Spencer Eth

Witness to Violence: The Child Interview

In this paper, we present a widely applicable technique of interviewing the traumatized child who has recently witnessed an extreme act of violence. This technique has been used with over 200 children in a variety of clinical settings including homicide, suicide, rape, aggravated assault, accidental death, kidnapping, school and community violence. The easily learned, three-stage approach allows for proper exploration, support and closure within a 90-minute initial interview. The format proceeds from a projective drawing and story telling, to discussion of the actual traumatic situation and the perceptual impact, to issues centered on the aftermath and its consequences for the child. Our interview format is conceptualized as an acute consultation service available to assist the child, the childs family, and the larger social network in functioning more effectively following the childs psychic trauma.

Treatment of posttraumatic stress disorder: a review.

This article analyzes the literature on the treatment of posttraumatic stress disorder (PTSD).It briefly exposes the theoretical basis for each treatment modality and extensively examines pharmacological, behavioral, cognitive, and psychodynamic therapies, as well as group and family therapies, hypnosis, inpatient treatment, and rehabilitation. Articles were identified by scanning Medline and PsychLit for all papers in English reporting treatment of PTSD. Anecdotal case reports were, then, excluded. Eighty one articles were identified and categorized as either biological or psychological, with the latter category further divided into behavioral, cognitive, psychodynamic, and other treatment modalities. Information regarding the type of trauma, the sample studied, the treatment method, and the results of the treatment has been extracted from each article and is presented briefly. A synthesis of findings in each area is provided. Most studies explored a single treatment modality (e.g., pharmacological, behavioral). The cumulated evidence from these studies suggests that several treatment protocols reduce PTSD symptoms and improve the patients quality of life. The magnitude of the results, however, is often limited, and remission is rarely achieved. Given the shortcoming of unidemnsional treatment of PTSD, it is suggested that combining biological, psychological, and psychosocial treatment may yield better results. It is further argued that rehabilitative goals should replace curative techniques in those patients with chronic PTSD. A framework for identifying targets for each treatment modality is presented.

Stress-Induced Enhancement of Auditory Startle: An Animal Model of Posttraumatic Stress Disorder

Abstract An innovative animal model of posttraumatic stress disorder (PTSD) is proposed in which nonhabituation of the acoustic startle response is developed in rats subsequent to tailshock exposure. Subjects (n = 31) received 30 minutes of intermittent tail shock on 2 days followed by exposure to the tailshock apparatus on the third day. Compared to baseline startle reactions, 9 of 31 tailshock-exposed rats developed nonhabituation of startle response reactions during the subsequent 3 weeks of testing. No control rats developed nonhabituation of startle reactions over a similar time period. These data suggest that this system models useful aspects of clinical PTSD emphasizing nonhabituation of startle reactions as a dependent variable. The method consistently identifies a subgroup of rats that develop persistent nonhabituation of startle in response to a tailshock-stress paradigm.

Impact of trauma on children.

Millions of children are affected by physical and sexual abuse, natural and technological disasters, transportation accidents, invasive medical procedures, exposure to community violence, violence in the home, assault, and terrorism. Unfortunately, the emotional impact of exposure to trauma on children is often unappreciated and therefore untreated, and yet the impact of exposures to disaster and violence is profound and long-lasting. This article first briefly discusses the epidemiology of trauma in children, and then reviews the psychiatric and neurodevelopmental impact of trauma on children as well as the effects of trauma on children’s emotional development. Trauma in children can lead to the development of posttraumatic stress disorder as well as to a variety of other psychiatric disorders, including depression, generalized anxiety disorder, panic attacks, borderline personality disorder, and substance abuse in adult survivors of trauma. Research has found that early exposure to stress and trauma causes physical effects on neurodevelopment which may lead to changes in the individual’s long-term response to stress and vulnerability to psychiatric disorders. Exposure to trauma also affects children’s ability to regulate, identify, and express emotions, and may have a negative effect on the individual’s core identity and ability to relate to others. The authors also discuss what has been learned, based on recent experiences such as the World Trade Center catastrophe, about the role of television viewing in increasing the effects of traumatic events. The last section of the article provides guidance concerning the identification and clinical treatment of children and adolescents who are having emotional problems as a result of exposure to trauma.

Addressing therapeutic boundaries in social networking.

