NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS

The prevalence of abuse histories in the mental health system

By: Mary Auslander and Darby Penney
National Association of Consumer/Survivor Mental Health Administrators (NAC/SMHA), 1998

In the last decade, the mental health system has begun to demonstrate some awareness of the prevalence of abuse histories among its clientele. Studies consistently confirm a 50-80% prevalence rate of sexual and physical abuse among persons who later acquire diagnoses of mental illness (Breyer, 1987; Beck & Van der Kolk, 1987; Rose, et al, 1992; Craine, et al, 1988; Stefan, 1996). While many professionals in the field still deny the validity of work documenting these histories, the mental health system is beginning to catch up with groups that have addressed violence toward women, child abuse, and runaway adolescents in realizing the connections between abuse and later difficulties (Alexander & Muenzenmaier, 1998; Smith, 1995; Harris, 1994; New York State Office of Mental Health, 1993; Mental Health Association in New York State & New York State Office of Mental Health, 1994).

Among consumers/survivors/ex-patients (C/S/Xs) themselves, the commonality of abuse histories has begun to be acknowledged. With that acknowledgment, the irrelevance of much of their "treatment" in the mental health system has begun to make sense in a new way. Many whose treatment focus has changed from medical model interventions to trauma-oriented therapies, whether professional or peer-run, have recovered in ways once considered impossible.

It would seem, therefore, that the mental health system's recognition of abuse histories would be welcome news among C/S/Xs. However, for many who know the system well, the news is greeted with deep ambivalence. For some, it is somewhat ironic, given the history of silence among most mental health professionals about abusive treatment that is often routine in mental health settings. Others are deeply relieved by professionals' long-overdue recognition of trauma as a primary issue to be addressed therapeutically, but fear that a system so entrenched in punitive ways will not be able to incorporate the kind of work necessary to heal from trauma (Kalinowski & Penney, 1998).

Some C/S/Xs have learned that the abuse in their histories has been the primary formative factor in what was called their "mental illness." Others see abuse or trauma as part of what affected them, but also believe that their symptoms had a variety of origins, including socioeconomic, spiritual, and/or biological causes. Whatever view individuals hold concerning the role of trauma and abuse in the etiology of their problems, their experiences in the mental health system may color their reaction to the system's new-found interest in trauma and abuse. Many people have spent years in the system without being asked about their trauma history or other aspects of their personal stories; their behavior, rather than their experience, has been the focus of treatment. Many have also felt constantly threatened with the loss of autonomy and civil rights (Blanch & Parrish, 1993). For these individuals, it may be difficult to appreciate the professional world's "discovery" of a new theory of mental illness, regardless of its relevance to the majority of people caught up in the mental health system.

Until recently, the term "survivor", as used within the C/S/X movement, meant one who survived the irrelevance and frequently the harm of psychiatric interventions. Commonly, individuals have needed to recover from the effects of being labelled and institutionalized in order to begin addressing the issues that led to their encounter with psychiatry. Now that the term means "survivor of abuse" to many practitioners, C/S/Xs seek evidence that the abuse perpetrated by the mental health system itself is also recognized. They are deeply skeptical of trusting clinicians who have never questioned the criteria for involuntary commitment and deprivation of civil rights for so many diagnosed persons. People who have experienced trauma and abuse perpetrated by the very system which purports to help them may have a hard time believing that this same system is now willing and able to assist them in overcoming the effects of trauma.

Thus, C/S/Xs who advocate against forced and punitive treatment as traumatizing violations of their humanity, now point out that the majority of diagnosed individuals are actually being re-traumatized in psychiatric settings (New York State Office of Mental Health, 1993). In the words of one C/S/X, if one was not a trauma survivor before entering the mental health system, one is sure to become one once labelled and locked up. In other words, no matter what theory an intervention is based on, unless the coercive culture of psychiatry is radically altered, many persons will continue to be traumatized, whether or not this such experience is repetitious of their pasts.

In regard to the theory itself, some C/S/Xs are relieved by the long-overdue recognition of trauma and abuse as primary factors in the development of symptoms that were once adaptive coping strategies. Believing that this recognition must preclude further violations, they want to do therapeutic work on the issues that trauma and abuse created. Their choice might be to work on this and only this in individual or group work with professionals and/or peers. Others see the traumatic aspect of their histories as part of what affected them, but also believe they have biological or socioeconomic reasons for "symptoms" as well. Thus, they see multi-faceted approaches as the only viable way to work.

Regardless of what C/S/Xs believe about the etiology of their difficulties, they want what they have always stated to be important: to be heard and treated as individuals and to have their subjective experience and self-perception respected. Also consistent with C/S/Xs' stated wishes over the years is the desire to be perceived and treated with hope (Zinman, Harp & Bead, 1987; Campbell, 1989; Chamberlin, 1990; Knight, 1991; Fisher, 1994; Penney, 1995). It is difficult to count on a system that has routinely dashed hope to now operate from a belief that recovery is possible. But this is essential to any therapeutic plan and one seldom emphasized in professional training.

