The ordinary response to atrocities is to banish them from consciousness. Certain violations of the social compact are too terrible to utter aloud: this is the meaning of the word unspeakable.
Judith Herman, 1992
Over my years of working in mental health services to promote trauma informed practice, many professionals have expressed surprise – sometimes even disbelief – about the exceptionally high rates of trauma prevalence among people diagnosed with mental health conditions.
They tell me that hardly any of their clients ever talk about trauma. Some tell me they already ask their clients about trauma, but people rarely disclose anything to them.
Of course, if you know the literature about trauma and mental health, you will know that both of these situations are true, and not true, at the same time. We consumers don’t always disclose trauma to our workers, even when prompted. And we also know that most of the time, people are not prompted anyway.
But we do know that trauma prevalence among people who are served by our mental health systems is exceptionally high. Higher, in fact, than any other issue you may care to think of. And significantly higher than for the general public.
Experiencing multiple childhood traumas appears to give approximately the same risk of developing psychosis as smoking does for developing lung cancer.
Bentall, cited in Slade & Longden, 2015
We also know that people often disclose in ways other than by using spoken words. What is so often framed as ‘symptoms’ may actually be a story about trauma that needs to be told and heard.
The surprise and disbelief about trauma that I so often come across tells me that our workers, organisations and systems in mental health are not well set up – yet – to work with trauma.
There is a lack of embedded processes to ask about trauma, a lack of knowledge about current research, a lack of staff training, a lack of engaging with messages from the consumer movement, and a lack of deep understanding about what trauma actually is.
For more information about a more nuanced understanding of trauma, read the info sheet ‘What is Trauma?’ on my website.
Disclosure of trauma takes too long.
A great paper called ‘Why, when and how to ask about childhood abuse’ (Read, Hammersley & Rudegeair, 2007) cited several studies that indicate how difficult disclosure can be, and how long it can take:
‘Survivors of childhood sexual abuse are usually very reluctant to tell anyone about it. A US study found that the average time before disclosure by individuals who had suffered childhood sexual abuse was 9.5 years.
Frenken and Van Stolk, 1990, cited in Read, Hammersley & Rudegeair, 2007
A New Zealand study of 252 women who had been sexually abused during childhood found that 53% waited at least 10 years to tell someone, and 28% had told nobody.
Anderson et al, 1993, cited in Read, Hammersley & Rudegeair, 2007
A survey of New Zealand women who had been sexually abused during childhood and were later treated by mental health services found that 63% had never been asked about childhood sexual abuse by mental health staff.
Read, et al, 2006, cited in Read, Hammersley & Rudegeair, 2007
Disclosure can feel really, really hard.
If you don’t have a personal lived experience of trauma, think about it this way: what would help YOU to disclose your most shameful life experience to another person?
- What would help you trust the person?
- What could prevent you from speaking?
- Is a medical professional the person you would want to tell?
- What about one who had the power to treat you involuntarily?
- Is there anything in your own life that you would find almost impossible to share with any other person, no matter how compassionate they were?
My experience of disclosure.
I can still remember feeling terrified before disclosing my own experience of trauma. I was convinced that people would be disgusted and repelled by me. This might be hard to understand, because I know that even I look back now and I’m shocked at how deeply and completely I blamed myself for what had been done to me as a child. But these feelings of self-blame, of overwhelming shame, are really common.
This fear stuck with me through many disclosures to different people: a therapist, friends, family, colleagues, peers. It finally shifted for me due to the compassionate tough love of Peter Bullimore, a friend, colleague, survivor, and founder of the UK National Paranoia Network when he told me that I needed to tell my story in a different space, a public space. He not only put me on the schedule as a speaker at a UK conference about trauma, but gave me half the money needed for my airfare. ‘Come and tell your story about trauma, madness and suicide,’ he said, ‘it will make a difference’.
Well, I thought it sounded like the most depressing public talk ever. It was also beyond terrifying. But that half of an airfare to the UK was awfully tempting. And so I did it.
