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International Conference on Trauma, Attachment and
Dissociation
Transforming Trauma: Critical, controversial and core issues
Melbourne
September 12-14 2003
Saturday September 13 2003, 4.30-5.30.
Diagnosis: Dr John Read & panel.
‘Why aren't mental health professionals asking about child sexual abuse?
(A transcript).
Dr John Read:
...the danger of me chairing myself is that you could still be here at
midnight. So somebody needs to take responsibility at 5 to 5 saying ‘time for
questions, John'. Or you can do it collectively, you know: ‘Shut up John,
it's time for questions.' So I will just make a start, if that's alright.
Okay. My name's John Read and I should just briefly say a little bit about
myself. I hate it when people stand up and start twittering at me without me
having any idea who they are or what on earth gives them the right to stand
up there. Not sure I have the right, but I'll tell you who I am anyway. I'm
currently a director of clinical psychology training at Auckland University.
And a very, very quick potted history. I might do a slightly longer one
tomorrow at the keynote. I've worked for 20 years almost exclusively with
people diagnosed psychotic, schizophrenic and so forth in America, the UK and
most recently in NZ.
And I'm only going to tell you - everybody has a hundred stories of course,
from their own clinical work, I'm only going to tell you one, which is one
that probably started me thinking a long time ago because what I'm going to
tell you, I really received no training in whatsoever, which is sadly still
very true of most of our professional training programmes. We're beginning to
get a little bit better, perhaps. But we still have a ways to go.
So my story is before I was trained, when I was 20 working as a psychiatric
nursing aid in the Bronx in New York and probably because I hadn't been
trained I used to talk to schizophrenics which is a really - at that point
was fairly unusual because you might damage them, and things like that.
Anyway to cut a long story short we had this - the quiet room - on the ward,
which of course is always the noisiest room on the ward, except in this
particular case because the person I was specialling, as they called in,
specialling meaning of course somebody had to be with this person one on one
24 hours a day because they had tried so hard to kill themselves so long.
It was a pretty stupid thing to do because this was a 19 year old woman with
a 20 year old man and we were locked in a room together for her safety.
Astonishing really, but there you go. She had been diagnosed catatonic
schizophrenic and hadn't spoken for weeks or months. And there was little old
me with no training whatsoever, which may have been a blessing perhaps. I
don't know.
And she said nothing of course, for the first two-hour session, and then had
another session where we were just sitting there staring at the wall, really,
with me trying to keep as still as possible. I didn't want to freak her or me
out. However, about the third or forth day she got one word out. Which was
‘my'. I said sensible things out of the textbook like, you know ‘thank you
for sharing that' or, I don't know what I said. I said something that was
meant to communicate - if you want to talk some more that's cool; if you
don't that's cool too. That's probably what I said. Something like that. So
she didn't.
Until the next day when she said ‘father'. And on the 3rd day she said
nothing. And on the 4th day she said ‘me'. ‘my father' ‘me'. And that was
possibly the first time I started thinking about what had happened to a lot
of people who end up in psychiatric hospitals, and indeed, she had been raped
by her father from age 8 through to 12.
The talk: ‘Why aren't mental health professionals asking about child sexual
abuse?' seems like a silly title because I would guess that some of you, not
all, some of you might assume that we are all doing that.
Those of you who work as trauma counsellors or therapists sometimes, certainly at the beginning but
you learn pretty quickly I think, have a fairly idealised view of people
higher up this hierarchy of ours, the psychologists and the psychiatrists -
don't take offence but hierarchies exist, I'm sorry. We're getting it all
right, and asking the right questions, and so forth.
This talk could really be called The Birth Complications of a Trauma Policy.
And there's bad news throughout here, as so often is the case, as we heard
this morning - mental health professionals do silly things, or often fail to
do the right thing. But there's bad new, and good news at the end. That's
just to acknowledge that other people have helped with this research. Now I'm
not going to dwell on this because this is the subject of many talks over
these 3 days.
This was my first attempt, when I got into university - back into university
to be a lecturer or whatever, after 20 years working the field I was
determined to find out: is there any literature out there to support what I
kept finding over and over and over again, even without asking people about
trauma.
