I am driving to my work as a clinical psychologist, doing battle with the abuse-related voices in my head…
I can hear a voice which goes something like this:
“You are useless.”
“You are worthless.”
“You deserve to die.”
“Kill yourself.”
When I arrive at work, I attend a meeting during which a patient who is hearing similar voices, which also relate to the abuse she suffered as a child, is told that she is suffering from ‘schizophrenia.’ The psychiatrist informs her that she must take antipsychotic medication for life, that she has “no hope of anything amounting to a normal life,” that she “will never work,” “will never improve or recover” and must no longer drive her car. There is talk of writing to the licensing authority, with a view to having her license removed, so that she will no longer be permitted to drive.
The patient protests that she needs the car to take her children to school. What is she going to do, she asks — how is she going to be able to cope without her car? I try to speak up in support of her. The voices she hears relate to the abuse she suffered as a child, I explain. There are ways we could help her to understand the meaning of the voices and manage the voice hearing from a psychological perspective.
However, her protests and my explanations are all in vain. Our voices are not heard. The only voice which counts is the psychiatrist’s. He informs the patient and the team that I am wrong — the history of child abuse is irrelevant and unrelated to this patient’s difficulties. We are told instead that she is suffering from “an incurable brain disease called schizophrenia” for which she “must take anti-psychotic medication for life.”
So begins another day in the life of the ‘mad’ psychologist.
At least this time, the psychiatrist responds to the formulation I provide, albeit to dismiss it completely out of hand. I am often ignored when I raise the issue of child abuse and trauma. Throughout my career, I have come across very few psychiatrists who understand the importance of trauma, whether experienced in childhood or adulthood, and the damage it can do to people. They fail to do this because they have not been taught to understand. Instead, they have been trained to regard trauma-related distress as evidence of underlying pathology — biological disease processes, brain disorders and faulty genes.
It is very rare to see a psychiatrist question a patient about the nature of the voices they hear. As far as most psychiatrists are concerned, as soon as a patient answers “Yes” to the question “Do you hear voices?” they begin to diagnose ‘schizophrenia.’ Evidence that the voice hearing experience is varied and meaningful (Romme and Escher, 19931; Romme et al., 20092; McCarthy-Jones, 20123, 20174; Longden, 20135 and 20166; McCarthy-Jones and Longden, 20137; Corstens et al., 20148) is routinely dismissed and ignored. There is consistently no understanding that voice hearing has a context, can be meaningful, and that it often relates to people’s life experiences, in particular experiences of abuse and trauma. Psychiatrists are trained to work with a checklist, which aims to diagnose people with ‘mental illnesses’ according to the Diagnostic and Statistical Manual. However, this is a far from helpful way of understanding and supporting people in distress.
How do I know what is going on with this person? How am I able to understand the link between her voice hearing and the history of child abuse? It is certainly not because I have learned about the link between voice hearing and trauma during my mental health training, or because this is the way the system understands it. Quite the contrary. I know why this patient is hearing voices and how they relate to her life experiences because I am a voice hearer myself and because of my experience of working and learning alongside many other voice hearers over the years.
The patient is severely reprimanded by the psychiatrist, as if she were a child, and told in no uncertain terms that she must not drive her car as she has “suffered a relapse” and is “too unwell.” Against her will, the medication is again increased and there is talk of ECT if the voices do not go away. She is scolded and put in her place, humiliated in front of the team by the psychiatrist’s punitive, judgemental approach.
The psychiatrist has no idea that the colleague who has been sitting in front of him across the room for all these years, who drives her car to and from work every day, who works full-time and does not take any psychiatric drugs, also hears similar distressing voices, and for similar reasons. I am not able to share this information, even privately, colleague to colleague. I am left with no doubt that, were I to do this, I would immediately be told to leave.