I was right. It was terrifying. I travelled to the other side of the world. I couldn’t plan my talk because I kept dissociating. But then I stood in front of a room full of people I didn’t know, and I told them about running away from home, being abducted for 2 weeks, being raped and what has happened in my life since then. I cried during the talk, I kept losing track, my voice was whispering inside my mind that I was a rapist and everyone would know it, and I felt this terrifying physical sensation of being choked.
I was waiting for the looks of horror and even for people to walk out. But of course that didn’t happen. Instead almost everyone in the front half of the room rushed forward with tissues. People stayed back to talk with me. I had never felt such compassion. And through the conference I met a myriad of other survivors, of compassionate and wise professionals, and my thinking began to shift.
Obviously a conference would not be the right space, or even an accessible space, for most people to disclose trauma. This worked for me because I already had a history as a consumer public speaker, and I was lucky to be friends with someone as remarkable as Pete Bullimore. It was an unusual situation. But it does makes me reflect about the power of group work, and of group witnessing, for this type of difficult but often powerfully healing process of disclosure. And it makes me want to make the point, again, that it is really, really, really hard for many for us to disclose. And that the fear and shame doesn’t go away easily.
So, to all you workers out there, if we don’t disclose, please don’t assume that there isn’t a story there. Give it time and space. And in your work, always assume a trauma history is possible, because you are then far more likely to work in supportive and respectful ways that doesn’t cause further harm.
Sometimes the concept of trauma doesn’t work for people
In addition to the difficulty in actually disclosing about trauma, is the reality that many people simply won’t relate their own life experiences to this concept of trauma.
One type of trauma that is often not disclosed, for example, is the witnessing of harm being done to others, or distress experienced by others. Often these survivors will not even conceptualise their own experience as trauma, and this where language such as ‘life adversity’ or ‘times where you felt emotionally overwhelmed and completely powerless’ may be more useful.
Examples of this are when children are exposed to domestic violence, or the abuse of a sibling or friend. Or growing up with a parent who was experiencing emotional distress and suicidality. For many people who have this type of ‘witnessing trauma’, they do not frame their own experience as trauma. They think the other person experienced trauma, and so they do not understand the profound impacts that they experienced themselves, particularly if they were still children.
So if you ask these people if they experienced trauma they are likely to say ‘no’. And yet, they may well have experienced serious emotional harm, enormous distress, powerlessness, and overwhelming fear – all of which are hallmarks of traumatic experience. We need to ask in different ways.
Some considerations for asking about trauma
Here are just some considerations about trauma disclosure that may be helpful to reflect upon in the context of our mental health services.
1. Do you ask people?
2. How do you ask people?
The hearing voices approach is one body of knowledge that offers many useful strategies for asking about trauma in different, and person-centred ways. Such as asking people what was happening in their life when they first started hearing voices. Or asking whether any of the characteristics of their voices, or the content of what their voices say, remind them of anyone or anything in their personal history. I have heard Ron Coleman use a lovely technique when asking people to make a lifeline of their personal history and experience of voice hearing, where he suggests that if there is anything that is an important part of their history, but too difficult to talk about, that they can just indicate this with a big black scribble on the page.
3. When do you ask?
4. Whose role is it to ask?
5. Does the person feel able or ready to disclose?
6. Have we asked in culturally appropriate ways?
For example, is the person asking of the same gender? If there is an interpreter in the room, what impact might this have?
7. Is the person fearful of the impact of disclosure?
This could include still feeling threatened by perpetrators, or fear of rejection, inaction or disbelief by the worker, or fear of possible consequences in the family, or fear of not being able to cope with speaking about it. Think about these types of fears when you think about ways of asking.
8. Does the person see their experiences as ‘trauma’ or as something else?
Could other language be more appropriate, such as life adversity, times of having no power, feeling unsafe, feeling frightened?
9. Do they want to disclose? Do they trust us? Do they believe that you will be in their life for long enough for this to make a difference?
10. What exactly do we ask about?
Read my information sheet ‘What is trauma?’ for more about this.
11. Do we ever, even inadvertently, filter, minimise or re-interpret the person’s experience?
12. Has the person possibly had past negative disclosure experiences, such as not being believed? Or being heard, but no action being taken?
About believing people.
