What is recovery? Recovery in mental illnesses can mean living a meaningful and productive life despite a disability. It can also refer to a reduction or complete remission of symptoms and a healing transformation of the self. For most people, it refers to the power of hope in healing disorders that were once thought to be hopeless. As Henry Ford once said, "Whether you think you can, or you think you can't, you're right."

Tuesday, December 22, 2015

Addressing Sexual Trauma in Clients with Psychosis

Studies show that clinicians are less likely to ask about child abuse if a client is psychotic, even though studies show a strong correlation between childhood maltreatment, including sexual abuse, and psychosis (Read, et al., 2008). People with psychotic disorders also experience increased rates of adult sexual assault (Read, et al. 2003; Elklit & Shevlin, 2008). Sadly, people with psychotic disorders are not only less likely to be asked about trauma but also less likely to have their needs met if they do disclose (Read, 2006). This post will examine facts and clinicians concerns about sexual trauma in people with psychosis, followed by a discussion of how to ask about it, how to respond, treatment options available, and clients’ sexuality and intimacy needs after the trauma. 
Facts about Sexual Trauma and Psychosis
A meta-analysis of forty studies found that 50% of female outpatients with psychotic disorders had experienced childhood sexual abuse (Read, 2006). Among male outpatients with psychotic disorders, the rate was 28% (Read, 2006). 79% of women with severe mental illness have been sexually assaulted as an adult, and 17% of men (Read, 2006). A causal relationship is suspected (Read, et al., 2008; Elklit & Shevlin, 2011). One study based on a Danish registry of sex offenses matched women who had been sexually assaulted with controls and found that sexual assault was a significant predictor of later psychosis, even when controlling for other factors (Elklit & Shevlin, 2011). 
Although this post focuses on sexual trauma, trauma in psychotic disorders is not limited to sexual trauma. Trauma affects psychosis in three major ways: by the influence of childhood trauma, by the trauma of diagnosis and treatment, and by further instances of trauma that frequently result from increased vulnerability to victimization (Callcott & Turkington, 2006). A study of 275 patients with schizophrenia and bipolar disorder found that 98% had experienced at least one traumatic event, with 43% concurrently qualifying for post-traumatic stress disorder (Mueser, et al., 1998). 70% of people who hear voices started hearing them immediately following a traumatic event (Romme & Escher, 2000). Among the various types of trauma in psychotic disorders, one study “found that sexual abuse and bullying were the most common traumatic events… They may also be the most toxic” (Smith, et al., 2006, p. 256). 
Sexual trauma informs the content of hallucinations, either directly (i.e., the voice of the abuser or what was said during the abuse), or indirectly (i.e., hallucinations about being otherwise violated or having one’s trust betrayed, or hallucinations representing the dynamic between the victim and the abuser)  (McCarthy-Jones, 2011; Smith, et al., 2006). Clients who have been abused tend to have earlier first hospital admissions, longer and more frequent hospitalizations, more time in seclusion, higher doses of medication, increased self-mutilation, and higher global symptom severity (Read, 2006). Abuse is also linked to the high rate of suicidality in schizophrenia, and one study found this factor to be more important than depression (as cited in Read, 2006). More treatment options than are widespread now need to be made available, particularly because those whose psychotic symptoms are linked to trauma have a particularly poor response to medication alone (Callcott & Turkington, 2006).
Clinician Concerns
In treating psychosis, other problems often seem more pressing than a history of trauma, and sometimes they are. For this reason and other clinician concerns, it is not uncommon for a trauma history to be delayed indefinitely (Read, 2006). However, clients are not likely to disclose this information without being asked; one study showed that women take an average of sixteen years to disclose childhood sexual abuse (as cited in Read, 2006). 
Clinicians often fear that psychotic clients will get upset and may decompensate if asked about sexual trauma (Read, 2006). In fact, clients are often more disturbed about not being asked (Read, 2006). As one person put it: 