The next time this patient is seen, she is again asked by the psychiatrist whether she is hearing voices. This time, she reports that she is not. When she leaves the room, the psychiatrist congratulates himself, pronouncing the medication “a great success.” He is completely unaware of the fact that the patient’s difficulties have in no way improved. In fact, they have worsened with the increase in drugs. She lied about the voices having gone away, she later tells me, in order to avoid having the drugs further forcibly increased. She trusts me enough to confide in me, putting me in a difficult position, although I understand why she has chosen to do so. She wants to find favour with the psychiatrist, to avoid further increases in drugs, as well as the possibility of ECT, and she hopes to get her driving license back. I understand her concerns about ECT, having seen it forcibly administered over the years, and witnessed the considerable harm it can do9.
Like so many people over the years, she has been forced into a corner, feeling that the only way forward for her in the circumstances is to lie, to play the game in order to keep the doctor happy. Of course psychiatrists are none the wiser because they generally have no way of knowing about patients’ difficulties, other than what they choose to tell them, or not to tell them, as in this case. In this sense, as in so many other ways, the practice of psychiatry is not scientific; there are no objective ways of verifying the reports of patients.
The prevailing medical model means that most psychiatrists attribute problems and solutions to biological factors. If someone is distressed, then they need more drugs; if they improve, then this is due to the effects of the drugs and/or ECT, regardless of what has gone on or is going on in people’s lives. This model keeps psychiatrists from understanding the wider contexts of people’s lives, including the impact of abuse, trauma and adversity.
I bite my lip and button down my anger and pain. On to the next patient… This is another person with a history of child abuse, with symptoms similar to my own. She is again diagnosed by the psychiatrist with ‘schizophrenia.’ She and her family are told that she “will never work,” that she “will be on medication for the rest of her life” and that she “will never improve or recover.”
Over the months, I sit by and watch as she descends into a state of hopelessness, helplessness, despair and institutionalisation. I sit by and watch as she is increasingly affected by the adverse effects of the cocktail of psychiatric drugs. The life force, the energy, the zest and zeal for life she once had, are gradually knocked out of her. This once-vibrant human being changes from a lively, interested and interesting person — a person who actively engaged with life, who had hopes, dreams and goals, but who was in deep pain and distress — into a numbed, shuffling, twitching shadow of her former self. Yet again, I can do little to help.
Placing her trust in the psychiatrists, she accepts what she is told, takes her medication obediently like “a good girl.” Despite the fact that she is a grown woman in her thirties, the doctor even calls her “good girl” when she follows medical advice. So long as she continues to do what she is told, then she will be deemed “compliant” and will be noted to “have insight into her condition.” Doctor knows best… Apparently.
On to the next patient. This is someone who is self-harming, who cuts herself on the arms and legs. She also has a history of severe child abuse. She is brought into the room, which is dauntingly packed with different mental health professionals, in order to discuss the details of her self-harm. It is again a degrading, humiliating and intimidating experience. Numerous intrusive personal questions are fired at her. However, the psychiatrist does not seem to notice her obvious distress. If others do, then they know to keep quiet. Like countless other patients over the years, she is reprimanded in the strongest possible terms by the psychiatrist for her self-harming behaviours, made to feel ashamed, embarrassed and worthless, spoken to like a stupid, naughty and disobedient child. In terms of the self-harm, she is told to: “Just stop it,” “Just stop cutting,” “Just stop being so silly.”
It is an extremely daunting and humiliating experience, and I feel very concerned for the welfare of this patient when she leaves the room. I worry that she might kill herself on account of the cruel, punitive approach of the psychiatrist, who believes that the patient is being “manipulative and attention seeking,” and the degrading, traumatising experience of being interrogated and reprimanded in front of a room full of professionals.
I decide to risk speaking out because I worry for the immediate welfare of this patient. Her welfare now becomes more important to me than the anger I know my comments are going to provoke. I am endeavouring to advocate a more compassionate, respectful and supportive approach towards her care. I am very worried that if I do not do this, then the patient will leave the room feeling so low, so useless and worthless (and she already feels this way, feelings which are linked to the abuse and her self-harming behaviours in the first place), so judged, blamed and misunderstood, that she will either seriously harm herself possibly to the point of death, or take a lethal overdose.