Surprisingly there was. I did a review and found 15 inpatient studies, and
those are the figures that when people are asked, those are the figures of
inpatients. Those figures probably won't surprise many of you, but they're
fairly astonishing to a lot of psychiatrists and psychologists.
Perhaps 3 or 4 years ago the male figures might have surprised some of you.
As the research caught up - there was no research on anything for a long time, then somewhere in the 80s
people decided that well maybe women
who were in bad shape had been sexually abused and physically abused. After that they started
enquiring about men.
Tomorrow I'll do an update on that because we now have 30 to 40 studies
documenting the actual prevalence among psychiatric inpatients. I won't dwell
on this either. That's roughly, my very crude attempt to list the effects.
Roughly in the order of the power of the relationship, but we could dispute
that forever, and tomorrow I'll argue it doesn't really matter as many other
people have argued - John Briere, Colin Ross and so forth.
The one that people immediately dispute on the list is schizophrenia, but
that's for tomorrow. Our own study in NZ on suicidality, and this shocked
even me, a study of 200 community mental health centre clients found that in
adult clients a history of child sexual abuse was a better predictor of
current suicidality than a current diagnosis of depression.
Of course a current diagnosis of depression is predictive of suicidality, I'm
not saying it isn't, but if you're in a silly situation of having one
question only you wouldn't do a Beck depression inventory, you'd ask about
trauma. And of course you need to do both - just to make a point.
In terms of inpatient admissions, and I stress inpatient admissions because
there has been this assumption, which again I'll talk about tomorrow that yes
trauma is related to PTSD and depression and eating disorders.
But then there's this iron curtain that comes down and the really mad
mentally ill biologically and genetically based illnesses in the hospitals
are really not so trauma related, if trauma related at all.
But one of the best studies actually in the world. I'm not just being a proud
Kiwi now, because you've got him now anyway - Professor Paul Mullen - in the 90s showed that after
controlling for most possible intervening variables, women who've been
sexually abused as children are 12 times more likely to have a psychiatric
admission. 12 times more likely. Not 50% v 42%, and that's significant to .05
& that sort of thing. 12 times.
Anyway, a lot of the research we do, quite rightly, is about the effects and
the incidence and so forth. There's very little research actually about what
are mental health professionals actually doing out there. I don't mean that
in the sense of Jeff Masson - what on earth are we doing, we shouldn't be
anywhere near - on a bad day I share that view. What I mean is - what are we
actually doing about this?
So I looked in the research literature. Is anybody researching how much abuse
we are identifying?
What came out was absolutely, to me, very depressing. The only good news
about it is it shows that the false memory people who run around saying that
we're busy planting memories and forcing abuse histories on people are so far
off base it isn't believable. Because these are the figures.
What I'm going to show you next is the
only studies I know of that look at - when researchers go into a clinical
population and do a proper interview schedule around trauma - the percentage
I'm going to show you are the percentages of what they identified, that had
already been identified by clinicians.
In other words, it's the percentage of childhood trauma that clinicians
identify, and it's not very good. I leave that gap there purposely. It's my
attempt to be optimistic because after that little gap there, the more recent
ones are slightly higher. So I like to persuade myself things are getting
better, and I think they are, to be honest. But that is not impressive,
really, is it?
So we wanted to have a look at what was going on in NZ around this.
Sometimes you design studies very cleverly and come up with perfect research
methodology, sometimes they fall on your lap by mistake. This next study I'm
going to show you did exactly that. When I got to NZ ten years ago I worked
in the inpatient unit in Auckland and we, for a year, developed a trauma
policy.
Endless consultation with all the professions, nurses, manager,
psychiatrists, psychologists and we came up with the wonderful complicated
policy that we should ask everybody. Sophisticated eh?
Unfortunately, just as it was about to be introduced the head psychiatrist at
the medical school put his foot down and said ‘Absolutely not, for two
reasons. First of all, I'm not going to have my trainee psychiatrists dictated
to by unit policies. They have to exercise their clinical judgement.' Imagine
a nurse writing that? Bye bye. But equally significantly - ‘You can't trust
mad people to tell you the truth, so what's the point of asking them.' This
sort of stuff.
