Psychiatric Teams Have a Responsibility to Think About the Psychosis/Sexual Abuse Link

Jay Watts, DClinPsy
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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:

  1. 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.
  2. 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.
  3. 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.
  4. 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).
  5. 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).
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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.

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14 COMMENTS

  1. I agree with almost everything you’re saying, but this: “CSA is so unequivocally horrific…” and this, ” 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…”

    It is possible to suffer childhood sexual abuse and not even suffer PTSD from it. A person who has been sexually abused as a child certainly has issues to work out with counseling; but that doesn’t mean that every aspect of that person is damaged and that that damage is greater than any other. In fact, I stopped seeing the psychiatrists and psychologists who helped me so much with the effects of sexual abuse, when they stopped talking about anything else. When for instance, a came into an office feeling a little angry because a man had been following me in his car for three blocks while I was walking, making vulgar movements with his tongue, while I was wearing a tank top and shorts because it was near a hundred degrees outside, the psychiatrist asked what that made me think of my stepfather. It didn’t. I was thinking that that kind of thing happened a lot in the summer when some predatory men interpreted summer wear as an indication that a woman wanted nothing more than being sexually involved with random men they encountered on the street.

    The whole field seemed to have been under the impression that women had to be looking for men to sexually harass, abuse, or assault them or their children, even to the degree that it was considered common knowledge that a women who had suffered CSA tried to “recreate” situations in which they were abused. And every bit of sexual objectification and abuse a woman suffered was related to her abuser. What color is the sky on that planet? My ex-husband had a tendency to get really frisky when I needed sleep for mid-terms or finals. One night he kept bugging me until I said, “I feel like I’m being sexually abused!” He suddenly looked so concerned and sympathetic, which made me even more angry, until I realized what was happening and said, “Don’t you dare! I’m not feeling this way because of what happened to me as a child, I’m feeling this way because YOU are ABUSING me. I said, ‘NO’ and meant it! Don’t touch me!”

    When a person can’t get counseling for a traumatic event that really did cause PTSD, and is instead told that they need to deal with their childhood trauma more than anything else, even when that person is over it, in part, because they’ve divorced their family completely and are free of their abuse; then a lot of imposition is going on.

    Perhaps, some people are stronger than the mental health professional they are seeing. Perhaps that person had a very strong bond during their formative years. Perhaps, some people had other people who were sources of strength and comfort, who helped the patient understand that their family life was temporary and that they could move on. Perhaps, some people understood that it was not them that was sick even when they were children. Perhaps, some people enjoyed their lives outside of their family trauma and were so liked by and liked others so much that they knew that they were going to be alright and that they weren’t the problem.

    If someone says that they didn’t suffer from flashbacks and night terrors about CSA until ten years after suffering from flashbacks and night terrors about a separate event and they very much wanted to talk about that traumatic trauma; then a good counselor should listen and talk about what the patient wants to talk about instead of using their CSA hammer on the client. You know who knows better than the counselor how much a person was hurt by sexual abuse? Right— the person who was abused.

    People who were sexually abused as children aren’t all the same, and we’re not little machines that have been sexually abused as children and so will malfunction according to the manual. Please, stop insisting that people who suffered sexual abuse as children are all permanent victims who are “damaged goods”. It’s not any less damaging for a person to be told by mental health professionals that they are permanently damaged by sexual abuse for psychological reasons, than it is for them to be told that their stock value plummeted when they were sexually abused because they lost their innocence.

    No one is getting their innocence back, but we should at least be able to assess the damage ourselves and to be believed by people who think that they’re here to help us.

    • Hurrah – workers who push their interpretation of your suffering instead of just offering it if they feel so moved for you to leave or take up as you see fit – bah!

      I’ve supported people who were sexually assaulted as children and while it does usually effect them, often profoundly, life is always so much more than that and often it is the surrounding circumstances that effected them.

      At the same time the number of people I meet in the psychiatric system who have been sexually assaulted as children and no workers knows because no worker is interested is large. So I suspect the trauma being ignored and a diagnosis and drugs being prescribed is more common than bad therapy where the worker insists their interpretation is correct, though both are bad of course.

      • Yes, John, and I didn’t mean to suggest that some people aren’t suffering PTSD and overwhelmingly debilitating feelings from CSA. There is nothing “wrong” with a person who suffers psychotic inducing pain and confusion as a result of CSA. It just shouldn’t be assumed, and should definitely not be assumed to be a single cause of psychosis-inducing stress at any time of life for any person. Just the fact that so many people somehow managed to ignore all the alarms while a child was being sexually abused by an adult is enough to make it horribly difficult to trust others. When a world is indifferent, then a world is indifferent, and people should be expected to act accordingly.

