Judicial System Inaccessibility for Those with Psychiatric Injury Legal Abuse Syndrome as a Psychiatric Injury and Diagnosable Subcategory of Post Traumatic Stress Disorder
Karin Huffer, M.S., M.F.T. and Barbara Parrett, M.S., R.N., C.N.S.
New distance treatment options are being created to improve accessibility to the courts for those with psychiatric injuries. The literature on Post Traumatic Stress Disorder (PTSD) over the past decade has expanded the concept of PTSD to include symptoms reported from extensive studies on bullying in the workplace done in the UK and Australia, ongoing research into Legal Abuse Syndrome, and the various conditions treated by the Department of Veterans’ Affairs. Current thinking is converging on the expanded concept of Complex PTSD. Complex PTSD refers to symptoms of PTSD that, untreated, may last a lifetime resulting from prolonged, negative stress profoundly affecting the quality of a person’s life. Van der Kolk’s research clearly demonstrates that no one greets a traumatic event in a vacuum. Early childhood trauma causes vulnerability toward succumbing to critical events by developing PTSD. It is important to note that all people experiencing the same event do not become equally symptomatic. This means any life altering, negative, prolonged stress can and does create hormonal, emotional, mental, and physical symptoms. This includes stress from litigation. (Van der Kolk, 2004 Kinchin, 2001 Huffer, 1995 Baker, 2005)
Complex PTSD and physical threats from disasters, wartime or bullying are clearly understood. However, there remains a population of Americans who are unable to effectively use their judicial systems to attain reasonable protection when threatened by disputes or conflicts. This population consistently reports symptoms of PTSD from being bullied and traumatized in an invisible way during divorce and custody litigation, contractual conflicts, disputes that can become irrational, even terrorizing due to various frauds and assaults on character common in court proceedings.
A reporter for The Oklahoman newspaper, March 28, 2005 characterized this rampant but invisible force in the following as her column. It is representative of the increasingly popular attitude toward our American court system whether from comedians’ jokes, or more than one million websites asking for legal reform, or the positive peer reviews of Karin Huffer, M.S., M.F.T.’s research and thesis that inadvertently the justice and legal enforcement systems can and often do cause Post Traumatic Stress Disorder termed Legal Abuse Syndrome and may cause the Judicial system, supported by taxpayers, to be inaccessible to the average person and progressively less accessible as PTSD manifests with all the symptoms of psychiatric injury:
A prosecutor once told me, "If it's funny, it's not a crime." I had plenty of time to ponder that notion a few years ago during a seemingly endless string of trial delays. I said to myself: "Self, if you do not laugh ... then you are a victim." Victims hope justice will prevail. Survivors know better. So, I decided to become a survivor. In my spare time sitting around the courthouse, I did a lot of deep thinking -- about how life sometimes doesn't turn out the way we plan -- and how mine was starting to resemble a really bad episode of ‘Roseanne.’ Also, I had time to write a best-selling, self-help book: "Stalking for Dummies."
OK ... I admit ... it wasn't a best-seller. But it made me laugh..., which technically, is not a crime .I, observed that victims are like "eggs" in the pancake batter of our legal system. Blending with other ingredients (i.e. judges, lawyers & perpetrators), the mixture becomes hopelessly convoluted, overpaid and undercooked when poured upon the luke-warm griddle of American jurisprudence. Bad breakfast analogies aside -- let's face it -- there are some things in this life over which we have no control. Justice is one of those things. The outcome of any court case isn't necessarily based upon its merits, truth, the egregious nature of a situation and/or the suffering of its victims, many of whom become unwitting actors in a grotesquely litigious theater of the absurd.
In courtrooms across America, the faint but persistent cry for justice is barely audible over a cacophony of legal egos -- and, in Oklahoma, at least one electronic sexual device. Still, our capacity to render justice remains predicated upon judicial power and restraint, or the lack thereof (refer to previous paragraph). A failed system is no comfort to a grieving, single dad whose little girl was snatched from her bed and brutally slain by a convicted sex offender. It offers no apologies to the innocent man who spent 20 years in prison for a crime he didn't commit.
Nothing can fix the betrayal felt by a terminally ill boy allegedly molested at the ands of his ‘hero’ -- a narcissistic, hypochondriac pop star. The search for truth has eluded heart-broken parents who waged a futile court battle on behalf of their brain-damaged daughter. Instead, ‘justice’ sentenced them to endure the sight of her slowly starving to death. Sadly, we live in a country where common sense no longer applies ... where respect and compassion have surrendered to self-reason and faulty human logic. Judges, appellate courts and politicians would rather be RIGHT, than do the right thing. Our failure offers no consolation to those faithful, abiding souls who dutifully walked America's halls of justice, only to discover there was none. By Sally Allen Anti-News Editor NewsOK.com
Sally Allen writes of current events in 2005 with a sarcastic twist. Huffer witnesses, daily, American citizens who are living under the oppression of terror and whose cries for help and justice are left unheard. Our systems too often fail to serve those suffering PTSD as the following few examples portray:
Case A, involves a woman who married a man with fraud as the woman’s intent. She romanced the man, married him, and learned how to manipulate the law enforcement “hot buttons” of spousal abuse. She created scenes and falsely reported abuse causing the man to be arrested. While he was in jail, she emptied his house and bank accounts and left town. He lost his business, he is still fighting to regain his reputation. He has unfairly spent time in jail leaving him with open emotional wounds and PTSD.