Anyway, it didn't happen, and I was about to take up my university position,
so with the consultant psychiatrist on the unit, who was very supportive, and
very upset and embarrassed by his senior squashing all this. We just simply
wrote into the admission form - trauma questions.
What came out of that was a nice little study because then we could see what
actually happened. So even when that abuse section was included in the
admission form, 68% of the psychiatrists, and I say psychiatrists because all
the admissions were done by psychiatrists in the hospital just skipped that
section.
They didn't skip many other sections, others were equally intrusive. But it's
unfair to give them a hard time about this because it's a huge ask. We just
naively assumed that we could have a whole world shift just by writing
something on a piece of paper, and that was very silly.
But what interesting was that we could then compare what happened when you do
ask, and when you don't ask, and those are the figures at the bottom. So if
the psychiatrists asked, on admission, the child sexual abuse rate was 47%.
If they didn't, and waited for spontaneous disclosure at some point during
the hospitalisation, it was 6%. The figures, if you include rape and serious
physical assault as an adult are even more staggering.
Of course you can see the self-fulfilling prophesy in that. Because if you
don't ask, and very few people disclose, you're going to think -well yeah,
that's right, in this population it's not that relevant. We did repeat this
study in the community mental health centre. It was slightly better, but not
a lot.
So I'm going to move on now to two studies, which as far as I know are the
only ones in the world about how the community mental health staff respond
when somebody discloses abuse. I find that interesting that there aren't any
studies on that. I would think that is a fairly important part of training.
Perhaps it will be in the future.
So this is not rocket science. This is just a chart review of 100 inpatients
which is actually quite perfect for this particular study. Sometime simple
studies are what you need. So we had out of 152 - there were 52 cases of
childhood or adulthood abuse in the notes which of course will be a massive
under-representation of what there actually was.
In 34% of the notes of the people who disclosed some sort of trauma or abuse
there was some documentation of previous disclosure or treatment. That at
first glance sounds quite petty. Why were we bothering to look at that? Well,
as soon as you think about it you'll get it. There is a huge difference
between somebody who is just telling you for the 57th time, and they told mum
at the time, and they got some support, and it was all relatively alright;
versus someone who has carried that for 15, 20, 25 years and just told you
for the first time. That's a fairly major thing that needs dealing with.
Our category of support - one, in hospital, we caste as broadly as possible -
anything we would have counted as a support in hospital - somebody to talk
to, a pamphlet, anything - and there was nothing in any of the notes at all.
That's not fair though because I know, I worked there and I know that some of
those nurses were superb, and they would have talked to them.
So it actually raises a different issue: why weren't they recording it? We
couldn't answer that from this study. My own guess is - an attempt to be
respectful.
But it's not helpful. Apart from anything else, someone's going to ask them
again unnecessarily, or it needs to go into a treatment plan, or something.
Or they need to be asked, what do they need around that. Rather than have
these private - it's understandable but it's not good practice, and
psychologists were terrible on that. They really thought they would make
these promises to people - you know, around confidentiality, if you tell me
about your trauma I won't tell anybody else.
They're part of a multi-disciplinary team of 30 people and they're hoarding
this secret. It's bordering on collusion. It's not meant that way, but it
actually is in practice.
So how many were referred for any sort of counselling: 9%. How many were
reported to legal or protection agencies: none. Remember this is including
adult abuse. Some of these cases will have been ongoing physical beatings at
home. There was none reported to anybody.
So we thought - inpatient, afraid of chaos, not their job, let's look what
happens when they get to the community mental health centre. So we did it
again with 200 outpatients at the community mental health centre.
It was a little bit better, not on the documenting previous disclosure or
treatment, which you would think would be quite important if this is where
you're going to see someone for weeks or months. It made it into a summary
formulation at discharge time in about 37% of cases. Just disappeared the
other 2/3 roughly.