I explain that no doubt she is not self-harming on purpose, that she is struggling with difficult feelings linked to experiences of trauma. We could help by working with her to understand her feelings, difficulties and needs, supporting her to consider the possibility of other coping strategies.
I can feel what the patient is feeling in this situation, but the psychiatrist is oblivious to this and believes they are doing right by her. I am reminded of the C.S. Lewis quote: “Of all tyrannies a tyranny sincerely exercised for the good of its victims may be the most oppressive.”10
I am also aware of what Dr Z is thinking in this situation and how they are likely to react to what will be perceived as a challenge, a downright flouting of their absolute authority as head of the team.
Later, inevitably, I am taken aside and reprimanded in the psychiatrist’s office in the strongest possible terms for “questioning doctor’s expert opinion in front of the patient and the team.” I do not regret having spoken out and made myself unpopular with the doctor though. I would only regret had the patient left the room without having felt in the least bit supported and understood — had she proceeded to harm herself further as a result of this, or taken her own life.
Sadly, this is exactly what happens to another patient some months later, when I am no longer working at the hospital and with this psychiatrist. The patient, another survivor of child abuse, leaves the meeting and goes home to kill herself. Later, some of the patients at the hospital approach me and say they wish I had been present at the time, as they believe I would have been able to prevent the death of this person.
I am firmly put in my place… Doctor knows best and if I know what’s best for me, then I will keep my mouth well and truly shut! So much for the Multi-Disciplinary Team. I should know by now, after all these years, that MDT does not really stand for multi-disciplinary team, but rather ‘Medically Dominated Team.’ It was the psychiatrist R.D. Laing who exclaimed: “I am still more frightened by the fearless power in the eyes of my fellow psychiatrists than by the powerless fear in the eyes of their patients.”11
I should also know, after all these years, that these meetings in which patients are supposedly cared for are often degrading, humiliating and damaging experiences for the people involved. They are also very painful and difficult for me. The regular, relentless abuse of patients by the system is extremely distressing to watch, particularly when there is little you can do about it.
Psychologist Dorothy Rowe commented, in connection with psychiatry and case conferences: “What is so appalling about cruelty (and why I write about it so much) is that we find it very hard to see the cruelty which is right before our eyes. Nurses and administrators who would be horrified by a television picture of soldiers beating a defenceless civilian see nothing cruel in a psychiatrist humiliating and punishing a patient, as happens every day in case conferences. Not for nothing did Goffman in his study of asylums call case conferences ‘degradation ceremonies’.”12
***
I am sitting in a team meeting, when a patient whose difficulties I have assessed as being related to the severe abuse she suffered as a child is diagnosed with ‘personality disorder.’ My opinion is completely discounted, the history of abuse dismissed, and this patient and the team are told that she is in fact “being difficult,” that she is “attention seeking and extremely manipulative.”
This woman has severe self-harming behaviours in relation to the severe abuse she suffered at the hands of her father and other members of her family as a child. She has difficulties in relation to attachment, self-esteem, boundaries, relationships and re-victimisation. She has developed behaviour patterns around ‘allowing herself’ to be used sexually by men (in many ways a re-enactment of the abuse she suffered, during which time she would experience the only ‘closeness,’ ‘warmth’ and ‘affection’ she received as a child), and then attending the local hospital casualty department, having taken an overdose or harmed herself by cutting her arms, as she subsequently felt so disgusted with herself for having been used by these men, both now and in the past. She has an extremely fragile sense of self, is confused and dissociated, and was abused in the most horrendous ways, the nature of which most of us would not even want to think about let alone experience ourselves.
As the psychiatrist has not enquired into this patient’s history, he is not aware that she has a history of severe child abuse. He is not aware of the motivating factors behind her difficulties and behaviours. Like the vast majority of psychiatrists, he would not even think to enquire into and consider these issues as being in any way relevant to her presenting difficulties.