There were so many doctors and registrars and nurses and social workers in your life asking you about the same thing, mental, mental, mental, but not asking you why. I think there was an assumption that I had a mental illness and because I wasn’t saying anything about the abuse I’d suffered no one knew. I just wish they would have said, ‘What happened to you? What happened?’ But they didn’t. (qtd. in Read, et al., 2008)

In treatment, deliberate reliving of trauma may need to be reduced (Callcott & Turkington, 2006) or eliminated (Smith, et al., 2006) in order to avoid psychotic decompensation, but there is no evidence that trauma assessment itself is harmful unless completed insensitively (Read, 2006). Only a minority of clients find such questions “stressful,” and even that minority report that they still benefit from being asked (Read, 2006). 
Some clinicians fear that reports of sexual trauma by people with psychosis may often be delusions (Read, 2006). However, the rate of incorrect allegations of sexual trauma is no higher in people with schizophrenia than in the general population (as cited in Read, 2006). In general, clients on inpatient units are more likely to under-report abuse than to over-report it (as cited in Read, 1997). A minority of clinicians believe that asking psychotic clients about sexual trauma can trigger false memories; this is also untrue (Read, 2006). 
Sometimes, however, clients may present with confusion about whether or not they have been abused and in what way. In this case, counseling can help people sort through their experiences and discern the truth behind their sense of having been violated (Callcott & Turkington, 2006). For example, “Harriet” was confused about whether or not she had been sexually abused by her father in a cave in the presence of Margaret Thatcher (Callcott & Turkington, 2006). With counseling, Harriet remembered that she was once lost from her mother in a cave (Callcott & Turkington, 2006). She was also very angry at her father for preferring her half-sibling and for not believing her when a babysitter he hired raped her (Callcott & Turkington, 2006). Ultimately, Harriet, with the support of her therapist, came to the conclusion that strong anger toward her father gave the visions of her father in the cave a vividness approaching that of true memories, although they were not (Callcott & Turkington, 2006). In this case, inquiry about sexual trauma led to the dissolution of false memories for Harriet. 
Other barriers to asking clients with psychotic disorders about sexual trauma include fear of vicarious traumatization, fear of being accused of “family-blaming,” the client or clinician being male, the clinician being opposite gender than the client, lack of clinician training on how to ask and how to respond, and a strong bio-genetic causal belief regarding psychosis (Read, et al., 2008). Not asking is also an extension of widespread denial and minimization of child abuse in general (Herman, 1997; Read, 1997). However, given the high rate of abuse across all diagnoses, it is important that all clients be asked about it (Read, 2006). Read (2006) recommends training for clinicians in how to ask about abuse and how to respond to it, with particular emphasis on asking those clients who are least asked: psychotic clients, male clients, and older clients. The Sexual Medicine Team in Vancouver stands out for deliberately addressing the sexual needs of clients with mental illness, and clients there are asked about sexual assault (Maurice & Yule, 2010). However, clinicians there refer to such questions as “specifically for women” (Maurice & Yule, 2010, p. 479).
How to Ask 
Simply asking, “Were you sexually abused?” will not consistently produce accurate answers. Many people who have been abused do not define their experiences that way (Hammersley, Read, & Bullimore, 2006). A more helpful question is, “As a child, did anyone ever do something sexual that made you feel uncomfortable?” (Read, 2006, p. 209). These questions should not be asked out of the blue, but instead, in the context of a more thorough assessment of the client’s psychosocial history (Read, 2006). It is important to ask during the initial assessment (Read, 2006). If there is a good reason not to ask about sexual trauma, such as flagrant psychosis or acute suicidality, clinicians should note very clearly in the chart that trauma history has not been recorded and then follow-up when the client feels less distressed (Read, 2006). “The tendency of some clinicians to wait for an imagined magic moment when rapport is just right should be challenged, not least with the point that for some clients the act of asking may be crucial to establishing rapport” (Read, 2006, p. 210). 