Back in 2011 the Chief Psychiatrist of Victoria released a document called
‘Service guideline on gender sensitivity and safety: Promoting a holistic approach to wellbeing’.
I was so excited when I first read this document. While I think it has some gaps, it also quite clearly and directly calls for trauma informed practice across our public mental health system. It acknowledges the prevalence of trauma, including child abuse, and acknowledges that what are often seen as ‘symptoms’ may in fact be responses to trauma.
There is one line in the document which saddens me every time I read it. I am glad it is there, because it needs to be. But I wish it didn’t need to be. I can’t wait until it seems ridiculous to have to say such a thing in an official mental health document. The line is in the section about child abuse, and it says this:
‘believe the person (where the person has experienced delusions, do not assume that this is one of them).’ (p 15)
Sadly, many people are still not believed when they disclose experiences of trauma. Just two weeks ago I listened to a clinician speak, clearly displaying her own sadness, about coming across a woman who has been in and out of psychiatric hospital for twenty years. And throughout that time her record has included mention of childhood abuse. But this has never been acknowledged or addressed in her treatment. I have heard this story far too many times. This has to stop.
To workers, please understand that many of us who have tried disclosing in the past were not believed, and that this experience is devastating. We may need to build significant trust in you before we expose ourselves to such an experience again. But please don’t give up on us.
It’s worth you asking, even if we don’t tell.
I want workers to know that the act of asking is meaningful, even if we choose not to disclose, or feel unable to disclose. Because it demonstrates awareness, it shows compassionate interest, and it acknowledges the possibility of unspeakable truth, even if we are not yet able to speak it. Your question may just be the tiny signal that someone needs to start a journey of healing.
If you don’t ask, please start. If your organisation doesn’t support you to acknowledge trauma, then start educating them. Join a quality improvement committee. Distribute research. Become a change agent. We are all responsible for improving the mental health system.
I want survivors to know first and foremost that there is a way out. I know a lot of people go on about the importance of having hope, and sometimes this can feel a bit empty (well, it often did to me). But hope is true. Life can get better. Back when I was in and out of hospital, living on the brink of suicide, and drowning in inexpressible fear, shame and anger, I would never have believed that I would even be alive today, let alone living the kind of life I have. No, it’s not perfect. Yes, some days are still really bloody hard. There is no magic pill, no quick fix, no perfect happy endings. But there is healing, and growth, and strength that comes from truth.
Don’t feel rushed to disclose or explore your own experiences of trauma and adversity. It takes time, and going slow is one of the best ways I know to keep the process safe. But when you are ready, find the right people, the right place and the right approach that works for you.
Trauma is hard to speak about, hard to ask about, and hard to listen to. Sometimes the impacts of trauma are so deeply shattering, that others may begin to see us as mad, and worse, may even believe that our truth is somehow an expression of madness, rather than the other way around – that sometimes life can drive us mad. But no matter how mad we may seem, under every layer of distress, and within all of our unusual ways, there lies a meaning that deserves and needs to be heard.
‘The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma. People who have survived atrocities often tell their stories in a highly emotional, contradictory, and fragmented manner which undermines their credibility and thereby serves the twin imperatives of truth-telling and secrecy. When the truth is finally recognised, survivors can begin their recovery. But far too often secrecy prevails, and the story of the traumatic event surfaces not as a verbal narrative but as a symptom.’
Herman, 1992
For more information, visit the resources page on my website.
References
Department of Health, Victorian Government. (2011). Service Guidelines on Gender Sensitivity & Safety: Promoting a Holistic approach to wellbeing. Melbourne, Victoria, Australia: Author. Retrieved from: http://docs.health.vic.gov.au/docs/doc/81B991D400F3ACA5CA25790300100797/$FILE/service-guidelines-gender-sensitivity-safety.pdf
Herman, J. (1992). Trauma and Recovery. Basic Books, NewYork.
Read. J., Hammersley, P., and Rudegeair, T. (2007). Why, when and how to ask about childhood abuse. Advances in Psychiatric Treatment, 13, 101-110. DOI: 10.1192/apt.bp.106.002840. Retrieved from: http://apt.rcpsych.org/content/13/2/101.short
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