Over the years I have seen many people, both female and male, inappropriately labelled with ‘personality disorder.’ This can happen when psychiatrists fail to understand the impact and after-effects of a history of severe trauma. It can also be applied as a punitive ‘bin category’ to patients they don’t like, to punish patients who do not obey, who complain, question or challenge their authority. The inappropriate application of the diagnosis to survivors and people in general has been discussed (Lewis and Appleby, 198813; Shaw and Proctor, 200514; RITB, 201615), and many people describe feeling deeply unhappy with the label.
When I write a detailed report and explain to the psychiatrist and the team that this patient has a history of severe child abuse, along with my psychological formulation of her difficulties and treatment needs, this information and my input as a psychologist are completely dismissed, passed over as usual in favour of a psychiatric account of her difficulties.
Telephone calls are made and letters written by the psychiatrist (calling himself a “Responsible Medical Officer”) to those who might make “the mistake” of offering this patient understanding, support and care at the hospital casualty department, should she continue to engage in self-harming behaviours or take an overdose and attend there for treatment again. The hospital staff are instructed by the psychiatrist that under no circumstances is this patient to be offered any kind of support or care. She is “an extremely difficult and manipulative patient who is doing this on purpose and for attention.” She is therefore to be dealt with in the harshest possible way, so that she will “snap out” of these “ridiculous, manipulative and attention seeking behaviours.”
Ridiculous from the point of view of this psychiatrist, perhaps, but not so ridiculous to those of us who have been on the receiving end of severe child abuse.
Thankfully, despite the extensive abuse she has experienced over time at the hands of the system, this patient is still alive and making progress. Sadly, many others have not been so fortunate.
***
Yet again, I am witnessing a dangerous scenario, during which the well-being of a fellow survivor is being put in jeopardy by the overall approach of psychiatry and the mental health system, and yet again I am in a position in which I am powerless to do much about it. That night, not for the first or the last time, I go home in deep distress. I lie on the floor and cry. A friend tries to console me by suggesting that even if I can help a few people some of the time, it will have been worth it. However, I remain unconvinced. Helping a few people some of the time does not seem good enough. I am weighed down by the enormity of the problem, by the enormity of the cruelty, inhumanity and abuse I am witnessing on a regular basis, and which is being repeated regularly in mental health facilities, not only in the UK, but in many other parts of the world too. In deep distress, I reach for my prayer book and read some prayers. The next day, I return to work.
I have been asked to assess a patient who has a history of severe child abuse and trauma and who has some unusual ideas, which the psychiatrist has described as “delusional.” In my assessment report, with the patient’s consent, I describe the nature of the severe abuse she suffered at the hands of different members of her family as a child. I also describe the after-effects of this on her mental health. She hears voices which are abuse-related, experiences visions which are abuse-related, and created a fantasy world for herself as a child, as a way of coping with the painful reality of her life. The psychiatrist has dismissed the history of abuse, has described the fantasy world as “delusional” and is using this as evidence for the diagnosis of ‘schizophrenia.’ I, on the other hand, know from my own experience, as well as that of many others, how and why such unusual thinking can develop. I am describing the beliefs as a protective coping strategy which has been helpful and adaptive for this patient. They have helped to lift her mood, helped her to survive the unthinkable and have prevented her from killing herself. I am aware how such so-called “delusional thinking” can be protective and even life-saving. But the system doesn’t see it this way.
Despite my clear report, detailing the extent of the abuse she suffered and the associated after-effects, including the nature, development and function of the fantasy world, the team and the patient are told by the psychiatrist that I am wrong. The patient is suffering from ‘schizophrenia’ and ‘personality disorder’ and will be treated as such.
She is traumatised by these diagnoses, by the dismissal of her experiences of child abuse, as well as the description of her fantasy world as “delusional.” Having spent quite some time building up a good working relationship with her, as usual I am left to battle with the damage which is being done to her in the name of ‘mental health care.’
