Published in
The Journal of Mental Health
Administration 21(4): 374-387, 1994. Reprinted by permission.
Editor’s
Note: The reader is forewarned that, to provide a
realistic account of Anna’s experience and her attempts to communicate it to
others, explicit language and graphic descriptions of her behavior are
included.
COMMENTARY
On Being Invisible in the
Mental Health System
Ann Jennings, Ph.D.
Abstract
The author
provides a case study of her daughter’s sexual abuse as a child and subsequent
experiences as a chronically mentally ill client in the mental health
system. Information from 17 years of
mental health records and anecdotal accounts are used to illustrate the effects
of the abuse, her attempts to reach out for help, and the system’s failure to
respond. There is evidence that a
significant subset of psychiatric patients were severely sexually traumatized
in childhood. Yet standard interview
schedules consistently neglect to ask questions about such abuse, appropriate
treatment is seldom available, and clients are often retraumatized
by current practices. Psychiatry’s
historic resistance to addressing abuse as etiology is being challenged today
by powerful economic, political, and professional forces leading to the
emergence of a new trauma-based paradigm.
This commentary brings into question one of the basic assumptions
operating in the public mental health field today – that mental illness is
biological or genetic in origin and is therefore treatable primarily by symptom
control or management. A case study of
my daughter Anna, a victim of early childhood sexual trauma, is used to
demonstrate the need for inclusion in the field of an additional view of the
etiology of mental illness. Forces
supporting the emergence of a new trauma paradigm are highlighted.
Anna’s Story
From the age of 13 to her recent
death at the age of 32, Anna was viewed and treated by the mental health system
as “severely and chronically mentally ill.”
Communication about who she was, how she was perceived and treated, and
how she responded took place through her mental health records. A review of 17 years of these records reveals
her being described in terms of diagnoses, medications, symptoms, behaviors,
and treatment approaches. She was
consistently termed “noncompliant” or “treatment resistant.” Initially recorded childhood history was
dropped from her later records. Her own
insights into her condition were not noted.
When she was 22, Anna was
reevaluated after a suicide attempt. For
a brief period, she was rediagnosed as suffering from
acute depression and a form of posttraumatic stress disorder. This was the only time in her mental health
career that Anna agreed with her diagnosis.
She understood herself—not as a person with a “brain disease” but as a person
who was profoundly hurt and traumatized by the “awful things” that had happened
to her.
Address
correspondence to Ann Jennings, Ph.D.,
What Happened
to Anna?
Anna was
born in 1960, the third of five children, a beautiful healthy baby with a
wonderful disposition. At the age
of about 2½, she began to scream and cry inconsolably. At age 4, we took her to
a child psychiatrist who found nothing wrong with her. When we placed her in nursery school, her
problems seemed to lessen.
That Anna
was being sexually abused and traumatized at the time is clear now, verified in
later years by her own revelations and by the memories of others. Her memories of abuse by a male babysitter
were vivid, detailed, and consistent in each telling over the years. They were further verified by persons close
to the perpetrator and his family, one of whom witnessed the perpetrator years
later in the act of abusing another child.
Anna
described the experience of being forcibly restrained and sexually violated at
the age of about 3½:
He
tied me up, put my hands over my head, blindfolded me with my little T-shirt,
pulled my T- shirt over my head with nothing on below, opened my legs and was
examining and putting things in
me and all that. . Ugh. It hurt me.
I would cry and he wouldn’t stop.
To do that when I was a little
kid was like . . . uh, I don’t know. . . .It made me feel pretty bad. I remember after he did that I was walking toward the door out of the
room and I was feeling like I was bad. And why not Sarah and
Mary (her older and younger sisters) and why just me? And I had this feeling in me that I was bad you know . . . a bad
seed . . .and that I was the only one in the world.
