Abstract
To the Editor
A 36-year-old man presented with a letter from his solicitor requesting a psychiatric assessment detailing the nature, extent and severity of ‘psychological injury’ in order to support a claim from criminal injuries compensation.
The patient had been physically assaulted by a man who demanded money from him. The man initially came up from behind the patient and hit him on the back of the head, and as the patient lay on the ground in a dazed state, the man kicked him, screaming and demanding money. The man took his money and ran away. The patient sustained a laceration to the face, conjunctival haematoma, broken nose and fracture of the left zygoma.
Previously, the patient had a long history of impulsivity, aggression, dysfunctional interpersonal relationships and polysubstance abuse. This was probably because of a childhood characterized by attachment difficulties as a result of his mother leaving the family home when he was born and his father, who was a naval officer, treating him and his five siblings in a strict, harsh and emotionally distant manner. As a young child, the patient demonstrated oppositional behaviour and conduct problems, particularly at school, where he learnt to deploy aggression as a means of dominating other students. There was no improvement after being compelled by his father to see a psychologist. Upon leaving school, he had significant problems holding down a job because of anger, and he estimates that he has worked between 20 and 30 jobs in his lifetime. Most jobs ended within a few weeks or a few months because of the patient’s inability to submit to the wishes of his superiors, curb his frustration and, at times, verbal aggression and bullying behaviour towards his colleagues. The patient had been married once, for several years during his twenties, but his wife left him due to his aggressive behaviour. He has no ongoing contact with her or the two children borne from the marriage. Similarly, he had little in the way of ongoing friendships or contact with his father or his siblings. He admits to using cannabis from the age of 12 onwards, as well as amphetamines, alcohol and heroin. He was admitted to psychiatric hospitals on two occasions after the break-up of his marriage. He was apparently discharged with a diagnosis of antisocial personality disorder and polysubstance abuse.
Following the assault, the patient was fearful, hypervigilant, socially withdrawn and unable to sleep for several weeks. These symptoms have largely resolved. Although he currently lives by himself with a pet and prefers his own company, he stated that: “I am happier than I was . . . I’m not getting into trouble anymore.” He has stopped drinking alcohol and only uses cannabis in small amounts at night. He works 30–40 hours per week as a cleaner and has kept this job for over 12 months. He has been in telephone contact with his children and is seeking ways to establish a stable relationship with them. Since the traumatic event, he has had no interpersonal or legal problems. Mental state examination was marked by a reflective, integrated affect which was congruent to the themes of conversation. He mused that he could speak without anger regarding the event and that he was a different person. He sought to impress the interviewer that whereas at one time he could have become so angry that he would have assaulted the interviewer if he did not get his way, he could be more restrained and dispassionate. He was advised that there was no diagnosable psychiatric condition or compensable ‘psychological injury’, which he accepted without protest, anger or other adverse reaction. His main focus was the future and rebuilding his relationship with his children.
Psychological distress is very common in the early aftermath of traumatic exposure and can be considered a part of the normal response. A minority of people experience persistent symptoms, which may be diagnosed as posttraumatic stress disorder, and the lifetime prevalence rate of this condition for victims of crime is estimated to be about 25–28% (Australian Centre for Posttraumatic Mental Health, 2007). The study of pathological reactions to trauma remains the mainstay of work in psychiatry and related disciplines such as clinical psychology and counselling. However, this case re-emphasizes some unexpected outcomes that can be observed in victims of trauma, including the concept of posttraumatic growth, which refers to positive psychological change experienced as a result of trauma (Tedeschi and Calhoun, 2004). Trauma represents significant challenges to the adaptive resources of the individual, their ways of understanding the world and their place in it.
The concept of mentalization or reflective function allows a person to understand the behaviour of themselves or others in mental state terms. Authoritarian parenting can be associated with maltreatment and can retard the development of mentalizing capacity. Infants who experience caregivers as frightening, angry and hateful often introject these feelings and seek to control others through coercive, externalizing and punitive acts. Problems of violence and aggression can be understood as dismissive and preoccupied forms of non- mentalizing self-organizations. Others are forced to behave as if they were part of the individual’s internal representation, prototypically known as projective identification. Physical action centred strategies, particularly in threatening relationships, are defensive measures to try and integrate these unstable internal representations (Fonagy et al., 2000).
Language and narrative is a key indicator of mental states of self-organization and social understanding. Insecure individuals are noted to be poor at integrating memories and meanings of experiences and their narratives reflect disorganization and semantic or syntactic confusion. They highlight the difficulty in creating a distance between internal and external reality. As a result of the traumatic encounter, this man learnt to treat the world with more circumspection and respect. He had greater respect for self and for others and this has led to a change of behaviour with increased mentalizing capacity. This was particularly evident in his mental state, where he was restrained and reflective, accepting without anger or threats the outcome of the assessment that there was no compensable psychological injury. He was able to compare his current state with his former self, where he would have certainly acted out in order to have his needs met.
It is noteworthy that this man was not helped by the usual efforts of psychiatry to change his behaviour. Instead, it appears that the experience of trauma was instrumental in changing his behaviour and attitude, providing a striking contrast, given the failure of conventional psychiatric attempts to do the same. An increased appreciation for life in general, and many smaller aspects of it, along with a changed sense of what is important, is a common element of posttraumatic growth as described by other survivors of trauma (Frankl, 2006). Posttraumatic growth tends to surprise people, and has not usually been a conscious goal. This case emphasizes the need to consider alternative paradigms for sequelae arising out of trauma, including positive change.