SILENCE NO MORE ASKING THE QUESTION Professor John Read

Establishing trust by acknowledging trauma: A New Zealand training Programme on when and how to ask about abuse

‘ WHY, WHEN AND HOW TO ASK ABOUT CHILD ABUSE ’ Read J, et al., Advances in Psychiatric Treatment (2007) New Zealand training programme described for Royal College of Psychiatry (UK) journal 2008 NHS Guidelines – all clients must be asked and staff must be trained

Reliability of disclosures of ‘psychiatric patients Corroborating evidence for reports of child sexual abuse [CSA] by psychiatric patients has been found in 74% [HERMAN J, SCHATZOW E. 1987] 82% [READ J, et al. 2003] “The problem of incorrect allegations of sexual assaults was no different for schizophrenics than the general population” [DARVES-BORNOZ J- M, et al. 1995] High reliability and unrelated to severity of psychosis [FISHER H, et al. 2011] Psychiatric patients under-report abuse to staff. 85% of women previously admitted to psychiatric hospital reported CSA when interviewed at home [MULLEN, P. et al. 1993]

Evaluation of Training Cavanagh, Read, New (NZJP, 2004) Six week follow – up ‘The training has changed my clinical practice’ 67% Give examples: Majority reported increased knowledge and confidence 33% reported examples of specific behavioural changes

It’s our job to ask People are reluctant to spontaneously disclose Why ? Average length of time for sexually abused girls to tell anyone ? 16 years (Read & McGregor, 2004) Harder for men Why ?

Current Rates of Inquiry Chart review of 100 inpatients Read J, Fraser A. (1998) Even when an abuse section was included in the admission form, 68% of the psychiatrists skipped that section Abuse prevalences when asked, and not asked, at initial assessment : CHILD SEXUAL ABUSE: If asked: 47% If not asked: 6% ANY ABUSE, LIFETIME: If asked: 82% If not asked: 8%

Reasons for not asking ? New Zealand survey of 63 psychologists and 51 psychiatrists. Young M, Read J, Barker-Collo S, Harrison R. (2001). Most common reasons for not taking an abuse history: ‘There are too many more immediate needs and concerns’ ‘Patients may find the issue too disturbing, or it may cause a deterioration of their psychological state’

People particularly unlikely to be asked People diagnosed ‘schizophrenic’ Men Older people

Psycho-social History Early childhood, including birth School – academic and peer relationships Family/whanau environment during childhood Adolescence – friends and school, sexuality Abuse history Past and current safety issue (harm to/from self/others) Mental health history (including helpful and unhelpful contact with mental health professionals) Legal issues Substance abuse Medical history (including brain injury) Employment history (including unpaid) Interests/hobbies – past and present Major relationships in adolescence/adulthood Support history – who has/does client talk to about personal difficulties Spiritual, religious and other beliefs Current relationships/family

Reason for taking psycho-social history ? Getting to know someone Shared formulation Establishing TRUST Comprehensive and appropriate treatment plan

Principles of Abuse Inquiry Ask all clients As part of initial assessment (with some exceptions) Funnel towards abuse questions with general questions about childhood Don’t ask “Were you abused ?” Instead, use specific examples

General Questions How would you describe your childhood / your relationship with your parents? Best time in childhood ? Worst time in childhood ? How was discipline dealt with ?

Funnel from general to specific questions tell me a bit about your childhood best childhood memory? worst ? how did you get on with mum? dad ? how was discipline dealt with? specific abuse questions

Specific Questions Were you ever hit in a way that left bruises, cuts or broken bones ? Did anyone ever do anything sexual with you that made you feel uncomfortable ? Who did you turn to when upset ? What was the worst punishment you receives as a child ? Repeat 1 & 2 for adolescence/adulthood

Current Adequacy of Response - Chart review of 200 outpatients Agar, K. & Read, J. (2002) Percentage of childhood and adulthood abuse cases (n = 92) responded to with: Mention in Summary Formulation: 37% Mention in Treatment Plan: 33% Abuse counselling: 22% Reported to legal agencies: 0%

Improvement over time, with training Response to child sexual abuse disclosed in NZ community mental health centres: Formulation 22% 57% Treatment plan 20% 44% Referral for trt. 17% 23% Reported 0% 1%

Principles of Response to abuse disclosures Not necessary to gather all details Affirm that it was positive to tell Ask about previous disclosures Ask if client sees link between abuse and current problems Ask what they need Offer information about resources, counselling (have it available) Safety – of clients, of others Check mood at end of session

Service Users’ views about asking about trauma: Survey of NZ service users. Lothian J, Read J (2002) “There was an assumption that I had a mental illness and because I wasn’t saying anything about my abuse nobody knew” “There was 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 just wish they would have said ‘What happened to you?’ ‘What happened ?’ But they didn’t.”