Case B, involves a woman who witnessed her husband-to-be abusing his children. She ordered him to stop and reported him to the authorities. He threatened her, abused her, and reported her for being “crazy” and violent. She was arrested. While in jail, she was denied her medication, her pets died from neglect, she was told to leave the area and not come back or face re-arrest. He now sits in the house and property she bought with her funds, has not paid the mortgage and progressively damages her credit. She is still fighting for a chance to have her case heard in a fair court.
Case C, involves a woman who lost custody of her children in a divorce proceeding. She wants to reopen the matter. She pays child support when she can; however, every time she gets work, her ex-husband and/or his overzealous attorney contact the employer and inform them that they may be drawn into litigation if they employ her. Then when she is unable to pay her child support, she is arrested. She can’t see her children, work, prepare to go to court or even eat or sleep due to the terror of having been arrested and jailed for what she could not control. The woman has never committed a crime.
Psychiatric injuries result from a person feeling in severe jeopardy while being held helpless as to self-protection. The person suffering from Legal Abuse Syndrome will present with or develop any combination of the following psychobiological abnormalities. Think about it, PTSD/LAS is a psychobiosociolegal problem. Human physiology keeps the score and explains the basis for traumatic reaction that follows a severe usually invisible impact event in the Court. The event is usually traced to the moment adjudication favors the side committing fraud on the court through misinformation be used as strategy. There is no rational defense against a lie leaving the one defrauded helpless in the face of jeopardy; the formula for PTSD.
Hypervigilance, unable to relax or have peace due to intrusive thoughts/emotions
Stress Hormones reduced and down-regulation of receptors – numb/exhausted
Decreased activity inviting depression
Medication helpful but LAS sufferers often resist medication. They feel a compulsion to affect societal correction and live with a sense of unfinished business.
Increased opioid response to trauma related stimuli
Decreased hippocampal volume
Decreased immune system inviting physical illness
Weight gain or loss
Diminished immune system – succumb to any propensity for illness
Insomnia (Van der Kolk, 96)
Recent studies have shown that victims of childhood abuse as well as combat veterans actually experience physical changes to the hippocampus, a part of the brain involved in learning and memory, as well as in the handling of stress. The hippocampus also works closely with the medial prefrontal cortex, an area of the brain that regulates our emotional response to fear and stress. PTSD sufferers often have impairments in one or both of these brain regions. (Bremner, 1998) These disenfranchised people challenge the standards and procedures of the court due to their inability to withstand the rigors and requirements of putting an effective legal case together. Additionally, the sheer expense of retaining an attorney and sustaining a court case is estimated to be an average of $75,000. Litigant annual income average is $50,000, Huffer/Alexander, (2007).
The Court and PTSD/LAS
Hovering over the halls of justice has been a cloud of confusion about traumatic stress and its place in legal processes. Post Traumatic Stress Disorder, PTSD is one of the invisible afflictions that substantially affect the person’s ability to function effectively, especially being able to bear up to the emotional and verbal demands of a legal process. There exists a broad spectrum of attitudes toward traumatic stress whether it is believed that one uses PTSD to sue for damages simply for profit or whether it is observed that a litigant is slowly withering from the unrelenting stress and expense of the process. About 80 per cent of litigants will wither as their immune systems fail and severe physical symptoms take their toll.
A study of 4,000 participants conducted by Henry Miller and published in the British Medical Journal in 1961 concluded that there were frequent clinical findings of hysterical or anxiety-depressive symptoms he even coined the term “martyred gloom.” This led to an attitude that litigants will create a “compensation neurosis” as explored by Nay, (1975), when he claimed that, The patient gradually becomes involved in a stubborn, unyielding struggle against those he blames. Noy goes on to say that the illness is not healed due to unwillingness to give up the process of injury and compensation. Others will accuse the PTSD sufferer of malingering in order to misuse the court process for profit. (MPDLR, 1998, Noy, 1975.) The forensic pendulum swung against accepting PTSD believing that if that door opened to consider PTSD in the judicial system, frivolous cases would overwhelm the court.
Then in 1990, Americans with Disabilities Act, Title II, clearly covers PTSD as a condition requiring appropriate accommodations when needed. In 1995, the U.S. Judicial Conference adopted a policy on court access for individuals with communications disabilities reported in the MPDLR 26:5, September/October 2002. It is clearly the intent of this law that all persons have equal access to the courts. PTSD is one of the disorders that create amnesia, hypervigilance, intrusive thoughts, hormone changes and somatic symptoms all interfering with the kind of language delivery under stress that the court demands. The Veterans Administration recognized PTSD validating the symptoms. The climate is now changing to one of greater sensitivity toward those suffering after being traumatized. Malingering can be ruled out by a thorough structured interview and case history. Huffer, (1995)
What is Post Traumatic Stress Disorder/Legal Abuse Syndrome?
Huffer, (1995) used the DSM III, the official Diagnostic and Statistical Manual accepted and used by doctors and mental health professionals, to diagnose a mental condition. At that time, a criterion of Post Traumatic Stress Disorder leaned on the sufferer having faced a single major life-threatening event. Diagnosis did not formally allow for PTSD to result from "normal" events such as bereavement, business failure, interpersonal conflict, bullying, harassment, stalking, marital disharmony, or exposure to traumatic events. While most research and observation was done on veterans of war, and victims of physically traumatic stress, Huffer saw increased symptoms in patients who were involved in protracted litigation.
