Stockholm Syndrome - an overview (2023)

Stockholm Syndrome

The Stockholm syndrome refers to stress-induced alteration of the hostage's behavior such that the hostage aligns with the hostage taker. This phenomenon is thought to be an automatic, unconscious emotional response to the trauma of becoming a victim. It is not uncommon for hostages to transfer anger from the hostage takers to the society or situation that created the dilemma in which they are now victims. Individuals held in the grip of the Stockholm syndrome have been known to actively participate with the captor group in terrorist activities.

FUNCTIONAL IMPAIRMENT AS A CONSEQUENCE OF CHRONIC DOMESTIC TRAUMA

There has been much research and many publications on the impact of trauma associated with child sexual abuse and children living in a chronically traumatizing environment with domestic violence. In addition, many adults experience the consequences of the socially significant and chronically traumatizing life experience of domestic violence.

Case Scenario

A 39-year-old woman came to our clinic reporting headaches and bilateral knee pain. The patient was originally from Sri Lanka. She had no health insurance and was accompanied by another woman who seemed to be unrelated and of a different ethnic and socioeconomic status. The other woman insisted on remaining in the examination room with the patient and on responding to my questions, even though the patient was able to understand and speak English. The patient appeared submissive and had a flat affect and downcast eyes throughout the encounter. We suspected the patient was being exploited, perhaps as a result of human trafficking. What can physicians do if we suspect a patient is a victim of human trafficking?

Pitfalls

Training

The first of the three is problematic. According to Muuss and Rabern (2006), CEOs are often busy and do not assign a high priority to training. The CSO has to find a way to get past the reluctance. In this case, patience is a virtue; persuasion is a must. Horror stories and cajolery, while not always a good tactic, may help. In the context of orienting a new executive, Sennewald (1998) recommends asking the new CEO to compare the new company’s executive protection program over what he or she was accustomed to in the previous job. By pointing out the merits and virtues of the new program, the CSO may be able to overcome the new CEO’s reluctance to receive training.

Fortunately for the busy CEO (and all are), the key points of training are knowledge-based (i.e., the CEO can learn without actually getting up from a desk). The exceptions would be firearms and self-defense training. For many companies and many CEOs, the use of firearms is not seen as helpful, and for some CEOs, self-defense is not practical for reasons of age or inclination.

The CEO learns to closely control information that an adversary would need to be successful, avoid predictable behavior, and stay within the shell maintained by the protective party at public events. As to response, the CEO learns the early warning signals and how to recognize them, actions to take and not take, and most importantly, how to survive if taken hostage.

Training is a serious and difficult endeavor. It is serious because death or injury can result if the CEO makes an incorrect response. It is difficult when the CEO has little or no familiarity with violence, and without training stands little chance of surviving. Can such things be learned easily? The answer is no. Is this something that has to be learned? The answer is yes.

Additional descriptive terms associated with trauma bonding

The closest relational concepts to trauma bonding outcomes recognized in the literature is Stockholm Syndrome. Cantor and Price (2007), Jülich (2005), and Wallace (2007) recognized Stockholm Syndrome is a psychological phenomenon where hostages become devoted to their captors. The attachment association with other victims, such as DV and CSA illustrates the power imbalance in combination with intermittent kindness, which creates an emotional bond to the abuser (Adorjan, Christensen, Kelly, & Pawluch, 2012; Wallace, 2007). Although, one finds similarities between trauma bonding and Stockholm syndrome outcomes, there are a few key differences. In Stockholm Syndrome, a bi-directional reward and fear relationship created a bond between the victim and the abuser (Cantor & Price, 2007). Thus, the emotional bond has interchangeable characteristics and outcomes seen in victims of incest and DV (Adorjan et al., 2012; deYoung & Lowry, 1992; Wallace, 2007). Adorjan et al. (2012) explains that one demonstrated characteristic is reciprocal sentiment, where abusers seem to develop positive feelings for the victims they abuse, even making excuses for “teaching” or “demonstrating” love.

In trauma “coerced” bonding, a hybrid exists in trauma bonding where the bond is a direct outcome of the abuses and terror (Raghavan & Doychak, 2015).

Managed care as the great evil?

The angst engendered in many mental health providers at the mere mention of managed care is not hard to understand. Mental health treatment is inherently private and requires trust to be effective. In no other medical specialty is the doctor–patient relationship so tied to outcome. Managed care symbolizes an intrusive third party, a challenge to the provider's autonomy. Information may need to be shared with a reviewer, altering the notion of confidentiality and introducing concerns about how the information will be used. Additional hours must be spent on administrative tasks. The method of treatment may be dictated, with decisions about “medical necessity” and coverage resulting in altered treatment plans and possible discontinuation of care. Income is threatened or reduced. Instead of focusing solely on the needs of an individual patient and family, the provider is suddenly put in the position of being a double agent, asked to act on behalf of the patient and the health care system in which the patient is enrolled. Conflicts of interest, including those resulting from certain forms of financial payment and incentives based on performance, are inevitable.

