greater risk for cumulative trauma exposure, and for developing the negative mental health and medical problems related to stigma, minority stress, and trauma.

Trauma-Focused Cognitive Behavioral Therapy

Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based treatment for trauma-impacted youth, aged 3 to 17 years, and their nonoffending parents or primary caregivers.

 With 23 randomized controlled trials assessing efficacy, TF-CBT has the strongest evidence for improving youth posttraumatic stress disorder (PTSD) diagnosis or symptoms, as well as trauma-related depressive, anxiety, behavioral, or cognitive difficulties.

The TF-CBT model consists of 9 components summarized by the acronym PRACTICE; they compose 3 treatment phases (

). Typically, TF-CBT treatment includes 12 to 15 sessions, with each phase lasting 4 to 5 sessions. For youth who develop complex PTSD reactions to multiple or interpersonal traumas, the enhancing safety component is typically provided first, and the stabilization/safety phase may be longer relative to the other 2 phases, taking up to half of the treatment sessions. Parent participation is an important part of TF-CBT, with youth and parent(s) seen individually for half of each treatment session; several conjoint youth-parent sessions are also included. Abusive or rejecting parents have not usually been included in TF-CBT treatment. These sessions typically use gradual exposure, ie, increasingly calibrated direct discussion about the youth’s trauma reminders or personal trauma experiences and use of skills to cope with these. Evidence-based psychotherapies such as TF-CBT are the 

 with PTSD symptoms or other trauma-related difficulties.

During a year-long learning community sponsored by the National Child Traumatic Stress Network (NCTSN), TF-CBT was implemented with trauma-impacted 

 in order to modify the model for this population, collect data, and develop an implementation manual to describe these modifications. Family Acceptance Project (FAP) data so convincingly documented the impact of specific family rejecting and accepting behaviors on risk and well-being for SGM youth and provided an evidence-informed family intervention framework that TF-CBT developers made the decision to include rejecting parents of SGM youth in TF-CBT treatment. FAP developer, Caitlin Ryan, PhD, ACSW, helped incorporate core FAP principles and strategies into the modified TF-CBT SGM implementation manual.

 This manual describes an integrated TF-CBT-FAP framework for SGM youth recovery from trauma, and it is now available at no cost to clinicians.

For 1 year, -long program, 32 clinicians from 12 NCTSN sites used TF-CBT for trauma-impacted SGM youth in order to modify the model for this population, collect data, and develop an implementation manual to describe these modifications.

 The 24 youth—aged 8 to 12 years, with diverse gender identities and sexual orientations—experienced significant improvement on the University of California, Los Angeles PTSD Reaction Index for DSM-5 from pre- to post-treatment (mean scores of 44.0 [severe] to 17.89 [normal]; t = 5.59; P < .0001). In a subsequent 

, 19 youth aged 10 to17 years who self-identified as SGM and received TF-CBT with these modifications experienced improvement in the Child PTSD Symptom Scale for DSM-5 from pre-to post-treatment (mean scores of 50.05 [severe] to 26.21 [mild]; t = 7.65; P < .001).

The FAP is a research, education, intervention, and policy initiative that was developed in 2002 by Ryan and colleague Rafael Diaz, PhD. The goal was to help families support their SGM children to reduce health risks and promote well-being in the context of their families, cultures, and faith communities. FAP conducted the first comprehensive research on SGM youth and families and developed the first evidence-informed family support model for use in family guidance and treatment approaches for prevention, wellness, and care for SGM children and adolescents.

FAP’s family support model is grounded in participatory mixed methods research with diverse SGM youth and families. FAP’s research identified more than 100 specific behaviors that parents and caregivers use to express rejection and acceptance of their SGM children and measured these behaviors to show how they contribute to health risks and decreased well-being. FAP worked with racially, religiously, and linguistically diverse families and SGM youth to develop intervention strategies and multilingual research-based resources that can help families decrease rejection and increase support and acceptance for their SGM children.

FAP’s family support model can be implemented to reduce risk for suicidality, depression, illegal drug use, ejection and removal from the home; to decrease family rejection; and to promote well-being. FAP strategies and resources can be used in any setting and by families. Moreover, core FAP intervention components can be integrated into other models of treatment, prevention, and care—as was done to integrate FAP and TF-CBT to support recovery and promote well-being for SGM children and youth, whether or not 

 is related to the child or youth’s SGM identity.

