This is the second of a two part blog in which she discusses childhood sexual abuse in the context of ACE policy.
In part 1 of this blog (5/7/19) I outlined reasons why reducing childhood sexual abuse (CSA) in society, and addressing its damaging effects in adulthood, need to form and remain a key component of ACES policy. The considerable risks to mental health, and now increasingly to physical health also, have been widely researched and evidenced for decades: more so than any other of the original ten Adverse Childhood Experiences (ACES) compiled by Prof Vincent Felitti and his team, which have been widely adopted in studies and in policy ever since.
The relevance of a CSA history to persisting substance misuse, to blot out distressing effects of the trauma; to cognitive problems damaging education and career prospects, due to neurobiological effects of chronic early stress; and to higher rates of offending, due mainly to anger, alienation and involvement in drug and exploitative commercial sex cultures, are also well researched, and connect with findings of later ACE studies (Nelson 2016).
Yet although the recent, belated emphasis on understanding the role of traumas in general in the lives of children and adults which ACES have helped to promote is valuable and very welcome, attention within that to sexual abuse issues remains marginal, and at times non-existent.
Part 1 of this blog considered unmet prevention and therapy needs for abused children and teenagers. This second part will look at the implications for the diagnosis and treatment of adults who experienced CSA.
The importance of ACES work with adults
A key message from the original ACE studies was the need for changes in the way adults with ill health are listened to and treated. These original studies, we can recall, were actually sparked by the health behaviours of adults sexually abused as children (KQED, 2018). Yet traumatised adults have been rather surprisingly neglected in most ACES policy – except in negative ways, as mothers who risk increasing their children’s stress. Thus, in thinking about action against CSA as part of a wider ACES policy, we need to include both children and adults. The Scottish Government has indeed stated its clear intention both to prevent ACES, and to ameliorate their effects through the lifecourse (The Scottish Government 2018).
Mental health issues
On mental health, it is undoubtedly welcome that they are investing more than £250 million into mental health services over the next five years. It is very welcome too that training on working with trauma in general (not just CSA trauma) is being rolled out within the Scottish workforce, based on NHS Education for Scotland’s key documents setting out its training framework and training plan (NHS Education for Scotland, 2017, 2018).
However, given consistently high rates of CSA histories among psychiatric patients it will be vital for bodies such as the new National Quality & Safety Board for Mental Health to monitor and audit how far such welcome initiatives actually improve sexual abuse survivors’ experiences. This Board was set up after the Carseview mental health unit scandal in Dundee (BBC News 18/4/19).
My own research studies (Nelson et al 2013, Nelson 2018) confirmed the practice experience of support agencies that there has been considerable dissatisfaction among adult survivors of CSA, with both mental health and general health services. That is the starting point which national policy needs to address. These complaints have centred around adherence to purely medical-model diagnoses and stigmatising personality disorder diagnoses; around polypharmacy, with damaging side effects; failure to inquire into an abuse history or to follow it up; dismissal of disclosures, and unsafe or triggering behaviours and healthcare environments.
If they genuinely want to improve the lives of adults who suffered CSA and wider sexual trauma, they will need to monitor closely what is actually happening in mental health services, in hospital settings and in the community. How far is the rollout of trauma training undermining these longstanding complaints of CSA survivors, and are examples of best practice being identified and adopted across Scotland? That will include health services in prisons, homeless services and in drug/alcohol services, where many adult survivors of CSA are to be found.
In particular, the Scottish Government and health authorities now need to monitor the following:
- How far does psychiatric diagnosis now reflect recognition of post-traumatic effects, how far does it remain dominated by biomedical and personality disorder diagnoses? Dr Joanna Moncrieff and colleagues have meticulously traced considerable increases, for instance, in diagnoses of (and medication for) bipolar disorder (Moncrieff et al 2005, Ilyas & Moncrieff 2012,). Yet researchers like Prof John Read have painstakingly revealed the frequency of a CSA history even in patients diagnosed with serious mental illnesses such as schizophrenia and bipolar disorder (Read et al 2003, .Moskowicz 2011, Varese et al 2012).
- How far does the dominance of medication as the primary or sole treatment in mental ill health persist, even when a trauma history is recognised?
- How available are talking therapies, even if the modest and unsatisfactory goal of 90% of patients being seen within 18 weeks is reached by Scottish health boards?
Omission of longstanding therapies
How far are other therapies than a narrow range of psychological therapies, as prescribed in the NES Transforming Psychological Trauma documents, available as options for people with sexual trauma to choose? For example various counselling approaches, skilled groupwork, psychodynamic psychotherapy or EMDR (Eye Movement Desensitization and Reprocessing)?
It is remarkable for instance, and frankly rather insulting, that counselling and the skills of trained counsellors are barely mentioned throughout the NES documents, given counsellors’ consistent role over many decades in working with abuse trauma. It would not be patient- and client-centred if we were to substitute the traditional colonisation of mental health treatments by psychiatry with the same behaviour by psychology.
Connected with this point, how far are adult survivors of sexual trauma and their third sector support agencies invited to contribute collaboratively to the evidence base of “what works” among therapies; to the evidence base of the desirable personal skills and qualities of therapists; or to the outcome indicators selected for current therapies? In my long experience, the answer is very little indeed.
How far are alternatives to physical restraint, where many patients frighteningly re-live traumatic experience, now being pursued and implemented in psychiatric and penal settings, especially in the wake of public scandals involving violent restraint, such as Carseview?