        I don’t think I have ever suffered any kind of extreme stress that would not have been manageable with a savings account, the freedom to take a few weeks off from work, and the ability to live in a peaceful home without having to apologize for not being my usual highly-functioning and helpful self. These are things that working women don’t usually expect to have— we’ve been taught not to be a bother to anyone and that our failure to take care of others (regardless of reciprocity) is a failure at being a woman. What we need, is some slack.

        Having empathetic care with assurance that it takes time to work out major problems would make anyone feel more confident in their ability to heal. That applies to anyone, regardless of gender or sex, who can’t stop running without falling into a pit and taking on additional problems, and so becomes overwhelmed when personal stresses interferes with and threaten one’s ability to keep their head above water.

        I think, the harder a person tries not to stop, the more likely they are to have a psychotic break in order to just stop trying so hard to avoid it when part of them knows that the content of their psyche’s distress is the most powerful force in their lives at any particular moment and will not be put off any longer.

        Of course, there are probably a hundred other reasons to have a psychotic episode, many that have nothing or little to do with psychology. An attuned counselor in a reasonable system should be able to help a person take stock of what happened to them and help them figure out how to process it and to learn what they need, how to give themselves what they need, and how to ask for what they need.

        I see it as a sort of birthing process where the patient does almost all of the work, but the counselor assists, helps the one in labor stay focused, and knows the warning signs and what to do when deliveries go wrong. The mother’s job is to handle the pain and to push, the mid-wife’s job is to monitor the baby and the mother, to be supportive, and to know what to do when things go wrong.

        • ” the harder a person tries not to stop, the more likely they are to have a psychotic break”
          Not just psychotic: any kind of mental breakdown at all. Some people hear voices other just end up screaming in the corner because of a panic attack or slit their wrists or whatever.

      • It’s not only about sexual abuse. It’s generally when “therapists” think they know better than you why you behave or feel a certain way (and it’s always the childhood, if they can’t find anything I the childhood they’ll manufacture something for you). I am still angry at the guy who has ignored everything I said because it did not fit to his theory and tried to convince me that somehow my parents were to blame for the shit I got from other people later in life because they loved me to much (after he could not convince me that they must have abused or neglected me somehow). It was so incredibly insulting I just left.

  2. I think what the commenters have to say is very important. But I do think the author of this article has been very constructive. It is impossible to always know exactly what to do.

    My own experience with sexual abuse was being repeatedly raped by a worker at Bellevue Hospital when I was six years old and being given electroshock. I have been emotionally involved over the years with several women who have been sexually abused by their fathers, and I’ve always felt their experience was much worse than mine. Their abuse came from their parent, someone who was supposed to nurture them, while I had no emotional complication with my abuser. My feeling about him was very simple. I hated him.

    So I am saying something rather obvious, I know, that everyone exposed to sexual abuse is going to respond in a different way. And how they will heal, if they can, is going to be different for each person.

  3. From my research it appears the child abuse was not just limited to celebrities with TV connections but to person in high government positions, wealthy people, even some say members of the Royal Family. In fact reading the reports it sounds as if pedophilia was an established and accepted English activity. A tradition one might say. But one like wiretapping, not to be shown the light of ordinary day.

    No longer do we need to talk about the dark ages as they are with us now. Did they ever really leave? I have been told sexual abuse stories by a number of women. I have gotten used to the fact. I wonder if it ever happened in the rural American town I grew up in? I have never heard. But then would I have heard growing up there? Possibly. I was even a Catholic but never had any sort of interaction with a priest nor the hint of it. Does this signify a breakdown in societies at this time?

    Of course such an event would be highly destructive for a child or even an adolescent. Sex is highly intimate and personal; and to have someone intrude rudely into that solitude would be terrifying and shattering. One would lose self trust. Never after that feel safe to be oneself. One would have to live at a remove and keep an eye out for danger. Could easily ruin a life. It would involve a kind of self abandonment.

  4. Number 14 The person who has fucked the patient up the most isn’t necessarily the most obvious person.
    When the family believes in the diagnosis of “mental illness” , the family gets a scapegoat/lightning-rod to blame all the troubles on. And they don’t want to lose the scapegoat. He/she is the crazy one, not me, the doctor said so.

    • I’m coming to understand the dictum that the function of psychiatry is to stop society thinking about the causes of mental distress.

      I know a young man who has a diagnosis of schizophrenia, non of his friends want to know why he is distressed. The idea of inquiring seems weird to them. Of course the services do not want to know, and his family know he was sexually assaulted as a child but are not interested in how it effected him, which no doubt added to his distress, but for his friends to have no interest seems odd to me.

      Psychiatry provides the excuse for not listening to the distressed and finding out why they are upset, confused, odd.

      • “The function of psychiatry is to stop society from thinking about the causes of mental distress,” I agree. And it’s worse than that, psychiatry actually exists to cover up sodomy of children for the religions or others “in power.”

