A high proportion of psychiatric patients have experienced sexual abuse or violence. Yet very few patients are even asked if this has occurred, let alone treated appropriately – as survivors tweeting using the new hashtag #AbusedByServices made clear this week.
A recent systematic review of 21 studies – four from the UK – showed that between 0 and 22 per cent of psychiatric patients are asked about experiences of abuse and violence. This is despite the fact that the Department of Health have required staff to ask about these experiences since 2003.
Survivors are unlikely to disclose spontaneously, so not asking maintains a culture of silence. This is important given the early experiences of psychiatric patients with serious mental health problems. Between 13 to 64 per cent have experienced childhood sexual abuse, and between 22 to 66 per cent childhood physical abuse.
Traumatic early experiences have clear, demonstrable, long-term effects on the psyche, body and soul. For example, being abused can shatter a basic sense of safety, locking the body into a state of hyper-vigilance, and provoking a number of later symptoms such as hearing voices, feeling alienated or experiencing disturbances in one’s basic sense of self.
If only one traumatic event has occurred, it can be easier to speak about, especially if people in the immediate environment recognise that something bad has happened. If violence and abuse have been recurrent in one’s childhood, it can be more difficult to articulate.
The current focus on labelling and medication, which patients are socialised into from their first contacts with mental health services, can mask the fact that many symptoms that appear problematic to the distanced observer are actually desperate attempts to cope and survive.
Rage, for example, is often an attempt to keep the other at a safe distance: to mobilise some feeling as a defence against a hopelessness which would alternatively lead to suicide. Self-harm can serve to give a sense of control and agency which would not otherwise be present. Attempting to get rid of these types of feelings and behaviours, without attending to why and how they developed, is always silencing and can provoke a suicide attempt.
Mental health services can end up re-traumatising people who have experienced abuse and violence. For example, women who have been abused are often restrained by a team of men, or are punished for their attempts to cope by being stitched up after self-harm without anaesthetic. Many report that when they try to talk about experiences of abuse or violence, it is not taken seriously, being told that it is a delusion, or that they are “making it up to seek attention”.
It is as if society can only bear its victims to look and present in a certain way – to be able to proffer a clear narrative and demonstrate a trust that authority figures can help. This belies the legacy of early abuse and violence. When people present in a more messy way – for example by oscillating between desperate attachment to staff and then pushing them away – they are likely to receive a diagnosis such as “borderline personality disorder” which makes survivors feel like there is something fundamentally wrong with their character.
These kind of labels are deeply damaging: an ideological violence which serves to allow staff to distance themselves from the root causes of pain at the expense of the understanding and compassion so desperately needed.
Survivors using the #AbusedByServices hashtag report having been desperate to speak to staff about experiences of abuse and violence for five, 10, 20 even 30 years. I wish evidence suggested this was an exaggeration. In fact, the few specialist services that are available are desperately overstretched.
Given the prevalence of abuse and violence in the psychiatric population, the only way forward is to teach the whole workforce to be able to work using a “Trauma Lens”. Staff often report feeling unsure about asking about abuse and violence, because of a lack of confidence that there are appropriate services to refer people to and a fear that they will not be able to contain distress. This has to change.
Trauma Informed Care is a movement which is beginning to gain traction internationally. This approach shifts the focus of care from asking “what is wrong with you”, to “what has happened to you”. Trauma Informed Care tasks include auditing services to make certain that they do not actively re-traumatise patients and ensuring all staff are skilled to ask about, and be able to work, with the sequelae (condition resulting from disease or trauma) of abuse and violence.
We have a two-tier situation in the UK. Survivors with financial means can access long-term psychotherapy privately, where there is time and space to explore what symptoms are trying to communicate. Those from less advantaged backgrounds, already more likely to have experienced abuse and violence, are stuck with the NHS where, despite pockets of excellence, there is a paucity of understanding of the effects of abuse and violence, and where re-traumatisation is rife.
This is simply not good enough. It is time to listen to survivors of abuse and violence. It is time to move towards Trauma Informed Care.
Dr Jay Watts is a consultant clinical psychologist / psychotherapist