A. The person experiences a traumatic event in which both of the following were present:
1. the person experienced or witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others;
B. The traumatic event is persistently re-experienced in any of the following ways:
1. recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions;
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) as indicated by at least three of:
1. efforts to avoid thoughts, feelings or conversations associated with the trauma;
D. Persistent symptoms of increased arousal (not present before the trauma) as indicated by at least two of the following:
1. difficulty falling or staying asleep;
E. The symptoms on Criteria B, C and D last for more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. (APA,1994)
The words crazy, breakdown, mentally ill are often used to describe the symptoms of mental collapse of someone who has been under intolerable strain. The court routinely appoints a mental health professional to assess the targeted person. If the targeted person is without funds, the perpetrator and the court may hire their own “expert” to render an opinion as to mental stability of the targeted person. The court often misses the fact that PTSD is in the picture and that the demands of the entire matter leading to the legal process as well as the process itself can be creating a secondary, complex PTSD called Legal Abuse Syndrome. Further the conditions for an assessment to be effective are difficult to achieve in an adversarial environment. There has to be a degree of psychological safety in order to perform a valid assessment. Psychological assessments routinely ordered by the court are designed to measure mental illness. Complex PTSD is a psychiatric injury not a mental illness. Therefore the assessment of this condition expands the usual assessment parameters.
A stress collapse from a psychiatric injury is a normal reaction to an abnormal situation. Nothing is more abnormal than being assaulted, as in the above cases compounded by turning to the protective systems for help and finding oneself not only initially assaulted but now assaulted by adversarial opponents and sometimes zealous attorneys who wind up viciously intruding in every crevice of one’s life. The image of the targeted person is changed in the community through character assassination, libel, and slander destroying the person’s efforts to rebuild. These victims find themselves being accused of wild and invalid wrongdoings. Having to face the source of the trauma over and over for years in litigation intensifies cumulative PTSD. There is no rest, no closure, and no “R&R” for these people. This condition is preventable and not to be confused with mental illness. There are mental illnesses that cause what is known as a “breakdown” wherein the individual loses contact with reality; however, the LAS type of collapse is not a nervous breakdown or collapse indicating mental illness. The victim is in stark reality, unable to believe that such unconscionable pain can be thrust upon him with no helpful intervention from the court system his tax dollars support to protect him (Huffer, 1995) (Kinchin,2001).
Baker and Alonso describe what Veterans Affairs considers the critical components of a PTSD diagnosis.
What are the best ways to diagnose PTSD in light of the current trend? The diagnostic validity of PTSD is a critical factor since the Americans With Disabilities Act provides for accommodations in the courts. Also, PTSD greatly impacts directly upon the content of the case and the strategies that will be used. It is important that the professional doing the assessment be knowledgeable regarding complex and cumulative PTSD.
First, there is what is considered a “gatekeeper” criterion. This means that the person must have been exposed to a traumatic event. The person must have experienced items one and two of the DSMIV criteria listed above. To summarize, the event(s) experienced or witnessed must present actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. The response must involve intense fear, helplessness and horror. The description conjures thoughts of earthquakes, auto accidents, 9/11, and other such horrors. However, also qualifying are situations where the person is taken captive and loses control over the environment. Sensitive people in these situations are threatened as to their physical integrity. Examples of these are sexual assaults, kidnapping, or any traumatic stressor that removes the individual’s ability to protect the self. The cases above illustrate how a person can be traumatized as to threat to physical integrity and feeling intense fear, helplessness and horror. (Huffer, 1995) (Baker & Alonso, 2005)
Equal to any terror from natural disasters, wartime or accidents are those kinds of quiet and invisible kinds of terrorism to be found in cases A, B, and C wherein the targeted person develops PTSD/LAS. A woman on the run from an abusive husband, who stalks her, and uses the court as a weapon, is every bit as terrorized as any victim of the worst imaginable natural disaster. Whenever the stressor involves intimate violence, emotional abuse, stalking, and fraud the stressor threatens over a long period of time. Our police and judicial systems are impotent protectors in the case of non violent types of terrorism. Power structures are even used as a weapon against such victims leaving the person with no one to call for protection and in these cases. The Boston Phoenix in January 2003 wrote a ten thousand- word, front-page feature story profiling the severe malfunction of the family court. Cases were cited wherein protective parents reporting abuse have been punished by being denied custody, even denied visitation and in extreme cases mothers are serving months in jail for simply protecting their children Neustein & Lesher,( 2005.)
Some of the litigants who experience a collapse from the stress of legal proceedings, will be treated as if they have had a mental breakdown; they are sent to a psychiatrist, prescribed drugs used to treat mental illness, and may be encouraged - sometimes coerced into becoming patients in a psychiatric hospital. The sudden transition from a being a professional in a working environment to being confined in a mental ward containing schizophrenics, drug addicts and other people with genuine long-term mental health problems adds to rather than alleviates the trauma. Worse, the person is forever, stigmatized and invalidated. The perpetrator will often see to it that the news is broadcast and the damages become permanent. These legal abuses demonstrate the line between psychiatric injury versus mental illness. The line between judge and psychologist improperly overlaps with abusive lawyers, evaluators and judges practicing psychology or medicine without a license from the bench or the bar.