FAP’s family support model uses a strengths-based and harm reduction framework to help parents, families, and caregivers understand sexual orientation and gender identity as components of child development. It teaches them how specific reactions to their SGM child affects the child’s well-being and impacts their child’s risk for suicide, depression, illegal drug use, and HIV (

FAP has developed a series of research-based education materials to help parents understand the importance of family support, to guide behavioral change, and to educate extended family members as well as cultural and religious leaders. These resources include: family intervention videos that portray how diverse families move from struggle to support of their SGM children; family education booklets that are best practice resources for 

; assessment scales to measure growth and change; and a multilingual 

 series that tells the story of family acceptance and rejection, suitable for use in homes, congregations, and any other public, institutional and clinical settings (

Family Rejecting Behaviors That Are Traumatic

A critical element of FAP’s approach is helping parents and clinicians understand that family behaviors that reject a child’s core identity are traumatic and, combined with other trauma experiences, can contribute to complex mental health issues. Like Adverse Childhood Experiences (ACEs), the family rejecting (and accepting behaviors) identified and measured in FAP’s research are predictive of risk for suicidal behavior, depression, illegal drug use, risky sexual behavior and decreased well-being in adulthood. But unlike ACEs, these specific family rejecting behaviors are screened by few practitioners in 

 for these specific family rejecting behaviors. FAP’s family support model aligns these research findings with the parent’s underlying cultural and religious values to support positive behavioral change.

Parents are typically surprised to learn that these “well-meaning” behaviors to help their child fit in, have a good life, and be accepted by others are actually contributing to high levels of depression, suicidality, substance use, and other adverse outcomes. Yet, all of the specific family rejecting behaviors studied by FAP focus on trying to change, prevent, deny, and minimize a child’s SGM identity. Caregivers who believe that being gay or 

 is wrong routinely engage in rejecting behavior at early ages that undermine their child’s self-worth, increase isolation and hopelessness, erode the parent-child bond, and significantly increase the likelihood of suicidal and self-harming behaviors.

In aligning the FAP and TF-CBT models, the significant benefits of integrating them became obvious. Applying core FAP strategies and resources in TF-CBT enables clinicians to help parents understand the 

harmful impact of specific rejecting behaviors

, such as preventing the youth from having an SGM friend or making them pray or attend religious services to try to change their SGM identity (

). FAP’s behavioral approach motivates parents to change harmful rejecting behaviors and to engage in affirming behaviors that increase connectedness and reduce risk—even when they continue to believe that being gay or transgender is wrong.

While the focus of treatment in TF-CBT remains on the child or youth, FAP is expanding the focus on the critical role of family support. Efforts to change a child’s sexual orientation and gender identity expression are reinforced by social, cultural, and religious norms and are transmitted intergenerationally as a cultural default position. Helping the parent understand, take responsibility for, and ask the child’s forgiveness for behaviors that have denigrated the child’s SGM identity becomes part of the transformative narrative of TF-CBT for both the child and the parent.

TF-CBT and FAP’s integrated framework provides a pathway to healing and recovery that strengthens families and engages parents and caregivers as allies, not adversaries, for their SGM children.

TF-CBT and FAP help the parent and child to create meaning out of traumatic and harmful experiences and empower parents to nurture their SGM child. The COVID-19 pandemic has heightened vulnerability for SGM children and youth in numerous ways by confining them with rejecting and abusive family members, separating them from supportive peers and adults outside the home, and resulting in the sudden death of family members and cultural leaders. This combined treatment approach can play a crucial part of our national recovery.

is the medical director of the Center for Traumatic Stress in Children & Adolescents at Allegheny General Hospital in Pittsburgh, and professor of Psychiatry at Drexel University College of Medicine in Philadelphia.

 is the director of the Family Acceptance Project at San Francisco State University. A clinician and researcher with more than 40 years of experience working on LGBTQ health issues, she and her colleagues conducted the first research on LGBTQ youth and families and developed the first evidence-informed family support model to help diverse families to support their LGBTQ children. Dr Cohen receives grant funding from the Substance Abuse and Mental Health Services Administration and the National Institute of Mental Health, and royalties from Guilford Press, Up To Date, and the Medical University of South Carolina.

Treating Trauma and Traumatic Grief in Children and Adolescents, 2nd ed

2. Cohen JA, Mannarino AP, Deblinger E, eds. 

Trauma-Focused CBT for Children and Adolescents: Treatment Applications

3. Cohen JA, Bukstein O, Walter H, et al; AACAP Work Group on Quality Issues. 

Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder.

