The toxic experience of abuse - sexual, physical and emotional in child and/or adulthood - is endemic within our society and, not surprisingly, also within our service user populations.
a) Mental Health Services perspective
It became increasingly apparent, not least during the consultation phase of the Gender and Women’s Mental Health Implementation Guidance (DH 2003) that:
- The mental health sector was not consistently addressing abuse as an integral element of the care delivered to service users. There was a prevailing tendency to focus on - “What’s wrong with this person?”, their diagnoses and symptoms - and neglect the equally important question - “What has happened to this person?”, the roots of their mental distress.
- The higher education sector was clearly not educating students sufficiently - in their pre-qualifying training - on, for example, the prevalence of abuse; the impact and consequences of the different forms of abuse; creating a safe context for service users to disclose; how it relates to Safeguarding; how to support survivors to heal from their abusive experiences.
It takes enormous courage on the part of survivors of abuse to spontaneously disclose, it may take many years and some never do. As can be evidenced from many survivor narratives, when they have taken this brave step, the response they have received from mental health practitioners has often been negative and unhelpful. There have always been individual practitioners who have been compassionate and effective in the support they have provided, but this has been patchy so very much a lottery whether survivors have received the help they have needed.
b) Prevalence in Mental Health Services
A review of 46 studies of women service users revealed that just under 50% reported having been subjected to sexual abuse and 50% to physical abuse in childhood. The figures for men were 28% sexual abuse and 50% physical abuse in childhood. The proportion increases further when adult abuse is taken into account, often in the context of revictimisation because they were not provided with a safe space to heal from their original abuse, notably child sexual abuse.
We should also bear in mind that these are prevalence indicators derived from a context in which service users are not routinely asked about abuse in mental health assessments and therefore likely to be an under-estimate. Experienced practitioners who have been actively supporting survivors for many years consistently remark that it is the exception, not the rule, if service users don’t have any experience of abuse.
c) Impact and consequences of child sexual abuse
Research indicates that the:
- Severity of the impact is predicated on a range of factors including the form of abuse; it’s duration; degree of regularity; relationship with the abuser ie a family member or a stranger; whether they told or not; if they ‘did tell’, were they believed, protected and so on.
- Long term consequences can include anger/aggression; low self-esteem; feeling dirty/damaged/guilty; sleep disturbance; intrusive memories; inability to trust others; physical health problems.
- Future sexual relationships are fraught with difficulties.
- Coping mechanisms include drug and alcohol abuse; self-injury; avoidance of memories/thoughts; dissociation; somatisation.
- Experience of child sexual abuse can be a significant, contributory factor to all diagnoses - depression; obsessive-compulsive disorder; eating disorders; phobias; psychosis/ schizophrenia; bi-polar disorder; personality disorders. Post-traumatic stress disorder is a well known effect but, without a disclosure, this diagnosis cannot be made; many survivors are misdiagnosed as a result