How is injury vs. illness determined? A critical feature of mental illness is that the sufferer is unaware of the reality of the situation. In a psychiatric injury caused by prolonged, severe stress, (1) the sufferer is fully aware of not only the symptoms and circumstances but; (2), moreover, the sufferer actively cares and tries to right the wrongs for self and society. This is not related to psychosis of any kind. To put it simply, Legal Abuse Syndrome is the result of an abuse of power differential. The legal system represents the power to take a life, incarcerate a person, remove a person’s children, family or property. A court being twisted and used as a weapon can force compliance with outrageous orders in cases where lives are put on the line, children are returned to abusers, or misinformation is allowed to distort the picture rendering the judge unable to know the truth or being able to produce an informed and wise decision. The literature supports that conditions that cause Legal Abuse Syndrome come from often inadvertent but officially sanctioned bullying. When the trauma inflicted by another person, is especially intense, or the traumatized person is extremely close to the trauma, the severity of traumatization may be especially profound. Scaer,( 2001)
Etiology of PTSD/LAS
The focus of PTSD has been a single life-threatening event or threat to integrity. However, as we have shown, the symptoms of traumatic stress also arise from an accumulation of small incidents rather than one major incident according to (Scaer, & Kinchin, 2001.) Examples of stressors impacting Legal Abuse Syndrome include:
- Prolonged and stressful exposure to horrific memories as required by the court throughout years of litigation, production of evidence complicated by an adversarial setting;
- Court forces involvement for years with a perpetrator or the source of pain and conflict that brought one to court in the first place seeking to end contact with the perpetrator or find a resolution;
- Years spent waiting for news from the Trier of Fact or Judge as to outcome of critical events - anticipation as well as the delivery of bad news;
- Repeated violations to one’s psyche, the law, or personal boundaries such as in verbal abuse, emotional abuse, mischaracterization, invasive discovery as is rampant in our adversarial court system;
- Legal system allows intrusion and permits violation of the rules set up to ensure fairness. Violations of restraining orders, judges warnings, common decency, ambushes designed to strip one of the ability to fight back are routine;
- Being forced into economic disaster, inability to earn a living by interference with the means and energy required in gaining and sustaining employment.
Impairment in social, occupational or other important areas of functioning is a key factor in the final determination of a diagnosis of PTSD.
- Held hostage/abuser uses emotional captivity,
- Official Power used to hold hostage to the case with no means of escape,
- Repeated violation of personal boundaries,
- Betrayal of trust,
- Isolation, family, friends, resources weary of long legal battles
- Stunned, disillusioned – the rules don’t apply as anticipated,
- Hope turns to helplessness
- Loss of control over every facet of life
- Forced compliance with outrage leaves one beyond rage
- Mounting debt
- Grief over cumulative losses, listed in Huffer, 1995, p63: property, opportunity, relationships, money, material possessions, credit, social standing, pride, patriotism, the American Dream, family, home, pets, time, friends, reputation, businesses, borrowing power, networking power, health, earned lifestyle, trust/faith, lawsuits, hope, faith in any protective agency, faith in public servants, faith in professionals (attorneys), life’s time to build for the future.
- Health consequences
Huffer describes it as taking the person hostage. Abuse always emanates from power differential. It is the overwhelming nature of the events and the inability of the person to deal with those events that leads to the development of Complex PTSD. Situations which might give rise to PTSD/LAS include bullying, harassment, abuse, by attorneys, judges, police officers usually motivated by misinformation designed to slander and damage the target individual.
In cases of domestic violence the perpetrator has claimed the power, often taken the assets and holds the family hostage. When both sides present their cases to the court, very often the perpetrator has controlled the finances and can posture with power using counsel and misinformation in the court. The victim runs out of money, must act pro se, and is in a state of trauma lessening the victim’s chance of being effective in the court. Stalkers love the court system. They play with protective orders and taunt the victim frustrating police and finally causing the victim to look like they call law enforcement with invalid complaints. If stalkers are told to stay 500 feet away from the victim, they will park 505 feet from the victim. They will enter the victim’s premises and leave private proof of their invasion. Yet, when the victim calls for help, there is no visible proof. The victim remains bullied and terrorized. Huffer, (1995 )
The very fact of going to court creates expense that amounts to more than the annual income of most litigants. Studies show that the average cost of litigation with 200 persons sampled was $78,000. And seventy per cent of those were unable to complete their cases due to losing their attorneys for lack of funds.
A key feature of Complex PTSD/LAS is the aspect of captivity. The individual experiencing trauma by degree is unable to escape the situation. False arrest or threat of arrest for the law abiding and sensitive person either captures or threatens to capture the person. Litigants being jailed due to misinformation or court-created circumstances is a distinct, preventable, cause of PTSD/LAS. An example of court-created LAS is found as follows: the demands of court involvement; overzealous counsel; use of character assassination; slander in the community; damage to the adversary causing the person to be unable to get references; to interview competitively; and be reliable on a job without interference from the adversary or court calendar contributes to problems that can affect payment of child support. Jailing the victim suffering from these kinds of harassments and assaults is an etiology of PTSD/LAS.