4. Cohen JA, Mannarino AP, Wilson K, Zinny A. 

Trauma‐Focused Cognitive Behavioral Therapy LGBTQ Implementation Manual

5. Cohen JA. Trauma-focused cognitive behavioral therapy (TF-CBT) for LGBTQ youth. 

6. Cohen JA. Trauma-Focused-CBT for LGBTQ youth across systems of care. Paper presented at: American Academy of Child and Adolescent Psychiatry; October 19-24, 2020; virtual meeting. Accessed April 12, 2021. 

https://aacap.confex.com/aacap/2020/meetingapp.cgi/Paper/35840

7. Ryan C. Generating a revolution in prevention, wellness, and care for LGBT children and youth. 

Temple Political & Civil Rights Law Review

 Implementing the Family Acceptance Project’s family support model: practice guidance

. San Francisco; Family Acceptance Project, Marian Wright Edelman Institute, San Francisco State University.

9. Ryan C. Supportive Families, Healthy Children: Helping Families With Lesbian, Gay, Bisexual, and Transgender ChildrenFamily Acceptance Project at San Francisco State University; 2009. Accessed April 12, 2021. 

https://familyproject.sfsu.edu/sites/default/files/FAP_English%20Booklet_pst.pdf

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Change Efforts in Sexual Orientation and Gender Identity: From Clinical Implications to Contemporary Public Policy

"Well-meaning" behavior by parents or guardians could be contributing to high levels of depression, suicidality, substance use, and other adverse outcomes in their child.

The Trauma-Focused CBT and Family Acceptance Project: An Integrated Framework for Children and Youth

“Trauma eventually affects everyone on the planet,” says Randall Bell, PhD, who has worked on disaster recovery around the globe. But after the disaster, it is time to figure out how to survive, and then thrive.

In this Mental Health Minute, Bell discusses his latest book, 

Post-Traumatic Thriving: The Art, Science, & Stories of Resilience

. Marshalling a combination of scientific studies and personal stories, he lays out a 3-stage journey from trauma to recovery.

holds a PhD in socioeconomics from the University of California, Los Angeles. He is the Chief Executive Officer of Landmark Research Group, LLC.

Is unresolved trauma the number one problem on planet earth? An economist with expertise in disaster-related distress makes the case. 

The Global Burden of Trauma

The fallout from the COVID-19 pandemic, a lethal presidential transition, the ongoing reckoning with policing in America, and a gaping racial wound that has been present since well-before the nation’s inception have traumatized an untold number of Americans. Like most institutions associated with mental health services, graduate medical education in psychiatry will need to evolve in tangible ways to meet the demands of this moment. Here are 3 proposals that would help residency programs produce trainees that are adept at both treating and advocating for a traumatized populace.

Residency programs will need to continue their efforts to keep psychotherapy as a mainstay of psychiatric practice. Psychotherapy continues to be a 

cornerstone in the treatment psychological trauma

 Unfortunately, the role of psychotherapy training in residencies has dwindled considerably over the 

, though not necessarily because of a lack of interest or enthusiasm among residents.

A multi-site survey of psychiatry residents conducted between 2006 and 2007 showed that 

 considered being psychotherapists central to their identity as clinicians.

 Owing to its small sample size, one can hardly draw sweeping conclusions. That said, anecdotal evidence suggests that psychiatrists recognize psychotherapy as having an important place in practice and are concerned about its diminishing role. External pressure from the health care system increasingly confines them to the role of prescriber while outsourcing psychotherapy to therapists. While this is ultimately driven by perceived economic costs, it is a grossly short-sighted approach. Psychotherapeutic skills are critical even for psychiatrists who choose to practice from a predominately biological orientation. 

A possible solution could be to offer psychotherapy 

 Unfortunately, this could have the effect of disincentivizing residency programs from going beyond simply meeting the requirements of the Accreditation Council for Graduate Medical Education (ACGME). Since gaining competency in psychotherapy is a time intensive endeavor, perhaps the answer lies in expanded tracks within training programs that allow residents to pursue their interests in psychotherapy within the confines of a 4-year training program.

2. Formalized Education in Historical Trauma

 is defined as “complex and collective trauma experienced over time and across generations by a group of people who share an identity, affiliation, or circumstance.”

 In order to offer more than just an empathetic ear, psychiatrists should develop a subtle understanding of how patients experience the sequelae of historical trauma at an individual level. One way for programs to accomplish this would be to adopt a more formal education in historical trauma. Furthermore, hiring a trauma-informed workforce is among the key organizational changes proposed by the Center for Health Care Strategies in their 

 on the implementation of trauma-informed care.