More got abuse counselling this time. Remember in the inpatient unit it was
9% got some sort of trauma counselling. 22% here, which is much better.
Then back to this issue of reporting to legal or protection agencies. We now
have, if you put the 2 studies together, 144 trauma cases identified,
disclosed to mental health professionals and recorded in the notes. None of
those 144 were reported to anybody.
I'm not for a second saying that they all should have been. I mean, if a
woman discloses ongoing domestic violence to you, you don't, unless it's an
absolute matter of life and death at that point, you do not have the right,
obviously, to pick up the phone because you could actually be sentencing her
to death in fact, without wanting to get melodramatic. I think you're nodding
enough to know what I'm saying. You have to consult.
So then we went back - Where there any discussions? Because this is what a
mental health professional's responsibility is - to discuss with the client
the pros and cons of instigating any legal proceedings, and believe me
there's cons to doing that.
We found one, out of the 144 where the professional had had some discussion.
So this is all fairly bad news.
But we realised what we needed to do, instead of just sitting around feeling
miserable about it, is to get on and design a training programme to fix this.
I think universities are actually supposed to do things in the real world now
and again. Don't tell my colleagues about that. They think we're a bit
strange.
As chance would have it, Auckland Rape Crisis, which is a wonderful
organisation which doesn't just deal with adult rape, does deal with child
sexual abuse as well, already had a programme called ‘Dealing with
Disclosures' which they took round the schools for the teachers.
I was talking with a director about 5-6 years ago, 5 years ago now. I said,
‘That's great, we'll just take that to the mental health professionals. I
said, ‘But there's nothing in there about asking. This is just dealing with
disclosures.'
She said, ‘John, don't be stupid. Mental health professionals don't need to
be taught how to ask about trauma.' Then I showed her the research. So we put
an extra component in.
But we also wanted to find out first, what were the reasons. Why weren't
people asking?
You could probably predict most of the answers. We did a survey, a fairly
small survey, of psychologist and psychiatrists and we just simply asked
them: In circumstances where you don't take a trauma history, why not?
The two most common answers were - perfectly reasonable: There are too many
more immediate needs and concerns; and you can all think of circumstances
when it would not be the right idea to take a trauma history. If someone's
acutely suicidal, acutely psychotic. I don't mean just because they're
psychotic, or got a psychotic diagnosis. I mean when they're acutely
psychotic that would be the wrong time to ask.
However, the problem with this is that then, if they don't ask on admission
it never gets asked afterwards. There's no follow-up, so it falls through the
gap. But that's a good reason, I think.
Second most common reason - Patients may find the issue too disturbing, or it
may cause a deterioration of their psychological state. Yes. That's fair
enough. Especially if you do it badly. It can of course be upsetting to a
number of traumatic things.
But a lot of patients who've been in the mental health system for years find
it even more upsetting that they've been going through the system for 10, 15 years and no one's ever said ‘Excuse
me, what's gone on in your life, that you're in this state?' So that's a bit
of a mixed blessing. Or sort of a good reason and sort of isn't. It's a good
reason for learning how to do it properly, I think.
The third and forth reasons I won't put up because I was so sceptical about
it. Everybody suddenly, when asked this question, became terribly gender
conscious and culture conscious. So we were all the wrong gender and all the
wrong culture. So we can't ask that all of a sudden.
I'm not belittling those issues, the issue of gender matching, culture
matching, of course are crucial - but we were a bit astonished at how the
psychiatrists suddenly, suddenly got all interested in culture all of a
sudden when it came to - Why don't you ask about trauma?
Excuse my cynicism. We also found a couple of other reasons why people aren't
asking. This one makes me particularly angry: It seems - this is only a
correlation, couple of correlations - but it seems that the false memory
propaganda is actually inhibiting us from doing our work, or some of us.
The reason I say that is, in this study we had a little scenario and asked,
you know, what's the likelihood of you asking - I think it was a depressed
woman who's 30 and some self-mutilation - it didn't really matter what it
was. It's like - what's the chances of you asking? That was correlated with
the belief that if we ask about child abuse we might be suggestive and
therefore possibly induce false memories.