Assessment of PTSD
The Department of Veterans Affairs National Center for PTSD puts forth the follow criteria for assessing PTSD. The evaluator may not need or take a long period of time to assess PTSD depending upon the evaluator’s experience. The first criteria are to determine the traumatic event(s) and to assess the effects it has had on the person’s life. For forensic purposes, it is desirable to have a more complete assessment if it can be financially afforded. Structured interview is generally at the basis of a PTSD assessment.
What are some of the common instruments used to assess PTSD?
In addition to structured interview, self-report questionnaires are the next most used instruments in determining PTSD according to Veterans Affairs. Widely used self-report measures are the Impact of Event Scale-Revised (IES-R), the Keane PTSD Scale of the MMPI-2, which is the selection of Karin Huffer, M.S., M.F.T., Huffer, (1995.) This is the instrument of choice due to the number of cases involved in ongoing research providing greater validity and reliability of this instrument and maintaining a consistent pattern for statistical analysis.
Other self-report instruments recommended by The Department of Veterans Affairs are: The Mississippi Scale for Combat Related PTSD and the Mississippi Scale for Civilians; the Posttraumatic Diagnostic Scale (PDS); the Penn Inventory for Posttraumatic Stress; and the Los Angeles Symptom Checklist (LASC) Department of Veterans Affairs, Nat’l Ctr for PTSD, (2005).
The Clinician Administered PTSD Scale (CAPS) was developed by National Center for PTSD staff and is among the most widely used types of interviews. It has a format that requests information about the frequency and intensity of the core PTSD symptoms and of some common associated symptoms, which may have important implications for treatment and recovery. Another widely used interview is the Structured Clinical Interview for DSM (SCID). The SCID can be used to assess a range of psychiatric disorders including PTSD. Other interview instruments include the Anxiety Disorders Interview Schedule-Revised (ADIS), the PTSD-Interview, the Structured Interview for PTSD (SI-PTSD), and the PTSD Symptom Scale Interview (PSS-I). Each has unique features that might make it a good choice for a particular evaluation Department of Veterans Affairs, Nat’l Ctr for PTSD,(2005).
Huffer uses a debriefing method developed by the Department of Justice for use by the FBI combined with aspects from Bard and Sangrey, Selye and Zegan’s Handbook of Stress, Theoretical and Clinical Aspects. Also used is a copyrighted graphic sheet that assists in therapy, self-help, and communication with attorneys as to actual losses and pain and suffering (Bard and Sangrey,),(1986, Zegan,1982), (Selye,1956), (Huffer, 1995.) This method is due to longitudinal research being conducted by Huffer, therefore, the consistency and longevity of these instruments lends to scientific value and reliability and validity.
Overcoming Distance and Financial Barriers Faced by PTSD/LAS Sufferers
Usual psychological assessments are accomplished by meeting with the client face-to-face and performing, structured interview, self-reporting checklists and any other assessments that create and ideal review. Then cues can be perceived from the client, rapport built, and a professional relationship established in a setting designed for the purpose. In the matters of cases like those listed above, an attitude of flexibility may have to adjust the usual and preferred patterns of assessment, diagnosis and therapy. LAS and the traumatic stress that emanates from the experiences of the LAS victim usually render the client economically devastated and unable to travel or pay for psychological services. Congress responded to this need and the requirements of the ADA by passing the Balanced Budget Act (BBA), of 1997. This opened the area of internet counseling and assessment as well as telephone contact, text contact, and the breadth of new technology was introduced into the delivery of mental health services.
Third party insurance payment was given a boost by the federal government when TeleHealth and TeleMedicine was accepted as part of the Balanced Budget Act (BBA) that was introduced to congress on March 3, 1997 Balanced Budget Act, (1997). According to the Federal Register (1998):
In section 4206 of the Balanced Budget Act of 1997, the Congress required that, not later than January 1, 1999, Medicare Part B pay for professional consultations by a physician via interactive telecommunications systems. Under section 4206(a) of BBA payment may be made under Medicare Part B, provided the teleconsultation service is furnished to a beneficiary who resides in a county in a rural area designated as a Health Profession Shortage Area (5E). Federal Register, (1998).
The fee structure for TeleMedicine was broken down into 75% of the set fee would go to the professional doing the consultation and the other 25% would be for the referring practitioner Federal Register, (1998). The Clinical Social Worker and the Clinical Psychologist would be eligible to collect the fee as the referring practitioner. For example, a Clinical Social Worker in a Health Profession Shortage Area has a client who needs psychiatric services. The Social Worker could make a referral to a Psychiatrist who has this technology and assist the client with accessing help. Psychiatry is a covered service under Medicare Part B so both parties would be reimbursed Health Care Financing Administration, (1999).
Technology can greatly assist in reaching people who are unable to access legal and mental health services in the customary ways. Legislation as referenced above is a giant step in causing private insurers to develop proper policies and add telehealth services to their covered benefits. Fourteen states have already expanded their Medicaid programs to include telehealth Services.
