Mainstreaming silence: psychiatric services and sexual violence

Silence typically characterises the experience of sexual violence, particularly in childhood. It is a silence that is demanded and coerced by perpetrators, and sanctioned by families, communities and society. Sexual violence survivors have long described the way in which psychiatry can reinforce this silence, causing further harm to an already shattered self (e.g. Smith et al., Reference Smith, Dogaru and Ellis2015; Bond et al., Reference Bond, Ellis and McCusker2018). Collectively, we may recognise the silencing of the past, of the wives and daughters placed in Victorian asylums. But we deny the silencing of the present, for psychiatry is different now, not like the representations of One Flew Over the Cuckoo's Nest (Kesey, Reference Kesey1962), but benign, expert, well-meaning. We may concede that psychiatry silenced sexual violence survivors in the 1960s, maybe even the 1970s, but surely not now.

The experiential knowledge of survivors, shared in conversations, blogs, book chapters and beyond reveals a different story.

It is only in recent years that mainstream mental health research has established the role of gender-based violence in the development of significant mental distress (e.g. Bebbington et al., Reference Bebbington, Jonas, Kuipers and King2011; Khadr et al., Reference Khadr, Clarke, Wellings, Villalta, Goddard, Welch, Bewley, Kramer and Viner2018); this partially explains the paucity of research eliciting survivors’ views of support needs and services. Sexual violence survivors may justifiably expect that psychiatric services have a long-held fundamental understanding of trauma and sexual violence, how it impacts on people and survivors’ subsequent support needs. It often comes as a shock when survivors attempt to access help and realise that not only is there very little well-funded support available, but that the response of psychiatry can be actively harmful (Smith et al., Reference Smith, Dogaru and Ellis2015; Bond et al., Reference Bond, Ellis and McCusker2018). This can leave desperate people with a choice between harmful help, or no help (Jensen, 2004 quoted in Russo, Reference Russo2018, p. 10). Further, asking for help with nothing changing can replicate damaging early experiences (e.g. see Smith et al., Reference Smith, Dogaru and Ellis2015).

What do we mean when we describe psychiatric help as harmful? It is not uncommon, even in the #MeToo era, for sexual violence survivors to be disbelieved by psychiatric services, to be explicitly told ‘You were not abused, you have a mental illness’ (see also Hughes et al., this issue). Russo writes, ‘psychiatry is one of the best preventions of truth … becoming a mental patient was a good solution for everyone, except for me’ (Reference Russo, Read and Reynolds2002). Research has found that mental health staff often fail to validate disclosures because service users have psychiatric diagnoses (Mantovani and Allen, Reference Mantovani and Allen2017), and frequently use ‘alleged’ when recording disclosures in medical notes (Trevillion et al., Reference Trevillion, Hughes, Feder, Borschmann, Oram and Howard2014), a subtle form of silencing. Alongside inflicting immense psychological damage, denying sexual violence jeopardises criminal proceedings and risks keeping people in abusive situations.

Connected to this, the power and authority of biomedical psychiatric interpretations of mental distress can delegitimise people's own knowledge:

Whilst experiences of diagnosis are idiosyncratic, receiving a diagnosis can operate as a powerful signifier that it is you who are the problem, not your experiences, reinforcing silence. The label ‘personality disorder’, for instance, locates the problem within the individual and de-legitimses the search for meaning in one's responses to, and interaction with, the social world (Coles, Reference Coles2013). Watson has observed, ‘What messages is society giving to abusers when victims are given disorders as the explanation for distress?’ (Reference Watson2018). Similarly, Shaw and Proctor comment:

Prominent psychiatrist and trauma researcher Judith Herman argues that help is always harmful when it mimics the original trauma by taking power away from the survivor (Reference Herman1997). Everyday experiences of using psychiatric services can re-traumatise survivors and actively prevent healing. Consider the use of restraint and forcible injection, which can physically re-enact rape and sexual assault. Agenda, a UK-based non-governmental organisation, has found that one in five women and girls admitted to UK psychiatric units experience physical restraint, including repeated and face down, and that women and girls are more likely to be restrained than men and boys (2017).