Multiply this example by many many more — it is very painful and demoralising to work in a role which, to a large extent, involves trying to help people to heal from the damage which is consistently being done to them by the very system they are turning to for help.
I have lost count of the number of times I have witnessed psychiatrists disbelieve and dismiss reports of child abuse, by patients, myself and others, attribute them to mental illness, and fail to understand the link between trauma and mental health problems. The inherent dangers and potential harm associated with such a position cannot be overstated.
***
I am sitting in a meeting with a psychiatrist and other professionals who are discussing a patient who has been diagnosed by the psychiatrist with ‘paranoid schizophrenia.’ This is a woman who hears voices and sometimes hallucinates. I know, because I have assessed her in the past, that the voices she hears are those of the adult members of her family who abused her throughout her childhood. I also know that the visions, the so-called hallucinations she experiences, are flashbacks to the abuse she suffered. They tend to occur more often at night and involve shadowy figures around her bed. The team discussion is around where this lady is to be housed, since her marriage has broken down further to domestic violence. She has requested not to return to her family of origin, as members of her family were involved in the original abuse. When I discuss my findings with the team, they are dismissed by the psychiatrist as “irrelevant and unreliable” since “she is suffering from schizophrenia and cannot be trusted to provide reliable information about her life.”
Undeterred, I request that she be placed in a safe housing environment, away from her family, until more permanent housing options become available. However, at the psychiatrist’s insistence, she is forced to return to the abusive home environment as he declares that this would be “most conducive to her well-being in the circumstances.” Unsurprisingly, she quickly becomes even more distressed and attempts suicide. Thankfully she survives, and at my ongoing insistence is re-housed. As usual, my professional opinion is discounted, and as usual, it is an extremely painful and distressing situation to witness.
***
I am reading through the file of a patient who has a history of child abuse and whose difficulties I know to be related to this, only to discover that she, like so many other people, has received numerous different diagnoses and cocktails of harmful drugs over the years. The diagnoses have included: Schizophrenia, Schizoaffective Disorder, Manic Depression/Bipolar Disorder, Addictive Personality Disorder, Paranoia, Obsessive Compulsive Disorder, Borderline Personality Disorder, severe anxiety, severe depression, psychotic depression and Masochistic Personality Disorder. All of these ‘disorders’ so-called relate to the after-effects of abuse.
Assessment reveals that nothing positive has ever resulted from any of these different diagnoses and drugs over the years. Unsurprisingly, after more than 15 years, she is still, like so many others, going round and round the system, no better off than she was when she first entered it — in fact much worse off than she was in the first place. No mention is made in her file of the fact that she had an extremely abusive and traumatic childhood, during which time she suffered severe torture, cruelty and neglect on a scale most of us could not even bear to imagine.
While going to the waiting room to collect my next patient, I find another patient, who I have been working with for some months, crouching down on the floor in the corridor, extremely distressed and crying uncontrollably. Naturally I am very concerned. She is another survivor of child abuse, at the hands of her father. I ask her to come into my room. Once inside, she tells me that she has just had a meeting with the psychiatrist, who told her that she has ‘schizophrenia’ and that there is no chance of her ever making any degree of progress or recovery. She asks me whether I also think she is ‘mad’ (I tell her I do not). She then tells me that as a result of this meeting with the psychiatrist, she has gone into the hospital bathroom and self-harmed, cutting herself on her body. I examine her wounds. She explains that she has now lost all hope and is planning to go straight home to kill herself. Thankfully, after spending some time with her, I manage to talk her out of this and we continue to work together.
Yet again I find myself in the painful, ridiculous and uncomfortable position of having to try to do my best to repair the extensive damage which is being done to vulnerable survivors of child abuse by the system.