TeleMedicine, TeleHealth and technology in general has the potential for increasing access to quality health care, including mental health for all. Very simply the telephone by itself is proving to be a much overlooked and invaluable tool in assisting those who may otherwise not be able to receive the full range of mental health services or to make services more effective. The Journal of the American Medical Association published the first major look at treating depression with psychotherapy over the phone in August of 2004. Gregory Simon, the psychiatrist who led the research on 600 patients at Group Health Cooperative in Seattle reports 80 percent of patients who received phone therapy along with antidepressants said their depression was "much improved" six months later, compared with 55 percent of those who received the pills alone. The future of including telehealth techonologies is promising when considering people who have suffered from severe negative stress and have withdrawn from vital interactions as a result. TeleMedicine has the potential to improve the delivery of health care in the United States by bringing a vast array of services such as mental health services to under served communities TeleMedicine Report to Congress, (1997).
These changes have given birth to new standards being set for use of technology in therapy. The International Society for Mental Health Online is an organization that is setting standards to mental health services delivered in the new telehealth context. The results of their case research suggest that online mental health services while being traditional in many ways will evolve into new and innovative forms that are very different than the familiar face-to-face approaches. Communicating electronically from one individual to another--or to a group of individuals simultaneously, relying on the Internet, computer monitors, and written language skills rather than on one's eyes and ears and oral language shift the rapport normally established in the clinician’s office to a time-altered, less spontaneous method of interaction.
There are clear disadvantages ranging from clinician observation to treatment, which in cases of traumatic stress may include techniques such as EMDR, which cannot be done unless one is face to face. On the other hand advantages seem to free up the client allowing clients to relate without certain restraints emanating from shame-based feelings. The biggest advantage is economical and geographic. Clients who have limited funds, conditions that keep them housebound or restricted, or who are in delicate legal situations that prevent them from utilizing local mental health services are provided enhanced accessibility to legal and mental health services by these non traditional methods. The client also can communicate with therapist at any time rather than wait for an appointed time.
Special Accessibility Issues for PTSD/LAS Clients
Why isn’t more action taken to pursue actions to prevent psychiatric injury caused or exacerbated by the legal system or to compensate the injured for the damages? Why hasn’t it been identified and dealt with as a public health crisis? The following common symptoms of PTSD/LAS illustrate the fact that the more a person qualifies to pursue a claim for personal injury for psychiatric injury by satisfying PTSD DSM-IV diagnostic criteria, the more they are emotionally unable to pursue a claim.
When basic trust is violated, there is an overwhelming sense of betrayal and inability to trust anyone. Trust is lost for professionals, for systems or even those who are close to you. Emotional, physical and mental exhaustion overwhelm any desire to take action immobilizing the litigant. Huffer dramatizes how shame consumes the responsible and conscience-centered person, while the wrongdoer does not know shame and can thrive in the litigation milieu leaving PTSD/LAS sufferers in his wake.
Fear of retaliation or consequences also play into LAS victims’ ability to do something about the situation. They have usually been ambushed and then official powers mobilized against them. LAS sufferers live in a state of terror while being held as emotional hostages. Hostages rarely take action against their captors.
Typically with LAS this hostage stage eventually gives away to responsibility. The victim wants to take action to fix the system, improve society, and prevent a similar fate befalling others to follow. LAS sufferers typically have great empathy and are prone to identifying with other people's suffering. A sensitive person being in a helpless posture causes profound erosion of self-esteem as the person does not want to be seen as disabled and fights to regain independence.
Obsession then drives the desire to educate and perfect the system. A few imbalanced victims will succumb to revenge acts. However, most LAS sufferers focus on responsible actions Regardless of positive intentions they are usually limited by the economic burden of legal action leaving LAS sufferers, in most cases, financially broke, emotionally and psychiatrically damaged and with no effective way to pursue or protect their right to pursue happiness as promised in this nation. There is emerging a growing population of walking wounded who have been cast out of dynamic life. They exist saving their legal papers in boxes and suitcases with faint hope that someday someone, some agency, some court will care and listen and help them to attain justice. They are sentenced to lives of varying combinations of the following symptoms impairing all normal functionality.
- Hyper vigilance (feels like but is not paranoia)
- Exaggerated startle response
- Sudden angry or violent outbursts
- Flashbacks, nightmares, intrusive recollections
- Sleep disturbance
- Exhaustion and chronic fatigue
- Reactive depression
- Avoidance along with numbness
- Unable to relax
- Cannot laugh or cry or feel passion
- Physical symptoms, lowered immune system
- Overwhelming sense of injustice strong desire to do something about it but blocked.
Complicating the above list of usual symptoms are the following when LAS exists.
- The prolonged (chronic) negative stress resulting from protracted litigation can lead to threat or loss of job, career, health, and livelihood, often also resulting in threat to marriage and family life. The families of litigants are the unseen victims of litigation.
- Symptoms of PTSD/LAS are mental, emotional, and physical exhaustion along with reactive depression, which can lead to isolation and even suicide. Anxiety also goes off the scale even leading to panic attacks.
- Excessive stress depresses the immune system.
- Intrusive thoughts and memories disrupting concentration and relaxation.
- Sleep disturbances, nightmares,
- Terror is common. When protective systems that taxpayers support and depend upon their world becomes an invisible hotbed of terror.
- Avoidance and numbness is concurrent. All reminders are avoided.
- The sufferer becomes frozen in time, unable to have fond memories, plan for the future, or enjoy the present.
- Obsession takes over as the LAS sufferer tries to regain control of their environment and may focus on reliving the hostage experience.