So the more people believed that, the less likely they were to ask, which of
course is common sense, but it still made me sad to actually think that we
were not doing our job because of those idiots out there claiming epidemics
of false allegations and so forth.
It was also correlated to the percentage of disclosures believed. So we asked
all these people what percentage of disclosures to mental health
professionals do you think are false. The average was 4.9. There's no right
answer to that question. We could all guess. And they were guessing. The
point about that is the higher the percentage was, the less likely they were
to ask.
The other thing that seems to be operating is - again not surprising -
affected by genetic causal beliefs - people who were diagnosed psychotic or
schizophrenic, which is supposed to be the most biological and genetic based
of all mental health problems, but I'll blow that one away tomorrow, if you
need it still to be blown away - they were less likely to be asked.
The other two groups - what other two groups were less likely to be asked?
They're not diagnosis, they're demographics. Who is less likely to be asked
about trauma? Men. Yes. And older people. So if you're a forty year old male
person with a diagnosis of schizophrenia you have no chance whatsoever of
anybody asking you about this.
People with these diagnoses were also less likely to be referred for trauma
counselling. Best time to ask. This is important. This is just their opinion,
these psychiatrists and psychologists. 62% once rapport has been established.
Then a slightly contradictory, because you could give more than one reason,
47%, near half, said on admission unless the client is too distressed.
There's a contradiction there because you usually don't establish a
particularly good rapport when someone's admitted to an inpatient unit within
5 minutes. So there's a contradiction there.
In this audience - With the psychiatrists when we do the training we push
them hard to ask on admission because we know it doesn't get asked
afterwards. But with this particular audience I would stress a different sort
of worry. Sometimes I think counsellors and therapists and psychologists wait
too long.
Of course rapport is important, but you can wait for that special magic
moment after three years when the rapport is just right that you can ask that
awful question and all that time you've actually been - not colluding
purposely - but you've been creating the impression that you're not
interested.
So I would pose a question to you: Sometimes maybe asking what's gone on in
someone's life can help build that rapport. And not doing that, and waiting
for that magic moment can actually get in the way of building it.
Here's the good news to end with. I
still find this astonishing because I'm such a pessimist really, but
something happened in Auckland, the time was right or whatever, some very
good people there, and they introduced, partly as a result of our research
but mostly because there was just some very good people there. Mostly women,
but not all. Introduced a policy: the assessment of mental health clients
must include questions about possible trauma/sexual abuse to ensure that
appropriate support and therapy are made available.
Then the key thing that we had forgotten to do when we did our study 6,7
years ago - there must be some training. It's no good just having a policy.
I worked for 20 years in mental health. I never read a single policy. I'm
embarrassed to say so, but it's real. Too busy fucking doing the work to read
the policies.
So very quickly, here's what the training looks like. I'll come back to that.
That's merely there to say that of course trauma is only one piece of the
puzzle. You can get obsessed about trauma. Especially us lot. People who come
to trauma conferences.
Shit there's lots of other stuff goes on in people's lives other than sexual
abuse. So this is part of the thing we use in the training just to - you know
- you ask about trauma in the context of taking a proper psycho-social
history.
Principles - none of this will be - I'm going to whizz through this because I
have brought copies of the training manual, or sections from it. I've brought
about 20. So if you're going to take it - this is blackmail here, this is
emotional blackmail - take it if you think you might use it. In other words,
if you take it, you have to use it, or give it to somebody who might. Okay?
We say - ask all clients - because a lot
of people are still playing that diagnostic game where they look a bit
PTSD-ish so I think we'll ask them about trauma. Understandable 15 years ago
but that's why we put that list up at the beginning. The effects are across
the board. So we can't play those diagnostic games anyway anymore.
Don't ask: were you abused? In that general sense because so many people who
by any definition have been severely traumatised or abused will not have used
that word to themselves.
So you have to ask specific behavioural type questions. You do it in a
funnel. You come down from general towards specific. So often around physical
abuse. If you ask how was discipline dealt with, you sometimes get it there.