C/S/Xs frequently report that they were never asked about trauma or abuse and if they were, divulging such history did not yield a specifically responsive result. Most believe the relevance of abuse and trauma should be communicated sensitively, early, and consistently throughout encounters with the system. However, it must be understood that such an approach is still only theory until chosen as useful by the individual consumer/survivor.

Given the documentation that the majority of people with psychiatric diagnoses are abuse survivors, many C/S/Xs think the most effective way to address trauma and abuse histories is to assume that all C/S/X are potentially abuse survivors. It should be considered integrally important to one's development up to assessment/admission, and the process of encountering the mental health system can be assumed as potentially retraumatizing or at least "triggering" of previous experience. If trauma were presumed, anyone entering the system would be subject to a more humane, considerate, and relevant approach. Importantly, this would eliminate the need for separate units for "trauma survivors" as if they were different people from those called "mentally ill." Interventions such as restraint and seclusion would be deemed too traumatizing for anyone in crisis, not only for one whose trauma history is known.

This becomes more of an issue as mental health professionals begin to address how to treat abuse survivors, particularly on an inpatient basis. Indeed, the "trauma models" they use often appear much more humane and respectful of the person than do traditional approaches to people with psychiatric diagnoses, and some who specialize in this area believe the new paradigm should dominate the field, regardless of what has brought a person to a mental health crisis. However, as psychiatry gains a foothold in the area, a new division of "patients" can be seen: trauma survivors, with diagnoses like Dissociative Identity Disorder (DID) and Post-Traumatic Stress Disorder (PTSD) vs.(and sometimes co-occurring with) more standard diagnoses of mental illness. In this context, the system continues to employ inhumane methods, such as forced medications or restraints, with some diagnosed persons, while an effort is made to avoid "retraumatizing" others.

This division is disturbing to C/S/Xs who see a new hierarchy of oppression forming before their eyes after years of fighting for the full human rights of all who cross the path of the mental health system. They do not wish to see two groups of diagnosed individuals set up in opposition to each other, one treated with concern and compassion because of their trauma histories, the other treated in coercive, inhumane ways because they are thought to have a biological illness.

The issue of power differentials is crucial here. Abuse is about one person subjugating another- the violent assertion of one's will over another. Traumatic experiences, while not always interpersonal, similarly leave people feeling as helpless victims whose control was usurped by a more powerful condition or event. The risk for anyone entering the mental health system is fundamentally a loss of power. Even voluntary admissions to in- or out-patient services are governed by the coercive power held by psychiatry. The loss of power over one's life which usually accompanies a diagnosis is traumatizing for all people, whatever their past history of trauma or abuse.

Most C/S/Xs want to believe that practitioners care about outcomes beyond cost-efficiency and behavior control. Thus, it is crucial in their opinion that practitioners be aware of the often dramatic improvements in the lives of C/S/Xs that result from being listened to and treated as individuals. This also means not forcing a trauma-related diagnosis or trauma-model services on individuals who are not comfortable with that approach. Again, individuals need to be listened to; while it might be useful to have theories suggested, no success is possible when one is imposed.

Mental health professionals would do well to consider how survivors have managed all the years their abuse histories remained hidden. The strengths of individuals, peer support, and self-help gain new respect when it is recognized that for many, these have been the only avenues that have been available to them for support. The incorporation of trauma theories into the design and delivery of mental health services can provide a new opportunity to consider the integration of peer-run and other community resources as equally important to professional interventions.

Possibly the most important area being explored in services specific to trauma is one that C/S/Xs have also been exploring and advocating for years -- that of advance directives (Backlar & McFarland, 1996; Sherman, 1994). Out of efforts to avoid retraumatizing survivors of abuse, some mental health assessments now include questions about what triggers difficulty for individuals and what they find most helpful in especially troubled moments. Perhaps this is because trauma survivors are seen as more capable of knowing themselves and what helps them, but it is a way of planning in partnership with professionals that C/S/Xs have long been aware of and supported. Many would go so far as to say that recovery is only possible where this kind of partnership is built and honored.

Given the dominance of the medical or biological model of mental illness in the field at this time, C/S/Xs are eager to use what is effective from the framework of trauma survival. A great deal of difference could be made in the lives of individuals if this growing body of information were used to support holistic and hopeful views of what is happening to them and what is possible for their futures. As one C/S/X put it, perhaps the "Decade of the Brain" could give way to the "Decade of Recovery" -- recovery only being possible when all aspects of a person's development in context are given equal value, and a spectrum of healing possibilities are offered as real choices.

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