- Feelings of withdrawal and isolation are common; the person just wants to be left alone. Huffier describes it as having layers of cellophane wrapped around the person. You can see them, they might be present at an event physically but their emotional scar tissue keeps them isolated.The person loses personality dynamics. Numbness reigns. They are unable to laugh or cry and feel like love has left them.
- After losses of their life’s earnings and lifestyle, dreams of a future become too painful to experience. Careers are stunted, creativity is blocked, and society loses the contributions of the LAS sufferer.
- Nighttime is hellish. Sleep is disturbed, filled with nightmares and a sense of unbearable vulnerability leaves the LAS sufferer exhausted.
- Concentration is impaired to the point of precluding preparation for legal action, study, work, or search for work.
- The person is on constant alert because their fight or flight mechanism has become permanently activated.
The person has become hyper sensitized and now unwittingly and inappropriately perceives almost any remark as critical. For many, social life ceases and work becomes impossible; the overwhelming need to earn a living combined with the inability to work deepens the trauma. The literature in the 1990’s opened the entire concept of traumatic stress, recognizing that prolonged negative stress creates symptoms of Post Traumatic Stress Disorder. The incidence of PTSD is must greater than first recognized in the 1960’s. It is thought that 5% of males and 10% of females will develop PTSD in their lifetime says the National Institute for Clinical Excellence (NICE). Economy is impacted by loss of ability to work, plan a career, have hope, inspiration, trust, and the response to PTSD of “fight,” “flight,” or “freeze.”
Summary and Conclusions
With the prevalence of chronic complex trauma and the consistent reports of cases such as our Cases A, B, & C, it is shocking how little research has been done on this population whose quality of life is preventably devastated by the insensitive, toxic, and unrelenting demands of the forensic experience. PTSD over the decades has been a misunderstood and a slowly evolving concept as our society caught on that human beings do not experience battlefields, earthquakes, childhood abuse, and bullying or prolonged litigation with no predisposing factors in play. Whether an attorney in practice who believes in representing clients in the spirit of attaining justice against the established brotherhood of attorneys who intimidate and frustrate*; or a case of false arrest due to political power being able to distort our law enforcement and justice systems twisting them into weapons to be used against persons targeted as a result of doing no wrong but knowing the wrong people, each human being presents for mental health treatment or presents in the court for a resolution with a unique emotional history.
Rather than staying rigidly with the DSM IV which is merely a helpful guide to clinical practice open to dynamic change and dialogue, it would seem to be advisable to accept the concept of Complex PTSD and err on the side of human service and sensitivity if one must err. The mental health professions exist as an inexact science therefore leaning more on the good will, effort to empirically measure as much as possible, and then to abide by the Americans with Disabilities Act in our Courts to ensure accessibility to all. Once accepted as a psychiatric injury, PTSD/LAS can be treated and accommodated by the court allowing all those who use the courts of law to have a humane and manageable experience rather than the devastation of their lives. Attorneys also suffer compassion fatigue when they are helpless to affect the court toward promised justice.
“Clearly while the study of war neuroses, motor vehicle accidents, hurricanes and other non-interpersonal traumas has become respectable, investigating that darkest side of human nature: our capacity to horribly abuse and neglect our own offspring and intimates continues to rife with controversy.” Van der Kolk, (2001). Worse yet is the challenge of abuse of power differential between systems and the human beings they are intended to serve. Huffer is conducting continual longitudinal research that validates the experiences and symptoms above reported by attorneys and citizens who simply turned to their established systems for a right and reasonable solution to a critical problem. They found that instead of help, they wound up with Post Traumatic Stress Disorder of the Legal Abuse Syndrome subcategory plus a host of other impairments to daily functioning that can only be described as:
1. the person experienced or witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others;2. the person's response involved intense fear, helplessness, or horror. (DSMIV, 1994)
Or some just called it “Cruel and Unusual Punishment.”
*Statistics regarding the health consequences of being an attorney suggest that the milieu in and around the court system is toxic. According to the Journal of Occupational Medicine, attorneys in the United States suffer depression at a rate 3.6 times the national average. A 1991 Johns Hopkins University study of depression in 105 professions ranks attorneys first among all professions in the incidence and prevalence of clinical depression. According to other published studies, as many as 20 percent of all practicing attorneys experience clinical depression in any given year. Drinking problems correlated with length of practice: 18 percent of problem drinkers were found in those who had practiced two to 20 years, 25 percent in those who had practiced more than 20 years
Recommended Readings and Citations
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th end, revised (DSM IV-R) APA, Washington D.C., 1994.
Baker, Claudia, M.S.W., MPH & Alonso, Cessie, LCSW. Forensic Validity of a PTSD Diagnosis Department of Veterans Affairs National Center for PTSD.
Barak, A., & Buchanan, T. (2004). Internet-based psychological testing and assessment.In R. Kraus, J. Zack & G. Stricker (Eds.), Online counseling: A handbook for mental health professionals (pp. 217-239). San Diego, CA: Elsevier Academic Press.
Barak, A., & English, N. (2002). “Prospects and limitations of psychological testing on the Internet.” Journal of Technology in Human Services, 19 (2/3), 65-89.
Bard, Morton, and Dawn Sangrey. The Crime Victims Book. New York: Brunner/Mazel, Inc., 1986.