If you don't get it there you do actually have to ask the specific sort of
questions. Were you ever hit in a way that left bruises, cuts or broken
bones?
When we do the training, do the role play, everybody gets to the bit where
you have to ask about the sexual abuse. Did anyone ever do anything sexual
with you that made you feel uncomfortable?
We had a committee worked for a year on the wording of that question. There
were 8 of us. There's no magic way. Every time we had another meeting we
changed the bloody wording of it. So it's a guideline. It's something to hang
onto when you get to that moment when you've got to actually ask.
Because in the training you've got experienced, brilliant mental health
professionals, and the training gets to the role playing, they get to ask
[gagging sounds] they can't get the word out. It just doesn't happen. And I
still feel like that sometimes as well. Response to disclosures - are fairly
straightforward principles.
Most consumers actually say - when you ask consumers: How would you like to
be responded to if you disclose to a mental health professional? They say
just: Don't do anything in particular. Just sit still, will you. Don't freak
out. Don't go - Oh terrible that's really awful. Don't go - sexual abuse;
next. Somewhere in the middle like just - when in doubt do nothing, like be a
person, just sit still.
I want to end by going back to the quotes from - while we were asking the
professionals we asked 74 abusers about their trauma. No. Not about their
trauma so much as about whether they were asked about sexual abuse or
physical abuse, and how they felt about being asked or not asked.
We wanted this to use in the training so we could get the professionals over
this big thing about - that we're going to upset them. Okay. Here's just
three of the main quotes: ‘There was an assumption I had a mental illness,
and because I wasn't saying anything about my abuse no one knew.' ‘There were
so many doctors and nurses and social workers in your life asking you about
the same thing, mental, mental, mental, but not asking you why.' ‘I wish they
would've said: "What happened to you? What happened?" But they didn't.'
Questions: JR: All adults, 18 and above. --
Panel: Dr David Leonard, psychiatrist (chair); Dr Sue Bramm, psychiatrist; Dr
Janine Stevenson, psychiatrist, Dr Michael Crewdson, psychotherapist, Dr John Read, Kim McGregor
on ‘A dilemma for Diagnosticians and
their Insurance Company: PTSD and DID - Rarity, Feminist Fantasy, Artifact or afraid to bite the hand that
feeds them?' ... snip.... [poor audibility]
John Read: False memory people tell us that being feminist we all have hairy
armpits and ... lesbians and it's all their fault ... I know very little
about this. We have a different system in NZ as most of you will know. There
are a lot of similarities and parallels. I will defer to Kim McGregor here.
It's relatively easy to get payment for trauma therapy…...
Kim McGregor: I'm Kim McGregor. I'm a researcher at the university. ... My
involvement with ACC started when I was doing a review of abuse-focussed
therapy - the trauma model - a literature review.... the ACC allowed me to
publish this, which is a synopsis of the literature review of the trauma
model. It's called Therapy Guidelines for Adult Survivors of Child Sexual
Abuse. It really advocates for long-term therapy. ACC allowed me to write
this but -
Voice: asked you to write it -
Kim McGregor: Well yes. They asked me to write it, but they don't support it
in lots of ways. I have professionals around the country saying ‘Why don't
ACC sort of listen to the therapy guidelines that these people have
published?' It is a no fault scheme, but it's very difficult. We have
reports. Beginning - you have to disclose within four sessions?
Voice: You have to write three reports in the first 10 sessions. So the first
report is due after up to a maximum of 3 sessions.
Kim McGregor: and there's an issue about the amount of information. We're
talking about telling stories so that they get a full description of what
happened, but there's also a difficulty with giving that much information to
a bureaucracy where there may be sharing of information between
government departments at a later
date. There's an issue with diagnosing children who have been abused because
then that diagnosis goes on their school records, and I've had people who've
tried to get insurance for their mortgages and they have to say whether
they've ever been diagnosed with a mental illness and that covers PTSD.
Chair invites questions. ..... [nothing relevant to NZ or NZ speakers] .....
[much talk of ‘retraumatisation' ‘revictimisation' ‘disenfranchise' etc]
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