Still, the vehemence with which some mental health providers describe the threat posed by managed care is noteworthy and shows no sign of abating. Some have even characterized the relationship between psychotherapist and managed care organization as “traumatic bonding,” a connection forced on providers by the need for economic survival that can result in transformation akin to that seen between hostage and captor in the “Stockholm syndrome” [3]. Reading about the alleged evils of managed care, one is hard-pressed to remember some of the evils of the fee-for-service system that preceded it, most notable among them the incentive to overtreat and the harm caused by unnecessary procedures that resulted. There also was little incentive to engage in prevention or health promotion activities.

From the point of view of an individual patient or provider, however, there is no question that the fee-for-service system was the golden age, or, as Reinhardt [4] aptly put it, “the fairy tale that health care is a free lunch.” There was free choice of providers, claims were paid without argument or negotiated discounts, and the amount and type of care were decided solely by the provider with the consent of the patient. Equally important is that employer costs for this uncontrolled system were largely invisible to consumers, because of the way that deductions appeared on paychecks and because there was little cost sharing at the time that health care was received [4]. In this context of seemingly limitless resources, it is no wonder that patients and providers alike responded poorly to the limit setting and reduction of choice that were imposed by managed care.

There are additional reasons why, amid all of the upheaval and concern about managed care among the medical community at large, it would be reasonable to assume that mental health care would be particularly impacted by it. These include factors affecting the behavior of managed-care plans (increased opportunities for cost shifting to state programs or family members and the availability of clinicians other than physicians to provide care); factors affecting patients (the stigma associated with mental illness and the characteristics of the illness itself making patients less likely or able to advocate for themselves); and factors affecting clinicians (the criteria used to review psychiatric care are less clear or predictable than in other specialties) [5]. Psychiatrists are more than twice as likely as primary care physicians or other medical specialists to report intensive prior authorization requirements and three times as likely to face frequent denials [5]. They report that their staff spent less time appealing review decisions than other physicians, but that seems to be because psychiatrists themselves are devoting more time to the appeals process; they also report being less successful than other physicians in resolving disputes [5].

In a survey of physicians' beliefs about the impact of managed care on their practices, psychiatrists seem to be more concerned than are other physicians about their ability to make clinical decisions in the best interest of their patients without the possibility of reducing their income [6]. They also are less likely to agree that it is possible to maintain continuing relationships with patients over time that promote the delivery of high-quality care. Their concerns about patient continuity and the impact of managed care on the patient–provider relationship might have to do with a shift in behavioral managed care toward nonphysicians providing psychotherapy and reliance on psychiatrists for medication management [6].

Are these subjective assessments of the impact of managed care on practice to be believed? Certainly they should be viewed with caution. One of the most frequent complaints about managed care is that it creates pressure on physicians to increase productivity, to see more patients in less time. Physicians report that office visits have gotten shorter and that it is increasingly difficult to spend adequate time with patients. Between 1989 and 1998, however, two large data sets showed that the average duration of visits for primary and specialty medical care actually increased for prepaid and nonprepaid visits [7]. It could be that physicians perceive that visits are shorter because their case mix is more complex and the visits feel rushed or because of the amount of time they are spending on administrative tasks, but the reality is that medical visits are not shorter [7].

In contrast, a separate study of trends in the composition and duration of visits to psychiatrists, using one of the data sets above, found that between 1985 and 1995, visits in office-based psychiatry became shorter, less often included psychotherapy, and more often included a medication prescription [8]. It is fair to say that psychiatry has been disproportionately affected by some of the changes wrought by managed care. This is principally due to the special nature of the treating relationship in psychiatry and its exquisite sensitivity to the effects of cost-containment methods used by managed care organizations, the limited reimbursement levels, and the lack of parity in coverage with medical benefits.

Physicians, as a group, have been concerned about reduced fees under managed care and their effect on income; however, physician incomes, with the exception of a dip in 1994, increased throughout the 1990s [9]. A study of psychiatrists' salaries, however, revealed lower, flatter salary patterns than those for physicians in all other specialties [10]. Although compensation to psychiatrists has increased in the past 5 years, on an annual basis, the increase has failed to keep pace with inflation [11]. Even if reimbursement levels for psychiatrists were on par with those for other specialties, psychiatrists would still be alone in having the added difficulty of trying to integrate care when patients' mental health benefits are carved out.