The UK Royal College of Psychiatrists has issued a remarkable position paper, stating that people sexually abused in childhood have been failed by mental health services that often retraumatised them by not recognising past traumatic experiences.
The BBC calls it a “public apology” by psychiatrists for decades of mismanagement and misdiagnosis.
In the lengthy document, psychiatry’s professional body in the UK, acknowledges that for decades, mental health services focused too heavily on symptoms while failing to adequately explore what had happened in people’s lives. Survivors, the paper says, were misdiagnosed, given inappropriate treatment, disbelieved and, in some cases retraumatised by the very services they approached for help.
The report goes as far as to call this ‘iatrogenic harm,’ that is, harm caused inadvertently by the process of treatment, stating: “Iatrogenic harm has been done to survivors within mental health settings and this has been one of the driving factors for the development of this position statement.”
This is a huge development and vindication for people who have for years been calling diagnostic-led mental health services wholly inadequate to deal with abuse and trauma.
Given Ireland’s dark past in relation to childhood sexual violence, this surely means there will be a similar position taken by the Irish professional body, the College of Psychiatrists of Ireland?
The question is particularly urgent given that this country’s history of institutional abuse, clerical abuse, and industrial schools is so well documented. According to the Central Statistics Office’s Sexual Violence Survey, four in 10 adults (40%) reported experiencing sexual violence at least once in their lifetime (as a child or adult).
Ireland, then, cannot be immune from serious and systemic failures now being acknowledged in the UK’s mental health services. This means that we must ask the same difficult questions about what happens when survivors entered psychiatric services in Ireland.
Questions include, how many people were subjected to deeply traumatised practices such restraint, seclusion, forced medication or involuntary detention? Were people asked about what had happened to them and were their responses to overwhelming experiences understood in the context of those experiences? Was people’s distress, fear, dissociation, emotional volatility, difficulties with relationships, hearing voices or other experiences seen as a symptom of emotional pain or was it translated into a psychiatric diagnoses?
Unfortunately, these are not just historical questions and are still relevant in today’s mental health services that continue to view people and their issues through diagnostic labels rather than their life experiences.
Wider recognition for trauma
Another logical question is, if psychiatry accepts that childhood sexual abuse can later present as what it calls psychiatric symptoms, why would that reasoning stop at sexual abuse?
If sexual abuse in childhood can profoundly shape experiences later understood as symptoms of psychiatric disorder, the same question must be asked about other forms of childhood adversity.
Decades of research into Adverse Childhood Experiences (ACEs) has associated childhood abuse, neglect and household adversity with substantially increased risks of later psychological distress and a range of other poor health outcomes. And research shows that the relationship is cumulative: as exposure to adversity increases, so too does the likelihood of difficulties later in life.
Many members of the public would probably be surprised to discover that a psychiatrist in adult mental health service is not trained to work therapeutically with childhood trauma, abuse or other adverse childhood experiences.
The Royal College’s solution to these past wrongs is largely one of reforming psychiatry from within: greater awareness, better training and more trauma-informed psychiatric care.
Its report, however, does not propose the abandonment of psychiatric diagnosis or treatment. Indeed, its position statement continues to describe survivors as experiencing higher rates of depression, anxiety, PTSD, complex PTSD, psychotic illness, personality disorder and other psychiatric diagnoses. This begs the question: can psychiatry genuinely become trauma-informed if it does not overhaul coercive practices through which psychiatric power is exercised – and the laws that underpin such practices.
Where to now?
Regardless of where all of this will lead to in the UK, the acknowledgment that people can be traumatised within mental health services is a huge step forward. People in Ireland who have felt traumatised by our medical led mental health services also deserve to have their experiences acknowledged and addressed. This does not mean tinkering around the edges at a coercive system but a radical overhaul of how we treat people in distress. We need to do this in a humane way, in a humane place – not in a hospital with locked doors and labels that gaslight people into believing they have a brain disease while administering a cocktail of drugs that will numb their pain but not get to the core of it.
Trauma-informed approaches emphasise safety, trust, collaboration and choice. Yet psychiatry continues to retain the legal power to detain people, restrict their movement, restrain them and administer treatment without consent. Calling a service trauma-informed does not resolve that contradiction.
Taking trauma seriously requires considerably more than psychiatry adding trauma to its existing framework, it requires questioning the framework itself, particularly diagnosis, professional power and coercion.
The original ACE study is 30 years old. Since then, an enormous body of research has reinforced the relationship between childhood adversity and later mental and physical distress. Why, then, has it taken psychiatry so long to seriously confront what this robust body of evidence means for how the profession understands and responds to people?
Furthermore, if there is a genuine commitment to trauma-informed care, then the legal powers that allow psychiatry to detain, restrain and treat people without consent cannot remain outside the discussion. Until those powers are fundamentally reformed, there are serious limits to how transformative a ‘trauma-informed’ approach can be within the bounds of professional psychiatry.