The damage inflicted by ‘power over’ responses to distress also takes subtler forms, including overt and insidious pressures to accept prescriptions, treatments and diagnoses that may conflict with people's own beliefs and needs. This replication of invalidation, coercion and force can be hugely damaging, not only to survivors but also to staff, particularly those who are themselves survivors: research suggests that there are significant trauma rates amongst health and social care staff (e.g. Bracken et al., Reference Bracken, Messing, Campbell, La Flair and Kub2010; Esaki and Larkin, Reference Esaki and Larkin2013; McLindon et al., Reference McLindon, Humphreys and Hegarty2018). This is because the organisational expectation that staff will use ‘power over’ relational approaches can erode staff compassion (Sweeney et al., Reference Sweeney, Clement, Filson and Kennedy2016), with pessimism – rather than hope – protecting staff from feelings of helplessness (Chambers et al., Reference Chambers, Gallagher, Borschmann, Gillard, Turner and Kantaris2014). Biomedical dominance, insufficient support and training in sexual violence and trauma-informed approaches, and inconsistent access to structured, reflective supervision can act as further barriers to compassionate responses to sexual violence survivors (see Sweeney et al., Reference Sweeney, Filson, Kennedy, Collinson and Gillard2018). Furthermore, it is difficult for staff to face and accept the scale and horror of sexual violence and abuse without support (see Sweeney et al., Reference Sweeney, Filson, Kennedy, Collinson and Gillard2018). Bond and colleagues (Reference Bond, Ellis and McCusker2018) interviewed 28 CSA survivors, and found:

Sexual violence within psychiatric settings

Perpetrators of sexual violence are able to operate in institutions where organisational cultures reinforce silence; where there is a ‘conducive context’ (Lovett et al., Reference Lovett, Coy and Kelly2018). Following a recent investigation into the aid sector, the UK House of Commons International Development Committee concluded:

Psychiatric service users are also vulnerable to institutional sexual exploitation and violence, not least because psychiatric labels can undermine claims to truth and rationality (Roper, Reference Roper, Russo and Sweeney2016; Rose, Reference Rose2017). The few studies that have been conducted into sexual violence on inpatient wards are deeply troubling. A survey of 50 women in Australia found that 45% had been sexually assaulted whilst an inpatient, and of the 61% who reported this to staff, the overwhelming majority (85%) found the response unhelpful (VMIAC, 2013). One participant commented ‘If the assailant is not a patient but a nurse or doctor who can you trust or turn to for help?’. A recent investigation by England's Care Quality Commission found that on inpatient psychiatric wards over a 3-month period in 2017, there were reports of 29 rapes, 273 sexual assaults and 184 acts of sexual harassment, the majority against service users (2018). The report also concluded that recording rates may be low, partially due to staff desensitisation through the regularity of incidents (see Hughes et al., this issue, for further discussion). Police recording of sexual assaults on psychiatric inpatient wards has also been found to be inadequate (Foley and Cummins, Reference Foley and Cummins2018). Whilst the UK has a policy of gender segregation on inpatient psychiatric wards, this cannot protect people from sexually violent staff, or perpetrators of the same gender.

Out of the silence: grassroots and community-based responses

The UK has few statutory services for sexual violence survivors (Coy et al., Reference Coy, Kelly and Foord2009; Allnock et al., Reference Allnock, Radford, Bunting, Price, Morgan-Klein, Ellis and Stafford2012; Hawkins and Taylor, Reference Hawkins and Taylor2015; Kennedy and White, Reference Kennedy and White2015), with National Health Service trauma clinics often excluding experiences of childhood abuse. This, coupled with experiences of statutory iatrogenic harm, means that many survivors are seen in community-based specialist sexual violence services (Bond et al., Reference Bond, Ellis and McCusker2018). Despite survivors’ generally reporting positive experiences of these services (Bond et al., Reference Bond, Ellis and McCusker2018), they are often underfunded, resulting in long waiting lists, session fees and time-limited therapy (Smith et al., Reference Smith, Dogaru and Ellis2015). It is also uncommon for the sector's specialist expertise to impact on psychiatric services: indeed, there are concerns that the direction of influence runs the other way, with a psychiatric ‘creep’ into anti-violence services, such as the increasing tendency to establish separate services for the ‘mentally ill’ (Rubinsztajn, Reference Rubinsztajn, Russo and Sweeney2016).

Survivors who have experienced pathologisation and iatrogenic harm often move away from helper–helpee roles, connecting instead through mutual peer support (e.g. Filson and Mead, Reference Filson, Mead, Russo and Sweeney2016). Some survivors have established organisations fostering peer support, self-help, activism, campaigning and education, often simultaneously. In the UK, these include Survivors’ Voices (co-established/led by CP, http://www.survivorsvoices.org), Butterfly (established by VA, http://focus-4-1.co.uk/projects-services/) and The Survivors’ Collective (www.survivorscollective.co.uk). There are also important transnational sources of influence and inspiration. Endeavours like these are often run with little or no funding, reliant instead on the passion and commitment of key members.