Evidence that Anna was betrayed and sexually
violated at an even earlier age by another perpetrator, a relative, came to
light eventually through the revelations of a housekeeper in whom Anna had
confided at the time. She had told this
woman that a man “played with her where he wasn’t supposed to” and that the man
“hurted her.”
This abuse was kept secret for nearly 30 years.
Anna remembered trying to tell us,
as a little child, what was happening, but there was no one to hear or respond. When she told me a man “fooled” with her, I
assumed she meant a young neighborhood boy and cautioned his parents. When we took her to a physician, she
experienced the physical examination as yet another violation: “I remember the
doctor you took me to when I told you.
He did things to me that were disgusting
(pointing to her genital area).”
The trauma Anna experienced
was then compounded by the silence surrounding it. She tried to communicate with her rage, her
screams, and her terror. She became the
“difficult to handle” child. Her
screaming and crying was frequently punished by spankings and confinement to
her room. No one then could see or hear
her truth; sexual abuse did not “exist” in our minds. When later, as a young girl, she withdrew
within herself, somehow different and apart from her peers, we attributed it to
her artistic talent or independent personality. We did not see or attend to the
terror, dissociation, loneliness, and isolation expressed in her drawings, nor
did we heed the hints of trouble expressed by her behaviors. Two grade school psychologists were alone
among the professionals we encountered in sensing the turbulence underneath her
silence. “Anna is confused about her
sexual identity,” one reported. “You
must help her.” The other wrote, “It
would seem that Anna has suppressed or repressed traumatic incidents.”
Chaos and parental conflict existed
in Anna’s family from the age of 11 to 13.
Although her four brothers and sisters survived the multiple geographic
moves, alternative lifestyles, disintegration of their parents’ marriage, and
episodic violence and alcoholism, Anna did not.
She “broke” at age 13. A
psychiatrist prescribed Haldol to “help her to
sleep.” She suffered a seizure in
reaction, requiring emergency hospitalization.
Thus was she introduced to the mental health system.
Anna’s
Invisibility in the Mental Health System
Anna was a client of the mental health system for 19 years, until age
32. For nearly 12 of those years, she
was institutionalized in psychiatric hospitals.
When in the community, she rotated in and out of acute psychiatric
wards, psychiatric emergency rooms, crisis residential programs, and locked
mental facilities. Principal diagnoses
found in her charts included borderline personality with paranoid and schizo-typal features, paranoia, undersocialized
conduct disorder aggressive type, and various types of schizophrenia including
paranoid, undifferentiated, hebephrenic, and residual. Paranoid schizophrenia was her most prominent
diagnosis. Chronic with acute
exacerbation, subchronic, and chronic courses of
schizophrenia were identified. Symptoms
of anorexia, bulimia, and obsessive-compulsive personality were also recorded.
Treatments included family therapy; vitamin and nutritional therapy; insulin
and electro convulsive therapy; psychotherapy; behavioral therapy; art, music,
and dance therapies; psychosocial rehabilitation; intensive case management;
group therapy; and every conceivable psycho pharmaceutical treatment including Clozaril. The use of
psychotropic drugs comprised 95% of the treatment approach to her. Although early on there were references to
dissociation, her records contain no information about or attempts to elicit
the existence of a history of early childhood trauma.
Anna was 22 when she learned,
through conversation with other patients who had also been sexually assaulted
as children, that she was not “the only one in the world.” It was then that she was first able to
describe to me the details of her abuse. This time, with awareness gained over the
years, I was able to hear her.
Events finally became
understandable. Sexual torture and
betrayal explained her constant screaming as a toddler, her improvement in
nursery school, and the reemergence of her disturbance at puberty. It explained the tears in her paintings, the
content of her “delusions,” her image of herself as shameful, her
self-destructiveness, her involvement in prostitution and sadistic
relationships, her perception of the world as
deliberately hurtful, her isolation, and her profound lack of trust. I thought with relief and with hope that we
now knew why treatment had not helped.
Here at last was a way to understand and help her heal.