Bremner JD, Narayan M (1998): “The effects of stress on memory and the hippocampus throughout the life cycle: Implications for childhood development and aging.” Develop Psychopath 10:871-886.
Brown, James T. “Avoiding Litigation Neurosis: A Practitioner’s Guide to Defending Post Traumatic Stress Disorder Claims.” The American Journal of Trial Advocacy. Vol. 20, Number 1, Center for Advocacy and Clinical Education, Cumberland School of Law, Samford University, Birmingham, AL, Fall 1996
Goleman, Daniel. “Key to Post Traumatic Stress Lies in Brain Chemistry, Scientist Finds.” New York Times, 12 June 1990.
Herman, Judith L. Trauma and Recovery. New York: Basic Books, 1997.
Huffer, Karin, M.S,, M.F.T. Overcoming the Devastation of Legal Abuse Syndrome. Fulkort Press,
Las Vegas, NV, 1995 pp 20-26, 69-77.
Hurder, Alex J. “ABA Urges Equal Access to Courts for Individuals with Disabilities.” September/October, 2002 26:5 MPDLR.
The International Society for Mental Health Online
Johnston, Joni, Psy.D. “ShrinkRap Investigating PTSD in Psychological Injury Claims” LexisONE
A reporter for The Oklahoman Newspaper, March 28, 2005 By Sally Allen Anti-News Editor NewsOK.com
Neustein, Amy & Lesher, Michael. From Madness to Mutiny. The Northeastern University Press, Boston, MA: 2005Why zebras don't get ulcers: an updated guide to stress, stress-related diseases, and coping, Robert M Sapolsky, Freeman, 1998, ISBN 0-7167-3210-6
Scaer, , Robert C MD The Body Bears the Burden: Trauma, Dissociation and Disease, The Haworth Medical Press, NY, 2001.
Kinchin, David, Post Traumatic Stress Disorder: the invisible injury, 2001 edition, Success Unlimited, UK 2001,
The European Journal of Work and Organizational Psychology (EJWOP), 1996, 5(2), (whole issue devoted to bullying and its effects, including PTSD.) Published by Psychology Press, 27 Church Road, Hove, East Sussex BN3 2FA, UK.
O'Brien, Dr John T, MRCPsych, British Journal of Psychiatry, The 'glucocorticoid cascade' hypothesis in man: prolonged stress may cause permanent brain damage, Department of Psychiatry and Institute for the Health of the Elderly, University of Newcastle (1997), 170, 199-201.
Tuttle, David, Cortisol - Keeping a Dangerous Hormone in Check, LE Magazine July 2004
Keane, T.M., P.F. Malloy and J.A. Fairbank). “Empirical development of an MMPI subscale for the assessment of combat-related post-traumatic stress disorder.” Journal of Consulting and Clinical Psychology, 52, 888-891.
Nadel, L., & Jacobs, W.J. “The Role of the Hippocampus in PTSD, Panic, and Phobia.” In Nobumasa Kato, ed. Hippocampus: Functions and Clinical Relevance. Amsterdam: Elsevier, 1996.
Reese, James, James Horn, and Christine Dunning. Critical Incidents in Policing. Washington, D.C.: U.S. Department of Justice, 1991.
Pert, Candace, Phd. The Molecules of Emotion, New York:Scribner Books, 1999.
Selye, Hans. The Stress of Life. New York: McGraw-Hill, Inc., 1956.
Van der Kolk, Bessel, M.D. Yehuda, Rachel, Ed. The Assessment and Treatment of Complex PTSD Chapter 7, Traumatic Stress, American Psychiatric Press, 2001
van der Kolk, Bessel, “In the Eye of the Storm,” The Psychotherapy Networker, Jan/Feb 2004 pp45,66.
van der Kolk, Bessel A., Alexander C. McFarlane, and Lars Weisaeth, eds. Traumatic Stress. New York: Guildford, 1996.
Zegan, L.S. Handbook of Stress, Theoretical and Clinical Aspects. Ed. Goldberger and Breznitz, New York: Free Press, 1982.
http://www.legalabusesyndrome.org/ or http://www.legalabusesyndrome.com/
.(Health Care Financing Administration, 1999). http://www.cms.hhs.gov/medicaid/default.asp?
http://www.ismho.org/A nonprofit organization formed in 1997 to promote the understanding, use and development of online communication, information and technology for the international mental health community.
Internet Mental Health (http://www.mentalhealth.com/p.html) copyright © 1995-2005 by Phillip W. Long, M.D.
Essentials for litigating Post Traumatic Stress Disorder (PTSD) claims: http://www.lawandpsychiatry.com/html/Litigating%20PTSD%20Claims%20-%20Final.pdf
http://www.wellcome.ac.uk/en/genome/tacklingdisease/hg12b004.html The National Institute for Clinical Excellence (NICE) makes national recommendations on best practice in medical treatment and care, with the aim of ensuring an equal and effective service across the NHS in England and Wales.
Gillian Kelly, barrister at law, looks at the development of Post Traumatic Stress Disorder and the legal recognition thereof on her web site at http://www.telecoms.net/law/index.html as a recognised psychiatric illness, the condition has been demonstrated, in the course of the past 140 years, to be as worthy of compensation at law as any physical injury inflicted through negligence.