How far is routine inquiry into a sexual abuse history actually taking place in mental health services and others such as substance misuse and maternity-linked services? Is staff training in a topic which has traditionally caused anxiety and avoidance supportive and confidence-building rather than instructional and information-led, so that relevant, client-centred follow-questions about clients’ needs are always asked?
For instance, it is nearly ten years since Health Improvement Scotland set out practical and patient-centred guidelines for work with survivors of sexual abuse during pregnancy, birth and postnatal care.(HIS 2011). Is this currently being followed by midwives and other staff who work in this field?
Physical health issues
On services addressing physical health and abuse trauma, the original and follow-up ACE studies highlighted higher rates of a number of physical conditions in people with traumatic experiences –from greater risks of heart disease and some cancers to gynaecological, respiratory and gastro intestinal problems, and chronic pain (see Nelson, 2016 ch 7 and its references). Voluntary sector support agencies in Scotland report up to 85% of their clients experience significant physical health problems (Nelson 2018).
The biggest single complaint from abuse survivors about responses from health professionals is that once their abuse history or indeed their mental ill health status is known, medical staff readily dismiss their conditions as hypochondriacal or “all in their heads” while some GPs see them as “heartsink patients”. “Somatisation” has too often become a perjorative term, a diagnosis given to ten times as many women as men (McWhinney et al 1997). This shows that having CSA on your health records is not sufficient in itself to ensure an impartial approach to patients’ health problems.
To what extent is investigation into the causes of abuse survivors’ physical conditions and disabilities as open-minded, thorough and knowledgeable as it is with everyone else? How far are medical staff aware of the range of possible factors contributing to their conditions, including neurobiological responses to trauma and direct physical violence?
How far have wider health services, including GP practices, taken on board survivor-informed guidance about how to create safe and welcoming healthcare settings (including dentistry) for people whose trauma has made many fearful of such settings, and fearful of agreeing to intimate examinations? That question is of course also relevant to survivors of domestic abuse, and of violence experienced by refugees and asylum seekers. Pockets of excellent practice need to be copied throughout Scotland (Teram et al 2006, Schachter et al 2009, Nelson 2018).
As with my first blog blog on children and teenagers, the points above are not made as long and impossible ‘wish lists’. Nor of course can they all be implemented and resourced at once. Rather, if you promote an ACES strategy as Scotland does, you have to start showing – through action from Government ministers downwards – that you have actually thought how to begin addressing individual components of ACES.
A component, in this case, which decades of research and practice have shown to risk particularly serious and damaging effects on those who suffer it. In the case of adult services, the Scottish Government and health authorities need to consider how wide-ranging those actions may actually need to be. They then have to make a long- term plan, and begin step by step to implement it.
That will require working together with doctors and mental health professionals who see the need for change; and being prepared to take on and challenge those members of such powerful and dominant professions who decline to do so.
Healthcare Improvement Scotland, 2011: http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal_child/programme_resources/victims_of__sexual_abuse.aspx
Ilyas, S. and Moncrieff, J. (2012). ‘Trends in prescriptions and costs of drugs for mental disorders in England, 1998–2010’, British Journal of Psychiatry, 200(5): 393–98.
McWhinney, I. Epstein, R. and Freeman, T. (1997) ‘Rethinking somatisation’, Annals of Internal Medicine, 126(9): 747–50.
Moncrieff, J., Hopker, S. and Thomas, P. (2005) ‘Psychiatry and the pharmaceutical industry: who pays the piper?’ BJ PsychBulletin , 29:84–5.
Moskowitz, A. (2011) ‘Schizophrenia, trauma, dissociation, and scientific revolutions’, Journal of Trauma & Dissociation,12(4): 347–57
Nelson S. Lewis R. Gulyatlu S. (2013) ‘Male Survivors of Childhood Sexual Abuse: Experience of Mental Health Services’, In Pritchard J. Good Practice in Promoting Recovery and Healing for Abused Adults, London: Jessica Kingsley.
Nelson, S. (2016) Tackling Child Sexual Abuse: Radical approaches to prevention, protection and support, Bristol: Policy Press. Chs 4-9. References for mental health impacts of CSA are very numerous. Sample listing available from Sarah.Nelson@ed.ac.uk
Nelson, S. (2018) Surviving Well-useful information for health professionals working with people who have been sexually abused, 2nd edn, Alloa: Wellbeing Scotland.
NHS Education for Scotland National Trauma Training Programme
Read, J., Agar, K., Argyle, N. and Aderhold, V. (2003) ‘Sexual and physical abuse during childhood and adulthood as predictors of hallucinations, delusions and thought disorder’, Psychology and Psychotherapy: Theory, Research and Practice,76(1): 1–22.
Schachter C., Stalker C. and Teram e. (2009) Handbook on sensitive practice for healthcare practitioners: lessons from adult survivors of childhood sexual abuse, Public Health Agency of Canada, National Clearinghouse on Family Violence.
Teram, E., Stalker, C., Hovey, A., Schachter, C. and Lasiuk, G.( 2006) ‘Towards malecentric communication: sensitizing health professionals to the realities of male childhood sexual abuse survivors’, Issues in Mental Health Nursing, 27(5): 499–517.
The Scottish Government, Adverse Childhood Experiences (ACES), 2018.
Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., Read, J., van Os, J. and Bentall, R. (2012) ‘Childhood adversities increase the risk of psychosis: A metaanalysis of patient-control, prospective and cross-sectional cohort studies’, Schizophrenia Bulletin, 38(4): 661–71.