The reaction of the mental health
system was to ignore this information.
When Anna or I would attempt to raise the subject, a look would come
into the professionals’ eyes as if shades were being drawn. If notes were being taken, the pencil would
stop moving. We were pushing on a dead
button. This remained the case until she
took her life, 10 years and 15 mental hospitals later.
There was one exception. When Anna was 25 years old, the chief
psychologist on a back ward of a state hospital listened to her after a suicide
attempt and took seriously what she told him.
He initiated a new treatment approach that addressed her experiences of
sexual abuse. Antidepressant medication
was prescribed, but psychotropic drugs were viewed as suppressing the thought
processes and emotions she needed to feel fully so as to begin healing. Rather than relying on drugs as a solution to
escalating stress, Anna was helped through these crises and taught how to deal
with them. Art therapy was de-emphasized
and art lessons were begun, building her artistic talent and increasing her
self-esteem. Discussions began about
what she needed to leave the hospital and live in the community.
This situation was not to last. The state hospital was closed because of
rampant and intractable abuse. Anna’s
treatment team disbanded. She returned
to the system of public mental institutions and community mental health
agencies, a world in which she was—once again—invisible and undefended. In and out of the “protected environments” of
mental health institutions, she repeatedly experienced coerced or manipulated
sex, verbal and physical abuse, and rape.
When she “broke,” she became like a 3-or 4-year old consumed by rage and
terror. The thoughts, voices, and
nightmares that tormented her were sexual and torturing in nature. Violent itches, twitching, stabbing pains,
ice cold spots, and innumerable other somatic symptoms invaded her slight
body.
Over her remaining years in
community agencies, acute psychiatric hospitalizations, medical and psychiatric
emergency rooms, and the back wards of state mental institutions, she
experienced night terrors and insomnia; fears of being taken over by outside
forces and of “becoming someone else”; voices telling her she was evil,
commanding her to be raped and punished; and eating disorders, dysmenorrhea, and amenorrhea. She painted self-portraits covered with
tears, bodies in bondage without hands or arms, and images of multiple persons
and sexual acts. She was plagued by intrusive
thoughts of abusing her own child, of being tortured, of being seen naked by
everybody, and of people “getting off sexually” on her torment.
She would often “flash back” into
experiencing her childhood trauma, screaming in terror and pleading for
help. On one such occasion, I went with
her to a psychiatric emergency service.
Calmed enough to answer questions, she stated her diagnosis to be
“posttraumatic stress disorder.” The
psychiatrist seemed to be recording this information on the form when my
daughter went over looked at what she had written, turned to me, and said, “Mom,
she wrote down schizophrenic”.
She disclosed, in words and
behavior, fragmented details of the “awful things” that had happened to
her. Once, while in restraints, she
screamed over and over again, “I’m just a sex object,
I’m nothing but a sex object.” She told
her therapist of the “voices” inside her saying, “I’m a very young person,” “I
want you to help me,” and “the baby is crying.”
Once she called her therapist late at night, pleading for her to come to
the hospital because “the baby wants to talk to you.” Permission was denied by the psychiatrist in
charge.
Believing herself to be “bad,”
“disgusting,” and “worthless,” as child sexual abuse victims often do, 1-10
she hurt, mutilated, and repeatedly revictimized
herself. She put cigarettes out on her
arms, legs, and genital area; bashed her head with her fists and against walls;
cut deep scars in herself with torn-up cans; stuck hangers, pencils, and other
sharp objects up her vagina; swallowed tacks and pushed pills into her ears;
attempted to pull her eyes out; forced herself to vomit; dug her feces out so
as to keep food out of her body; stabbed herself in the stomach with a sharp
knife; and paid men to rape her.