In reflecting on a Berlin-based survivor-led sexual violence project, Rubinsztajn observes:

Carr writes of, ‘the persistent argument from service users, survivors, their organisations and communities … that we must have independent organisations, arenas and power bases from which to think and do for ourselves’ (Reference Carr2018). Rubinsztajn also voices concerns that survivor-led sexual violence projects can come to mimic the mainstream services they critique; she describes the lack of a single ‘we’ in survivors’ needs and perspectives, with some experiences highlighted and others unspoken, such as of racism. Adopting an intersectional approach is a shared core standard for a number of women's anti-violence services, benchmarking good practice (Imkaan et al., 2016).

The hope of trauma-informed approaches

Trauma-informed approaches may be a way of enabling all services – community and statutory alike – to come closer to meeting survivors’ needs, as well as improving staff experiences (e.g. see Sweeney et al., Reference Sweeney, Filson, Kennedy, Collinson and Gillard2018). Trauma-informed approaches are an organisational change process that can be described as:

The aim then is to improve experiences, relationships and environments for staff and service users. Whilst concepts like ‘strengths-based’ and ‘empowerment’ can seem almost meaningless because of their overuse, they are hugely significant in this context, intended to reverse the ‘power over’ abuses that are at the heart of sexual violence and iatrogenic harm (see Butler et al., Reference Butler, Critelli and Rinfrette2011; Sweeney et al., Reference Sweeney, Clement, Filson and Kennedy2016).

Fundamental to trauma-informed approaches is ‘seeing through a trauma lens’ – that is, understanding the connections between experiences and coping strategies – and preventing (re)traumatisation. Although further principles have been fairly well described (see e.g. Elliot et al., Reference Elliot, Bjelajac, Fallot, Markoff and Glover Reed2005; Butler et al., Reference Butler, Critelli and Rinfrette2011; SAMHSA, 2014; Filson, Reference Filson, Russo and Sweeney2016; Sweeney et al., Reference Sweeney, Clement, Filson and Kennedy2016), the approach is relatively complex and consequently, commonly misunderstood (Sweeney and Taggart, Reference Sweeney and Taggart2018). This increases the risk that where implemented, it could be diluted to the point of worthlessness (Sweeney and Taggart, Reference Sweeney and Taggart2018). Change is required at a systemic level, including staff support, training and reflective supervision (Bloom and Farragher, Reference Bloom and Farragher2010). Alongside commissioning meaningful trauma-informed services (Bush and Brennan, Reference Bush, Brennan and Bush2018), commissioners should develop and strengthen peer-led organisations, reinforcing local capacity to engage in service provision, peer support and campaigning (e.g. Bott et al., Reference Bott, Sweeney and Watkts2010).

Despite widespread interest in, and early implementation of, trauma-informed approaches, there is a lack of underpinning empirical research (see Christie, Reference Christie2018). And just as there are vast differences between grassroots and mainstream psychiatric services, so too there are vast differences between survivor-led and mainstream research approaches (e.g. see Russo, Reference Russo2012). Research led by and co-produced with survivors is needed to understand whether and how services meet survivors’ needs, and to investigate the potential – and potential failings – of trauma-informed approaches. This research should itself be trauma-informed (Shimmin et al., Reference Shimmin, Wittmeier, Lavoie, Wicklund and Sibley2017) and occur within an epistemic injustice framework (understanding discrimination and exclusion in knowledge generation and against knowers) (Fricker, Reference Fricker2007), with an understanding of how participation affects survivor researchers, particularly when working in partnerships (Roper, Reference Roper, Russo and Sweeney2016). The Charter for Organisations Engaging Survivors in Projects, Research & Service Development, currently being piloted, aims to provide a quality mark for safe, meaningful and effective survivor involvement in research (Perôt and Chevous, Reference Perôt and Chevous2018).

Closing thoughts

Survivors of sexual violence and abuse can feel let down over and over again – that the abuse was able to continue for so long; that perpetrators are able to continue abusing, including within psychiatric services; that the criminal justice system is stacked in perpetrators’ favour (as evidenced by low conviction rates, Walby and Allen, Reference Walby and Allen2004); and that the psychiatric system, which should understand and support survivors, is more often harmful and pathologising of individual responses, rather than recognising people's strengths and remarkable ability to adapt and survive. It is through validation (the act of believing) that a climate of support and recognition for victims and survivors of sexual violence and abuse is created. Our core belief, and one that is worth repeating, is that the expertise about what we need to heal lies with us.