Adopting this framework contextualizes trauma from historical injustices as a collective experience for members of a community. Moreover, it frames trauma as an ongoing process, as opposed to a singular historical event with a definitive bookend. Placing contemporary injustices in a historical context will bolster cultural competency, and in turn yield a stronger therapeutic alliance with patients.

This moment demands that psychiatrists accept our mutually reinforcing roles of healer and advocates for public mental health. Therefore, residency programs must incorporate seminars and/or workshops on advocacy into didactics, and the ACGME should consider instituting this as a requirement. As a specialty, psychiatry must be attuned to an individual’s socioeconomic status, as well as their sociopolitical circumstances—these are central to mental well-being. Improving a community’s mental health needs to simultaneously address the conditions that either predispose individuals to poor mental health or exacerbate current conditions. This requires engagement that goes beyond the clinic, hospital, or an electronic screen. The key challenge here will be to strike a precarious balance between respecting individual autonomy and paternalism.

Advocacy through meaningful community engagement can assume many different modalities, including but not limited to social media, coalition building, developing relationships with local stakeholders, or lobbying local legislators, etc. Programs may consider developing a formal curriculum that equips trainees with effective strategies for exploring these avenues. This should go hand in hand with developing networks of local advocates who can help trainees gain in-field experience.

The good news is that psychiatry already recognizes the indispensable role of social determinants to an individual’s overall well-being. This is why it is the specialty that tends to champion the various causes of social justice, whether they be racial, economic, environmental, reproductive, etc. Moving forward, it would be a boon to our patients if this became an occupational objective, rather than an occupational hazard. 

Acknowledgments: I am grateful to Dr James Knoll for his edits to this piece.

is a PGY1 in psychiatry at Upstate Medical University. The views expressed in this article do not necessarily represent the views of his institution.

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2. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. 

3. Lanouette NM, Calabrese C, Sciolla AF, et al. Do psychiatry residents identify as psychotherapists? A multisite survey. 

4. Moran M. Should psychotherapy be a psychiatric subspecialty? 

https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.3b6

5. Mohatt NV, Thompson AB, Thai ND, Tebes JK. Historical trauma as public narrative: A conceptual review of how history impacts present-day health. Soc Sci Med. 2014;106:128-136.

6. Menschner C, Maul A. Key ingredients for successful trauma-informed care implementation. April 2016. 

https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf

What should residency programs be doing to address current traumas? 

Three Proposals for Trauma-Sensitive Residency Programs 

H. Steven Moffic talks about trauma and posttraumatic stress disorder (PTSD) awareness month. 

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of being a Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

Are We a Traumatized Nation?

In a chilling scene of the television series, 

 set in rural North Carolina, an unnamed elderly white woman tauntingly sings these lyrics with a wide grin as she trespasses on the Black female protagonist Lucky’s property. This serenade foreshadows the racist violence that ensues after. This song, “Old Black Joe,” written by the “Father of American music,” 

 Foster also wrote many minstrel songs, a form of entertainment for white audiences in which white performers donned 

, a facial costume in which white individuals smeared their faces with burnt cork and drew on larger, red lips, with the intent of looking like Black/African-American individuals.

“Old Black Joe” represents an entire culture of songs, written by white composers, that were dehumanizing to Black individuals. These cringeworthy songs were enmeshed in American society to the detriment of the psychological wellbeing of Black individuals, and their songwriters are still memorialized even to this day. A statue of the renowned Stephen Foster, with an African slave sitting at his feet strumming a banjo, was only recently removed.

 is a horror/thriller series recently released on Amazon Prime. The series joins a growing collection of movies and television shows, like 

 that graphically illustrate 1 key point: the violence of white individuals towards Black individuals, simply due to the color of their skin, is scarier than any horror movie monster.

 expertly combines elements of reality and the supernatural to illustrate the horrors of racism and white supremacy to its audience. The series centers on a Black family who moves from the south to California in the 1950s, during a time in history known as the 

, in which Black families moved north to flee the racial violence of the South.

In fact, my mother’s family was one of them, having left the brutal environment of Mississippi for Ohio, hoping for a better life. I have cousins who were murdered by white individuals for attempting to register Black voters. My father’s family, from Macon, Georgia, remained in the South. My uncle, alive and well today, remembers seeing a Black man who had been lynched, swinging from a tree. He was just a child. His father, my grandfather, took pictures of the lynching and published it in a Black-owned Macon newspaper he led. White individuals in the area were furious—not because a Black man had been murdered, but because it had been publicized in the newspaper.

Black children have never had the luxury of being shielded from racism, and 

Psychiatrists who want to understand white supremacy should watch this series… 

Trauma And Violence