Again and again, as victims of
sexual assault often do, 11-21 Anna sought relief through
suicide. She tried to kill herself many
times—slashing her wrists, attempting to drown herself, taking drug overdoes,
poisoning herself by spraying paint and rubbing dirt into self-inflicted
wounds, slitting her throat with a too dull razor, and hanging herself from the pipes of a state hospital. She dared men to kill her—on one occasion by
throwing her off a bridge and on another by stepping on her back to break
it. Many times she would have succeeded
had it not been for outside interventions or her own fears of dying or eternal
damnation.
Many of the mental health
professionals she encountered were highly skilled in their disciplines. Many genuinely cared for Anna, and some grew
to love her. But in spite of their
caring, her experience with the mental health system was a continuing
reenactment of here original trauma. Her
perception of herself as “bad,” “defective,” a “bad seed,” or an evil influence
on the world was reinforced by a focus on her pathologies, a view of her as
having a diseased brain, heavy reliance on psychotropic drugs and forced
control, and the silence surrounding her disclosures of abuse.
In the months prior to her death,
Anna and I began to reconstruct her story.
She completed more than 200 pages of detailed memories of her childhood
from birth to age 15. In her own words,
including her writings and artwork and the memories of her brothers, sisters,
and others who had been close to her, she spoke her truth. ”Mom,” she said,
“I’m gonna try not to live in these places because I
want to get my life—find some
friends, get out some day. Maybe this
book will help. Maybe someone will come
along and understand me. And they won’t
just say “drugs, drugs, drugs!” She gave
her doctor a draft of her book. He did
not read it.
Four days after her 32nd birthday, after
another haunted sleepless night, she hung herself, by her T-shirt, in the early
morning bleakness of her room in a
The Wall of
Silence and Invisibility
The tragedy of Anna’s life is replicated daily in the lives of many
individuals viewed as “chronically and severely mentally ill.” Unrecognized and untreated for their childhood
trauma, they repeatedly cycle through the system’s most expensive psychiatric emergency , acute inpatient, and long-term institutional
services. Their disclosures of sexual
abuse are discredited or ignored. As
happened during their early childhood, they learn within the mental health
system to keep silent.
Clinicians who acknowledge the
prevalence of traumatic abuse and recognize its etiological and therapeutic
significance are deeply frustrated at being denied the tools and support
necessary to respond adequately.
Sometimes, as Anna’s psychologist did, these clinicians leave the mental
health system entirely, deciding they can no longer practice with integrity
within it.
A seemingly impenetrable wall of
silence isolates the reality and impact of childhood sexual abuse from the
consciousness of the public mental health system. No place exists within the system’s formal
information management structures to receive these data from clients. We do not elicit the information, nor do we
record it. Yet to respond
therapeutically without such knowledge is analogous to “treating a
A Paradigmatic
Explanation: The Inability to See
Although rehabilitative,
psychotherapeutic, and self-help approaches operate within the system, the
dominant paradigm within which these approaches are subsumed is clearly that of
biological psychiatry.
Thomas Kuhn, in his analysis of the
history and development of the natural sciences,” brought the concept of
“paradigm” into popular usage. He viewed
paradigms as the conceptual networks through which scientists view the
world. Data that agree with the
scientists’ conceptual network are seen with clarity and understanding. But unexpected “anomalous” data that do not
match the scientific paradigm are frequently “unseen,” ignored, or distorted to
fit existing theories.
In the field of mental health, a
biologically based understanding of the nature of “mental illness” has for
years been the dominant paradigm. It has
determined the appropriate research questions and methodologies; the theories
taught in universities and applied in the field; the interventions, treatment
approaches, and programs used; and the outcomes seen to indicate success.
Paradigmatically understood, the
mental health system was constructed to view Anna and her “illness” solely
through the conceptual lens of biological psychiatry. The source of her pain, early childhood
sexual abuse trauma, was an anomaly—a contradiction to the paradigm—and, as
such, could not be seen through this lens.
Her experience did not match the professional view of mental
illness. It did not fit within the
system’s prevailing theoretical constructs.