        My subsequent pastors read about what happened to my family, basically I was stigmatized and drugged, to cover up the abuse of my children by an unethical pastor and his best friend and a “bad fix” on a broken bone. They told me I dealt with “the dirty little secret of the two original educated professions.” Psychiatry’s function has always been covering up easily recognized iatrogenesis for incompetent doctors and child abuse for religions.

        Bu it’s staggering for me to learn an entire industry is so foolish as to believe all distress is caused by “chemical imbalances” in people’s brains – what an absurdly stupid belief system!

  5. One should maybe remember that there are also some rather harmful people out there, who basically get off on stories like that. I had a questionable pleasure to know a guy like that – he’d pick out a girl from a crowd who looked like she might be vulnerable and make the person trust him and he even had a personal story (god knows if it was true) to tell to make her more open and easy for manipulation. That was a pretty fucked up thing and a pattern for him – he did this deliberately, to multiple people. Fortunately he was no therapist but I’d be very careful with telling personal stories to anyone whom you have not known and tested and so called professionals also aren’t always good people.

  6. Jay,

    I thought I’d mention I agree with others here regarding your comments that child sexual abuse is insurmountable. My son was abused, at least twice, then he kicked, screamed, and refused to play at that friend’s house ever again. The wealthy parents’ became paranoid and had me stigmatized and majorly tranquilized, while I was still in denial.

    And since my psychiatric practitioners were denying my real life problems existed, because all my real life concerns were caused by “chemical imbalances,” my son didn’t see any psychiatric practitioners. But after my family’s medical records were handed over by decent doctors and nurses, with evidence of the child abuse and proof I’d been misdiagnosed based upon lies from the alleged abusers. Trust me, the first priorities of my neurologist were to try to get my child into the system and drugged, and to get me back on major tranquilizers. We switched doctors, and I was weaned off my last drug.

    But that doctor refused to treat us (since he didn’t want to be involved in a child abuse and malpractice cover up) after he’d weaned me off the last drug, and recommended we change not only doctors, but health insurance groups, too. We did. I didn’t pass my son’s and my medical records onto our next doctor (so we could keep a family physician). And a nice nurse did follow my family to each of these doctors, and helped protect my children and I.

    Nonetheless, my child did suffer from the typical symptoms of child abuse, including reverting back to diapers, refusal to let mom bath him any longer, and a switch from a “school from gifted children” to a public school in first grade, where he ended up in remedial reading. No professional thought this odd, but me. He was obsessed with police and justice for years, and there were other symptoms. But by eighth grade, with tough love, encouragement, and a mom who was very active in his school, sporting, and church activities, my son did overcome most his issues and got 100% on his state standardized tests.

    This is when the school social worker got involved (rather than when he was abused!) – long and ridiculous story pointing out the stupidity of the DSM (read “Misdiagnosis and Dual Diagnoses of Gifted Children and Adults”). Eventually, our school district conceded they were not equipped to deal with the genetically “gifted” students, and recommended a private school. My son graduated as valedictorian last year.

    My son is still experiencing confusion regarding his sexuality, likely due to the fact psychiatry is in the business of covering up child abuse for pastors and friends, and denying mom’s real life concerns, rather than properly addressing them. But sexually abused children given love, not drugs and psychiatric labels, can do quite well.

    My subsequent pastors did read my chronologically typed up medical records and confess to me that the psychiatric industry has historically been in the business of covering up child abuse for the religions and easily recognized iatrogenesis for the medical community. I was told I dealt with the “dirty little secret of the two original educated professions.”

    It strikes me the profession that historically and today covers up child abuse for the “elite,” isn’t really credible enough to be trusted to end the child abuse problems. And it concerns me that I’ve read around 20% of people are abused as children, approximately 20% of children in our society have been stigmatized by psychiatrists and are being medicated. And my experience with the psychiatric profession is they are here to stigmatize and drug all those going through difficult times, rather than help them.

    You’re profession needs to repent for it’s appallingly hypocritical history of harming patients, and current crimes against humanity, truly.

  7. I’m glad this issue is being discussed, but I think it’s important to state a few things that weren’t explicitly mentioned. First, sexual abuse is not the only form of childhood abuse that may result in trauma responses. Second, events that occurr in adulthood can also result in trauma responses. Third, not every horrific experience results in a trauma response. Trauma happens when a horriying event overwhelms an individual’s ability to cope. Everyone’s coping skills and abilities are different, and each person’s may be different at different times in their lives. And fourth, the overwhelming majority of people in the mental health system are trauma survivors,so the system needs to adopt trauma-informed approaches to be used universally with everyone.

  8. Jay,
    Nice article. You sound like you know what you are talking about. I’m glad to hear from posters that c.s.a. can exist without future p.t.s.d., but I’ve never seen it, myself. I think posters younger than 50 might have a different take after they reach that age and beyond. Alice Miller documents how high-functioning one can be until suddenly age and loss up the ante. That’s my 2 cents.