***
A patient who was abused at home by her father and while at school by some of the teachers has been diagnosed with ‘paranoid schizophrenia.’ She is struggling with after-effects of the abuse, including voice hearing, depression, anxiety, social anxiety, suicidal feelings and behaviour. She has made a number of suicide attempts over the years, none of which have been ‘successful.’ Amazingly, she is told by the psychiatrist that it is inevitable she will eventually end up killing herself. I refuse to believe or endorse this outrageous and unhelpful prediction and work with her on the after-effects of abuse she is struggling with (which include suicidality and self-harm). I am pleased to report that her life and mental health have improved and that she now works in the community. She has not made any suicide attempts for many years, and vows never to do so again. However, like many others, her progress is in spite of rather than because of psychiatry and the system.
Over the years I have worked with many people who have spent time on psychiatric wards as inpatients. Many are survivors of trauma in childhood and/or adulthood. However, they are hardly ever asked about histories of abuse and trauma. If they do disclose, then these experiences are regarded as irrelevant and/or delusional. The biological reductionism which pervades the system attributes all distress to biological ‘mental illnesses’ and endogenous pathology. The focus is on pills instead of people, on stigmatising victim-blaming labels rather than compassion and support.
Many of the practices on wards replicate previous experiences of abuse, trauma and violence, and can be deeply re-traumatising for people: lack of compassion and support, coercion, compulsion, control, restraint, seclusion, deprivation of liberty, forced drugging and ECT. Not having experiences of abuse considered, believed and taken into account can replicate the silence and shaming many have previously experienced. Not being given time to talk about their problems, offered kindness, compassion, understanding and support can exacerbate feelings of hopelessness, helplessness, alienation and despair. Having their wishes not to take psychiatric drugs ignored, being held down by staff and forcibly injected can mirror and replicate previous experiences of being raped and abused. Being forced to take drugs orally can also mirror previous abuse. Many people report feeling dehumanised and abused, describing feeling worse after an admission than they did before they went into hospital. However, the system consistently fails to understand and respond to such concerns.
***
A male patient who was physically, sexually and emotionally abused by his parents has spent more than thirty years in the system being treated for ‘paranoid schizophrenia.’ He has been receiving antipsychotic drugs, forcibly injected into his abdomen, for all these years. He has never seen a psychologist or been offered a psychological assessment. On seeing me, I assess his difficulties as being the result of the severe abuse he suffered as a child. As usual, I write reports and discuss my findings with colleagues.
For the first time ever, I am listened to by a psychiatrist. Needless to say, I am amazed! With his help, this patient’s antipsychotic medication is gradually reduced and finally tapered off completely. He does not suffer a ‘relapse,’ as previously predicted, and instead makes good progress. He still hears voices and experiences other after-effects of abuse. However, these gradually become less intense and he is able to find new ways of coping with them, with the help of a survivor group, a hearing voices group and psychological therapy.
As time moves on, this gentleman’s main concerns relate to the benefits (money) he has been receiving for the past thirty plus years from the state, on account of having been diagnosed with ‘paranoid schizophrenia,’ told that he “will never recover,” “will never come off medication” and “will never be able to study or work.”
Will he, he wonders, now no longer be allowed to claim benefits? Is it too late for him to think about study or a career? He is an intelligent man, with a lot to offer. What, he wonders, is he going to do with the rest of his life, given that he is now approaching retirement age? He feels angry about all the wasted time and years, believing, as he was told, that he was suffering from “an incurable and disabling brain disease called schizophrenia, from which there is no recovery” and being consistently told that he was “too ill to study or work.”
So many wasted lives and so much wasted talent, so many near misses, so many avoidable deaths, so much harm being done to so many vulnerable people in so many different ways. So little compassion, understanding and humanity. When and how is the system going to change?
***
The examples included here relate to the many people I have worked and learned alongside in different settings over the years. Many people have given their permission for me to use their experiences to educate and inform. In some cases, minor details have been changed in order to protect people’s identities.
Dr Z is a composite term for the many psychiatrists, male, female and from diverse backgrounds, with whom I have worked over the years. The majority of these doctors, however well-meaning, have practiced in harmful ways with patients, although there have been some notable exceptions.