There was not adequate language available within the profession to
articulate or label it. There were not
reimbursement mechanisms to cover its treatment. It was not addressed in curricula for
professional training and education, nor was there support for research on the
phenomenon. There were no tools—treatment, rehabilitation, or self-help
interventions—for responding to it. And
there was no political support within the field for its inclusion. Screened through the single lens
of
the biological paradigm, Anna’s experience could not be assimilated. It had to be unseen, rejected, or distorted
to fit within the parameters of the accepted conceptual framework.
As a result of this paradigmatic
blindness, conventionally accepted psychiatric practices and institutional
environments repeatedly retraumatized Anna,
reenacting and exacerbating the pain and sequelae of
her childhood experience. Table 1
illustrates that retraumatization.
The effect of this institutional retraumatization was to continually leave Anna “in a
condition that fulfilled the prophecy of her pathology” (p.5).24 This was especially true in the use of psychotropic
medication. Survivors of trauma tell us the capacity to think and to feel fully
is essential for recovery. Psychotropic
drugs continually robbed Anna of these capacities. Several years ago, she had been through a
crisis period without medication. For
days following, she asked for me to hold her.
She talked softly about her feelings, crying gently, showing trust
through touching and hugs. One day after
her newly prescribed medications were beginning to “take effect,” she said to
me with a flatter voice and her eyes again haunted. “Mom, the feeling of love is going
away.” As her feelings of rage, grief,
and terror were suppressed, so were here feelings of love, laughter, caring,
and intimacy, isolating her again from herself and from others and preventing
the possibility of healing.
Medication can be helpful if used
cautiously with the full understanding and consent of the patient. But without particular knowledge of the kinds
of medications that can alleviate symptoms and facilitate recovery from trauma,
medications can cause incalculable damage.
For Anna, the system’s reliance on psychopharmaceutical
treatment was a metaphor for her original trauma. As sexual assault had violated physical and
psychological boundaries of self, forced neuroleptic
drugs also intruded past her boundaries, invading, altering, and disabling her
mind, body, and emotions. She once said
to me, “I don’t have a safe place inside myself.”
The Emerging
Paradigm
Although the established paradigm may help to alleviate the suffering
of those whose mental illness is strictly genetic or biological in nature, it
is failing for a significant group whose histories contain sexual and/or
physical trauma. Rising cognizance of
this failure is one of several factors currently affecting the mental health
field, indicating the possibility that a new paradigm, based on trauma, is
emerging. The extraordinary resistance
to such a paradigm is also indicative of its power and its eventual
emergence.
Resistance to a Trauma
Paradigm
Although paradigm shifts mark the
way to progress and opportunity, they are always resisted initially. They cause
change, disrupt the status quo, create tension and uncertainty, and involve
more work.25 Resistance
to a sexual abuse trauma paradigm has existed for more than 130 years, during
which time the etiological role of childhood sexual violation in mental illness
has been alternatively discovered and then denied. In 1860, the prevalence and import of child
sexual abuse was exposed by Amboise Tardieu,26 in 1896 by Sigmund Freud,27 in
1932 by Sandor Ferenczi,28 and in 196229 and 198430
by C. Henry Kempe. Each exposure was met by the
scientific community with distaste, rejection, or discreditation. Each revelation was countered with arguments
that in essence blamed the victims and protected the perpetrators. Freud, faced with his colleagues’ ridicule of
and hostility to his discoveries, sacrificed his major insight into the
etiology of mental illness and replaced his theory of trauma by the view that his
patients had “fantasized” their early memories of rape and seduction.26 Today, 100 years later, in spite of
countless instances of documented abuse, this tradition of denial and victim
blame continues to thrive.
