In England, childhood sexual abuse (CSA) has become big news. A number of celebrities – figures who dominated television in the 70s, 80s and 90s when there were only three TV channels and no box-sets – have been exposed as paedophiles. This has inserted the prevalence of abuse into people’s lives in a way not even achieved by the children’s homes scandals of the 80s, and the church scandals that continue to rock us. Even the BBC, a pillar of the establishment and would be neutrality, has been rocked by claims people knew one of its biggest stars was routinely abusing youngsters and doing nothing about it. CSA is part of everyday thinking in a way it never has been before.
The increasing understanding of the level of childhood sexual abuse and how this produces mental anguish has of course reached the psychosis arena, and encouraged academic study. Any therapist who is privileged enough to have the space to speak with people about what their voices are saying has long known that these often index the voice of abusers. The ever-growing literature on trauma/psychosis bears this out, with one study showing that if an individual has been seriously sexually abused, they are over 48 times more likely to experience distressing psychosis. Such studies, and the increased societal acknowledgment of CSA, mean that whilst the majority of psychiatrists continue to privilege a biological explanation of psychosis, more and more workers recognise abuse as at least a trigger if not a cause of psychosis. Yet just as the public and media struggle with how to narrate the newly apparent prevalence of CSA, so do multidisciplinary teams. It’s thus important to develop thinking points for teams struggling with, or more generally avoiding, the CSA/psychosis link. What might this include? I’ve jotted down some ideas of things to bear in mind. I hope readers will add, criticise or agree with particular points in the comments section below and we can come up with something useful.
Thinking points for teams:
- When someone first joins a psychiatric service, they will often receive the most thorough assessment, including questions about early life history. If someone doesn’t want to talk about something once, it doesn’t mean that they will never want to talk about it. A ‘no’ can be a speed of light defensive reaction to get something unbearable away.
- Service users need to be asked explicitly if information about abuse can be written in shared clinical notes, and how. It can be a deadening experience to see ‘childhood sexual abuse’ written on a CPA form or risk assessment to be read by people one does not know. It can also be weird to know some workers know despite the fact that one has not told them, and not have this acknowledged. Yet not sharing this can solidify the reading of things like voices and delusions as symptoms of an illness. Each service user needs to be able to make their own informed choice.
- Overwhelmingly, the increased discussion of CSA is a long overdue opportunity to have abuse experiences listened out for, heard, held and acknowledged. To do this, there needs to be basic recognition that no experience of abuse is the same, even if it is two children within the same family. To avoid distress, professionals will often ask a few simple questions and then act like they know something. They must be able to bear the fact that they don’t.
- Service users should be told if they are being assessed by someone different from the person who may offer them treatment. It’s ethically dodgy and damaging to give someone the impression they have a first, safe place to speak of the worst things that have happened to them only to find out at the end of the meeting they will never see that person again. Linked to this, professionals need to be able to hold their own desire to be the trusted one someone opens up to for their own narcissistic gain, and even more so if it’s only likely to repeat a situation of that person being left alone (perhaps on a long waiting list for someone who can actually offer a treatment and stay with the disclosure).
- Multidisciplinary teams need to be aware that voices and delusions may hold within them explicit, implicit and disguised information about long-dissociated sexual abuse. Teams can shy away from thinking about this because they have by that time developed close ties with the clients’ family members, or because of fears that asking questions may implant false memories (with the echo of the 90s ‘false memory trials‘ perhaps in mind).
- CSA is so unequivocally horrific it can trump other experiences of adversity linked to psychosis such as bullying, displacement, physical violence, neglect, and so on. People with distressing psychosis who have not been abused can feel that they have less to say about why they ended up suffering so. This can be important to bear in mind, especially when running groups.
- Equally, one of the ways abuse is so damaging is that it is so big a trauma it casts a shadow occluding everything else in a life – other moments of rage, despair, and hope. It’s crucial to see someone as more than their abuse.
- You don’t have to like someone just because they’ve been abused. Though it might be worth thinking about what’s going on in your not liking them in terms of the defenses they have developed – or your own stuff.
- Despite the brilliant evidence base for family work, it is rarely offered, and rarely taken up because staff, clients and families struggle to think about cause and distress without getting into simple blaming accounts or retreating to ‘an illness like any other’ accounts. It’s noteworthy that despite the levels of childhood trauma histories with psychosis, family work leaflets and manuals insist again and again ‘schizophrenia is an illness, that is no one’s fault’. This may be one of the reasons engagement is so low, for all parties know that when bad things happen they screw us up.
- Calling family members ‘carers’ before finding out the childhood history of the client is problematic when the trauma literature suggests care may be far from what was on offer.
- Antipsychotics are major tranquilizers. When experiences are too much, tranquilization can help us get through the next days. But just because tranquilization after a bereavement can help without meaning the bereaved has an illness, so antipsychotic treatment doesn’t mean someone is schizophrenic rather than deeply, dissociatively traumatized.
- Psychology, psychotherapy and psychoanalysis can be life-changing opportunities to work through experiences of sexual abuse. However, mental health services often use therapists to hold the bits they can’t hold in quite a split-off way, meaning one part of the service is saying someone has a medical problem, and another part saying it’s life-trajectory related. This is not so helpful, especially when psychotherapy is so often time-limited.
- Joining survivor movements, and reading or hearing other people who have survived abuse and become psychotic can be incredibly powerful. However, they can also make people feel bad for not having recovered yet, or as publicly, especially as people who speak or write in public tend to come across as more together than they feel. Trailblazing survivors can often feel immense pressure to stay well for the cause, and keep these struggles hidden.
- The person who has fucked the patient up the most isn’t necessarily the most obvious person. It may be the mother who didn’t believe her daughter, rather than the teacher who raped her. Don’t assume too much too soon.
- Hearing about abuse can be really traumatic. There is a massive literature on vicarious trauma. It’s ok for professionals to stop someone who is disclosing and say they don’t feel they are the right person to hear this, but they have to make sure that they sort out a safe space for it as soon as possible, and keep to their promises. Broken promises can make someone feel more alone than ever before.
- If hearing about abuse makes evident that another child is still at risk, it’s important not only to protect that other child but to recognize that this will have ripple effects on the family system that needs to be contained, and that it’s quite normal to feel jealousy as well as relief that someone is getting protected.
- Sexual desire is incredibly complicated, bodies react even when we don’t want things to happen, and later masturbatory fantasies can hold elements of early abuse interactions because our bodies remember in this way. It’s important to be aware of this so professionals don’t look shocked if this comes up in conversations, their look reinforcing a false idea there is something wrong with the person who was abused.
- People who have been let down by their early caregivers, and especially people who develop distressing psychosis, tend to be the most brilliant bullshit detectors. If, as a clinician, you are hearing abuse and not really present, just nodding empathically because ‘that’s what you are supposed to do’, most clients will know. It’s far better to be authentic and search in oneself for why one is elsewhere and perhaps dissociating a little.
- Most people have some vicarious enjoyment in hearing about trauma – think of the obsession with gruesome celebrity deaths and how people revel in the details of crimes. People can ask too much detail or, conversely, too little detail because of their own desire. Mental health professionals need a space to think about this – a supervision or their own therapy.
- Positioning CSA as a trigger to distressing psychosis rather than a potential cause is not a politically neutral act.
Access to therapy is absolutely crucial, but so too are the messages all practitioners give which serve to encourage disclosure of, or lock away, secrets that hurt. Hopefully commenters on Mad in America will add their own thoughts below so we can come up with something together that will shift thinking in the psychiatric teams who so often first connect with the ‘symptoms’ that scream for help.