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Survivors of domestic violence are being routinely let down by a system that misdiagnoses their trauma, leaving many women and children unsupported and stigmatised. By Jane Caro.

How Australia treats complex trauma

In her office at Wollongong’s South Coast Private Hospital, psychiatrist Dr Karen Williams sees many patients suffering acutely from exposure to traumatic experiences in their work. Soldiers, police officers, paramedics, emergency personnel and firefighters who require support for post-traumatic stress disorder receive varying degrees of subsidy to access treatment. Such is the demand that the hospital’s entire top floor is dedicated to those seeking treatment for the condition.

Williams tells the story of a police officer who suffered from PTSD after he was first on the scene to a mother’s brutal domestic murder. He was haunted by the screams of the victim’s child, who had witnessed the entire incident. The officer’s suffering was great, and Williams was happy he was able to get the treatment he needed. However, she notes, “The child and the child’s guardian were unlikely to receive the same care themselves.”

Williams specialises in treating PTSD. In her private rooms, she treats those trauma sufferers whose access to help is severely curtailed by their lack of adequate subsidy. For victims who experience trauma in their personal lives, rather than on the job, support is often limited to the bare minimum – a mental health plan that offsets the cost of 10 visits to a therapist, although not necessarily one trained in PTSD. People can apply as victims of crime for additional therapy, but the process is complex.

As Williams explains, this cohort of trauma victims is often women, and the way women and children experience trauma is often different from the way professionals – many of whom are men – are exposed to it. “After all, without wanting to minimise the extreme suffering of PTSD among our emergency services,” she says, “soldiers, the police and others whose job can expose them to trauma are at least given some training on how to deal with it and what to expect. Victims of crime, whether it is murder, assault, sexual abuse, child abuse or domestic violence, are almost always taken entirely by surprise.”

Williams says many sufferers of long-term abuse and trauma don’t receive a diagnosis of PTSD. Instead, they are given a diagnosis of borderline personality disorder, which raises its own set of difficulties. A diagnosis of BPD can carry with it stigma because the condition is still viewed by some as a flaw of personality, and as such the label can result in many negative consequences. It can make retaining custody of children much harder, for example, and getting a job, insurance or even physical health needs taken seriously very difficult.

Annabelle Daniel, chief executive of Women’s Community Shelters, has repeatedly seen the effect a diagnosis of BPD can have on a victim of abuse. “We need to recognise that the lived experience of trauma and abuse is not a personal failing but the very common experience of a vast number of women,” she says.

To illustrate the harm a BPD diagnosis can cause, Dr Williams allowed me to speak to one of her patients – a woman who was abused by her father as a child and subsequently diagnosed with BPD. As an adult, she was raped by a housemate and, although the police believed her story, she was warned her BPD diagnosis could make her case harder to pursue. She also, as many women do, blamed herself for freezing when the assault began. She recalls asking herself: “Why can’t I scream and fight back? What is wrong with me? But I was just too afraid.” In the end, she decided not to press charges.

Six weeks after the attack, Williams’ patient found she was pregnant as a result of the rape. Lacking support, afraid her BPD diagnosis would compromise her parenting and traumatised by the assault, she decided to place her child into state care. Now, many years later, the man who raped her has applied for custody of her son, who lives in foster care. Williams and her patient fear he has a strong chance of winning, due at least in part to the stigma of a BPD diagnosis.

Williams adds that this patient’s mental health diagnosis has also resulted in her physical health problems – she is a severe asthmatic – being routinely ignored by healthcare workers and dismissed as anxiety. Perhaps if this woman had been diagnosed with a condition that carries less stigma, she would not be repeatedly punished for the crime of experiencing trauma but would be helped and understood. At the very least, she would know that freezing is the single most common response to a sudden traumatic event, whether on the battlefield, at a crime scene or pinned beneath the weight of a rapist.

Concern about BPD first entered the literature in 1989, when Harvard professors Bessel van der Kolk and Judith Herman published the findings of their interviews with men and women who had received a diagnosis of BPD. Van der Kolk and Herman found 81 per cent of these interviewees had experienced sexual abuse as children, and suggested they were instead suffering from what the psychiatrists labelled “complex PTSD” as a result of years of abuse.

But decades on, psychiatric professionals, including Professor Jayashri Kulkarni, director of the Monash Alfred Psychiatry Research Centre, are still working to address the stigma faced by victims of abuse who are diagnosed with BPD. According to Kulkarni, her research reveals the BPD label often leads to individuals being characterised as “manipulative” and “attention-seeking” and blamed for their own suffering by health workers. “That’s why the BPD diagnosis is wrong, wrong, wrong,” she says.

Kulkarni says a diagnosis of complex PTSD clarifies that abuse survivors are suffering because awful things have happened to them, not because of an innate or inherited personality issue. As Dr Williams explains: “The criteria for a BPD diagnosis include rage, impulsiveness, mood swings, substance abuse, feelings of emptiness, suicidal thoughts and self-harming. All of these, coincidentally, are also recognised as symptoms of PTSD. A personality disorder also implies the condition is chronic. A post-traumatic disorder diagnosis allows for some hope.”

The push to replace the label of BPD with complex PTSD is not without its detractors within the psychiatric profession, but it is gaining traction. The latest edition of the International Classification of Diseases has included both borderline personality disorder and complex PTSD. Kulkarni has been invited to work on complex PTSD being included in clinical PTSD guidelines.

As I researched this story, I was struck by the parallels between complex PTSD and the attitudes held towards sufferers of shell shock during World War I. Then, the collision of modern technology and old-fashioned battle tactics created a new level of trauma for soldiers in the trenches, never seen before or since. Those shattered men were at first considered by many – particularly their superior officers – to be morally weak, cowardly or malingerers. The punishment for desertion was often death by firing squad, a fatal consequence for what would now be understood as PTSD. Rather than being the fault of the sufferer or indicative of any weakness of character, this condition has been shown by modern psychiatry to be the result of exposure to horrendous and traumatic experiences that can leave a destructive mark on anyone.

Women’s health issues – including physical pain – have been minimised and dismissed since time immemorial. As Kulkarni told me, “Both Karen [Williams] and I have been called ‘hysterical’ even when we have presented the data.” No doubt approaches to treating those who experience trauma at work have become more enlightened and compassionate. In many ways, though, we remain a hundred years out of date in the way we treat trauma when it is experienced by women and children, especially in their private lives. We may no longer call sufferers of chronic and hidden trauma cowards, malingerers or morally weak, but still they are stigmatised too often when trying to seek help.

National Sexual Assault, Domestic and Family Violence Counselling Line 1800 737 732; Lifeline 13 11 14

This article was first published in the print edition of The Saturday Paper on Oct 19, 2019 as "Complex stress factors". Subscribe here.

Jane Caro
is a Sydney-based novelist, writer and documentary maker.