Psychiatrist Roland Summit refers to
this denial as “nescience” or “deliberate, beatific ignorance.” He proposes
that “in our historic failure to grasp the importance of sexual abuse and our
reluctance to embrace it now, we might acknowledge that we are not naively
innocent. We seem to be willfully ignorant,
‘nescient’ ”.31
At this point in history, however,
multiple and divergent forces are confronting nescience with truth. Although these forces will continue to meet
resistance, they appear to be forming a powerful movement that will help to
protect children from adult violation and will promote acceptance of a
trauma-based paradigm recognizing the pain of individuals like my daughter and
offering them “the radical prospect of recovery” (p.413).31
Implications
for Mental Health Administrators and Policymakers
Mental health administrators and
policymakers are in a unique position today to prevent the recreation of
tragedies such as that of my daughter Anna.
The tools and resources they need to do so can be found in the following
forces supporting the emergence of the new trauma paradigm.
·
Among the most significant forces for change are the victims
themselves. For the first time in
history, survivors of sexual trauma are speaking out—revealing their
experiences of having been sexually violated as children, lobbying politically
for services and legislative action, challenging societal denial and nescience,
and keeping the reality of the sexual assault of children in the arena of
public awareness. Growing numbers of
these survivors are former mental patients with severe dissociative
disorders. After years of
hospitalization and misdiagnoses such as borderline personality disorder, major
depression, and schizophrenia, they talk of how they could not have recovered
had not someone recognized and responded therapeutically to their childhood
experiences of abuse and torture.
Finally, ex-patients in the mainstream consumer movement are beginning
to reveal their experiences of sexual violation, the ways in which they felt retraumatized by treatment in psychiatric hospitals and
institutions, and their ongoing struggle to heal from both childhood abuse and
adult institutional revictimization.
·
The number of studies, instruments, articles, books, and professional
journals based on a trauma paradigm is multiplying, making visible the most
hidden and most damaged victims of childhood sexual assault and heightening
awareness of such anomalies to the psychiatric paradigm. Research is revealing significantly higher
prevalence rates of childhood sexual abuse among female psychiatric outpatients
and inpatients (as high as 50 to 70%)12
than those found in the general population.
Many of these clients require emergency, acute inpatient care, and
long-term hospitalization services.3,12-14,21,31-57 Studies
establish a history of childhood sexual trauma to have significant implications
for diagnosis and treatment, 4,7,8,11,12,14,18,31-34,36-40,42,44,45,47,49,50,55-90
and the routine inquiry about childhood sexual abuse to be an essential
component of emergency, acute inpatient, and outpatient psychiatric protocols.3,5,12,37,39,45,46,71,91,92 The growing pool of data indicates that when
trauma is recognized and responded to in specific therapeutic interaction,
possibilities of recovery exist even for those survivors of sexual abuse who
are viewed as schizophrenic, depressive, or borderline.31,40,61,76,84,85,89,93-101 Research findings showing inextricable
connections between trauma, physiology, and the brain are now pointing the way
to new relationships between these areas of data under a trauma paradigm.102
·
Political support for a new trauma paradigm is growing as
governmentally sanctioned committees are formed and local, state, and federal
governing bodies pass legislation requiring mental health systems to address
issues of physical and sexual abuse trauma in their clients. One such notable step is a 1993 congressional
mandate directing the national Center for Mental Health Services (CMHS) to pay
attention to women’s issues. After
surveying the field, CMHS established its priority focus to be on physical and
sexual abuse in the lives of seriously mentally ill women.
·
New therapeutic approaches to sexual and other trauma in seriously
mentally ill persons are being used and developed outside of and on the fringes
of the public mental health system.
Examples can be found in the dissociative
disorder units of private psychiatric hospitals, in the work of art therapists
using imagery and play therapy with traumatized children, in the treatment of
severely traumatized war veterans, in the specialized victims and offenders
services now serving severely mentally ill individuals, in incest survivor
self-help groups, in rape treatment centers, increasingly in the field of child
psychiatry, and in the work of private therapists.