Abstract Facebook is the leading social networking website, with over 500 million users. Prior studies have shown an increasing number of housestaff accessing the site. While Facebook can be used to foster camaraderie, it can also create difficulties in the doctor-patient relationship, especially when boundaries are crossed. This study explored the prevalence of such boundary crossings and offers recommendations for training. An anonymous voluntary survey regarding Facebook use was distributed to current psychiatry residents through the American Psychiatric Association (APA) listserv. Of the 182 respondents, 95.7% had current Facebook profiles, and 9.7% had received friend requests from patients. In addition, 18.7% admitted to viewing patient profiles on Facebook. There is a substantial utilization of Facebook among psychiatric residents as compared with prior studies. Specific guidance regarding social media websites and the potential for ethical difficulties should be offered to trainees.

Levels of trauma: a multidimensional approach to the treatment of PTSD

The historical course of professional interest in psychological trauma in the 20th century parallels the cycle of intrusion and denial characteristic of traumatized individuals, in which periods of recognition and concern alternate with times of forgetfulness and neglect (Glass et al. 1966; Ingraham et al. 1986). The inclusion of the diagnostic category of posttraumatic stress disorder (PTSD) in the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III-1980) inescapably confronted the mental health community with the problem of psychic trauma and catalyzed the quest for a deeper understanding of the disorder. This has led to a variety of explanatory models from such distant fields as neurobiology (Krystal et al. 1989; Pitman 1989; van der Kolk et al. 1985), psychophysiology (Kolb 1987), learning theory (Keane et al. 1985), psychoanalysis (Krystal 1978; Laufer 1988), cognitive psychology (Janoff Bulman 1985), and existential-humanistic philosophy (Lifton 1988).

The child victim as witness in sexual abuse proceedings.

The psychiatrist working with a child witness in a sexual abuse case is at an intrinsic disadvantage. Most of the activities take place in a legal system where the psychiatrist may feel like a stranger in a strange land. Further, a major area of concern to the courts is cognitive development and memory, which unlike phenomenology, dynamics, and therapeutics, are somewhat remote from the psychiatrists core expertise. It is not surprising, then, that the stress associated with the role of child advocate or expert witness often produces anxiety for the psychiatrist or may result in a frank avoidance of forensic tasks. This paper is intended to militate against such a reaction by familiarizing the psychiatrist with the salient issues of the sexually abused child as a witness.

Tarasoff defendants: social justice or ethical decay?

In 1976, the California Supreme Court ruled in Tarasoff v. Regents of the University of California that a duty to protect arises when a psychotherapists patient poses a serious danger of physical harm to an identifiable third party. Discharging this duty by the issuance of a warning breaches the confidentiality of the psychotherapist-patient relationship. However, the potential benefit to society offsets the possible harm caused by the breach of confidentiality. Until recently, such warnings have served little purpose outside of possibly preventing harm. However, the cumulative effect of three recent California Supreme Court cases has been to permit the use of these confidentiality breaches in criminal proceedings to fulfill prosecutorial goals. Nonetheless, the cost of achieving social justice may be at the expense of other important ethical values for both the psychotherapeutic professions and society in general.

Forensic and Ethical Issues

Publisher Summary This chapter reviews the forensic and ethical issues involving the aged, which encompass all of the ones that can be faced by any other adult. However, their frequency and complexity may be greater, reflecting age-dependent differences in the prevalence of important psychiatric and medical conditions that are the substrate for these legal and ethical concerns. Advancing age invariably results in a progressive loss of functional capacity of all biological systems. Old age is associated with an increasing likelihood of the specific degenerative changes within the central nervous system characteristic of dementia. Other body systems are also exposed to an accelerating risk of malfunction and disease, which can then directly or indirectly—through therapeutic intervention—give rise to organic mental syndromes. Functional psychiatric disorders develop anew in later life. The appearance of these mental and neuropsychiatric disturbances in the geriatric population plays a significant role in generating forensic and ethical concerns. The chapter presents an identification of the three critical themes that can clarify the legal and ethical analysis of the myriad problems found in a geriatric population at risk for mental, physical, and neuropsychiatric illnesses. By identifying the underlying themes of competency, consent, or confidentiality, a variety of common dilemmas can be framed and analyzed to suggest a reasonable resolution. In that vein, serious attention to the forensic and ethical domains will enhance clinical efficacy and personal satisfaction in working with this age group.

Silence or death: the limits of confidentiality when a psychotherapist is threatened by the patient.

When considering clinician safety, the threatening and/or assaultive patient quickly comes to mind. The authors discuss the ethical and legal dilemmas in a different type of situation resting on the boundary of confidentiality. In this case, a patient convincingly admits, during a therapy session, to having committed a serious crime and subsequently threatens the psychotherapist in an effort to enforce the therapists silence about that crime.