·
Respected national and international professional associations focused
on research and treatment of severely traumatized children and adults have
formed over the past decade, and networks of professionals, advocates, and
ex-patient survivors increasingly proliferate.
·
Women’s rights and mental health litigators are being asked to
recognize the connection between sexual violence, “craziness,” and the
treatment of women in psychiatric institutions.
These connections are seen to have consequences for rights to treatment,
rights to refuse treatment, and forced medication and seclusion and restraint
cases.24
·
Finally, a powerful force for paradigmatic change at this time in
history is the advent of health care reform, introducing managed care,
capitation, and the need for public mental health organizations to compete in
providing quality services to consumers in a cost-effective way. Incorrect diagnoses and treatment exacerbate
the condition of traumatized patients, making them dependent on the system’s
most restrictive and expensive services.
An analysis of 17 years of Anna’s records shows that she was
hospitalized a total of 4,248 days. The total cost for this hospitalization,
figured at $640 a day, was $2,718,720.
Had she lived to the age of 52, these costs would have nearly tripled to
$7,390,720. Not included in this
analysis is the cost of social services, police, ambulance and legal/court
services, conservator and patient advocacy services, residential treatment,
psychiatric and therapist sessions, crisis services, day programs, and
intensive case management. With studies
showing prevalence rates as high as 81%46 of hospitalized patients
with histories of sexual and/or physical trauma, the fiscal implications to
exploring a trauma paradigm are obvious.
Conclusion
The ideas, practices, and standard operating
procedures that got the public mental health field and its various agencies and
institutions to where they are today will clearly not take them into the
future. The rules have changed
dramatically. Forces shaping a new paradigm include health care reform and
managed care, the need to compete and to deliver quality services in
cost-effective ways, the emergence of political activism and public testimony
on the part of ex-patient survivors of trauma, the proliferation of research
and writing about sexual trauma and serious mental illness, the intense
interest and debate around the import of sexual abuse for treatment, the
developing legal interest in the system’s retraumatization
of sexually abused patients, the growth of private psychiatric hospital
services for persons with dissociative disorders, and
the advances around the fringes of the public mental health field providing
evidence that, when trauma is recognized and responded to therapeutically,
actual recovery is possible for persons with histories of hospitalization and
use of the most expensive services of the system. Resources for “retooling” the mental health
system to effectively address trauma are to be found in the forces pushing the
field to change. Institutions, agencies,
and systems that ignore the opportunities presented by the new trauma paradigm
will do their patients an injustice.
TABLE 1: INSTITUTIONAL
RETRAUMATIZATION
__________________________________________________________________________________________________________
Early
Childhood Trauma Experience Common
Mental Health Institutional Practices
__________________________________________________________________________________________________________
Unseen
and unheard Anna’s child psychiatrist did not inquire or see Adult psychiatry does not inquire into, see
signs of
signs of sexual trauma. Anna misdiagnosed. sexual
trauma. Anna misdiagnosed.
Anna’s
attempt to tell parents and other Reports
of past and present abuse ignored, disbelieved
adults met with denial and silencing. discredited. Interpreted as delusional. Silenced.
Only
two grade school psychologists saw Only two psychologists saw trauma as etiology. Their
trauma. Their insight ignored by parents. insight
ignored by psychiatric system.
Secrecy:
Those who knew of abuse did not Institutional secretiveness replicates that of family.
tell. Priority was to protect self, family Priority is to protect
institution, jobs, reputations.
relationships, reputations. Patient
abuse not reported up line. Public
scrutiny
not allowed.
Perpetrator
retaliation if abuse revealed. Patient
or staff reporting of abuse is retaliated against.
Abuse
occurred at a preverbal age. No one No
one saw the sexual trauma expressed in her adult
saw the sexual trauma expressed in her artwork with the exception of
one art therapist.
childhood artwork.
Trapped Unable to escape perpetrators’
abuse. Unable to escape institutional
abuse. Locked
up.
Dependent as child on family, caregivers. Kept dependent.
Denied education or skill development
Sexually
violated Abuser stripped Anna, pulled T-shirt Stripped of clothing when secluded or restrained,
over her head to hide her face. often by or
in presence of male attendants.
Stripped
by abuser to “with nothing To inject with medication, patient’s pants pulled
on below.” down, exposing buttocks and thighs, often by
male attendants.
“Tied
up,” held down, arms and hands “Take
down,” “restraint.” Arms and legs shackled
bound. to bed.
Abuser
“blindfolded me with my little Cloth
would be thrown over Anna’s face if she spit
T-shirt.” or screamed while strapped down in restraints.
Abuser
“opened my legs.” Forced four-point restraints in spread-eagle position.
Abuser
was “examining and putting things Medication
injected into body against patient’s will.
in me.”
Boundaries
violated. Exposed. No privacy. No privacy from patients or staff. No boundaries.
Isolated Taken
by abuser to places hidden from Forced,
often by male attendants, into seclusion others. room.
Isolated
in her experience: “Why just me?” Separated from community in locked facilities.
“I
thought I was the only one in the world” No
recognition of patients’ sexual abuse experiences.
Blamed
and Shamed “I had this feeling that I was bad….. a bad Patients
stigmatized as deficient, mentally ill,
seed”. worthless. Abusive
institutional practices and ugly
environments convey low regard for patients, tear
down self-worth.
She
became the “difficult to handle” child. She
became a “noncompliant,” “treatment-resistant,”
difficult-to-handle patient.
She
was blamed, spanked, confined to her Her rage, terror, screams, and cries were often
room for her anger, screams, and cries. punished
by medications, restraint, loss of
“privileges,” and seclusion.
Powerless Perpetrator
had absolute power/control Institutional
staff have absolute power/control over
over Anna. patients.
Pleas to stop violation were
ignored: “It Pleas and cries to stop abusive
treatment, restraint,
hurt me. I would cry and he wouldn’t seclusion, overmedication, and so forth, commonly
stop.” ignored.
Expressions
of intense feelings, especially Intense feelings, especially anger at those with more
anger directed at parents, were often power (all staff), suppressed by medication,
suppressed. isolation, restraint.
Unprotected Anna
was defenseless against perpetrator Mental
patients defenseless against staff abuse.
abuse. Her attempts to tell went unheard. Reports disbelieved. No safeguards
effectively There
was no safe place for her, even in protect patients. Personnel
policies prevent dismissal her own home or room. of abusive staff. No
safe place in institution.
Threatened As
a child, constant threat of being As mental patient, constant threat of being stripped,
sexually abused. thrown into seclusion, restrained, overmedicated.
Discredited As
a child, Anna’s reports of sexual assault As a mental patient, Anna’s reports of adult sexual
were unheard, minimized, or silenced. assault
were not believed. Reports of child sexual
abuse were ignored.
Crazy
–making Appropriate anger at
sexual abuse seen as Appropriate
anger at abusive institutional practices
something wrong with Anna. Abuse judged
pathological. Met with
continuation of continued, unseen. abusive practices.
Anna’s
fear from threat of being abused Fear
of abusive and threatening institutional
was not understood.
Abuse continued, behavior
is labeled “paranoia” by institution unseen. producing it.
Sexual
abuse unseen or silenced. Message: Psychiatric
denial of sexual abuse. Message to
“You
did not experience what you patient:
“You did not experience what you experienced”. experienced.”
Betrayed Anna
violated by trusted caretakers and Patients
retraumatized by helping professionals and
relatives. psychiatrists.
Disciplinary
interventions were “for her own Interventions presented as “for the good
of the
good”. patient.”
Family
relationships fragmented by separa- Relationships of trust arbitrarily
disrupted based on
tion and divorce. Anna had no one
to trust needs of system. No
continuity of care or caregiver.
And
depend on.
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