Hammersley, Read, & Bullimore (2006) recommend beginning with general questions, such as “What was your childhood like?” These can be followed with more specific questions, such as “What was the worst thing that ever happened to you as a child? Which person in your childhood did you feel most comfortable with? Which person, if any, in your childhood was it uncomfortable to be with?” (Hammersley, Read, & Bullimore, 2006, p. 8). Clinicians can support clients by offering ‘continuation responses’ that encourage engagement and information (Hammersley, Read, & Bullimore, 2006). Examples of these include “tell me more,” “okay… I see” and “do you feel okay to continue?” (Hammersley, Read, & Bullimore, 2006, p. 8).
If the client does not volunteer reports of abuse or assault, more specific questions can be asked:
Have you had any unwanted sexual experiences?
Did anyone ever do something to you that made you feel uncomfortable as a child?
Has anyone ever done something sexual to you against your will, or that you didn’t feel comfortable about? (Hammersley, Read, & Bullimore, 2006, p. 9)
How to Respond
Importantly, it is not appropriate for the clinician to immediately gather as much detail as possible upon disclosure of sexual trauma (Hammersley, Read, & Bullimore, 2006; Read, 2006; Read, et al., 2008). Instead, the details need to come out at the client’s own pace. An appropriate response is needed to affirm the client’s choice to disclose the sexual trauma (Hammersley, Read, & Bullimore, 2006; Read, 2006; Read, et al., 2008). After disclosure, the client may feel angry, ashamed, fearful, relieved, numb, or ambivalent (Hammersley, Read, & Bullimore, 2006). An immediate reaction which demonstrates that the client is believed and that their disclosure is acknowledged as positive can help them begin to process many of these emotions (Hammersley, Read, & Bullimore, 2006). Appropriate responses include “Thank you for telling me” and “This is an important thing you have told [me]” (Hammersley, Read, & Bullimore, 2006, p. 11). This can be followed up with a query that normalizes their feelings: “In my experience talking with people about this, people often find that although it is difficult, it can be really helpful to talk about it. How has it been/is it for you talking about this now?” (Read, 2006, p. 214). If the client demonstrates any shame or self-blame, affirm that this is a common experience but that what they went through is not their fault (Read, 2006). 
Once the client’s decision to disclose and resulting feelings are validated, it is important for the clinician to offer support (Read, 2006). If qualified, the clinician can offer, “Would you like us to talk about that at some point?” (Read, 2006, p. 214). Alternatively, the clinician can refer to someone more qualified: “Would you like to talk to someone about how you feel about it all now?” (Read, 2006, p. 214). It is important to ask if the client is still being abused, or if the possibility exists that the perpetrator is abusing others (Read, 2006). Some ways to establish safety are:
Do you feel safe now?
Is anything like that still going on?
Are you safe to leave?
Is anyone treating you like that at the moment?
I need to check now if you are safe.
As part of this I need to check if people around you are safe. (Hammersley, Read, & Bullimore, 2006, p. 13)
At the end of the session, it is important for the clinician to check-in regarding the disclosure and plan for follow-up. (Hammersley, Read, & Bullimore, 2006; Read, 2006; Read, et al., 2008). Clients need to be asked again how they are feeling about their disclosure, and given contact information for someone they can talk to if they become upset about it later on (Hammersley, Read, & Bullimore, 2006). They also need to be supported in making a plan of coping techniques they might use and support persons they might call if they do become upset (Hammersley, Read, & Bullimore, 2006). A follow-up appointment can help reassure both client and clinician that they will be able to check in again soon (Hammersley, Read, & Bullimore, 2006; Read, 2006; Read, et al., 2008).
Sadly, there are few tested treatments for people with psychotic disorders who are struggling with sexual trauma, because people with psychosis are usually deliberated excluded from trauma treatment studies (Read et al., 2003; Read, 1997). More research is desperately needed. A 1991 study on group therapy for “chronically mentally ill females” who had experienced childhood sexual abuse showed promising results, and a 1990 group therapy study demonstrated greatly reduced hallucinations in female incest survivors (as cited in Read, et al., 2003). The best available option for individual therapy seems to be CBT for traumatic psychosis, which addresses trauma of all kinds (Callcott & Turkington, 2006; Smith, et al., 2006). Although a search by this student turned up no studies examining this treatment, CBT for traumatic psychosis is based on a combination of two other best practices: CBT for psychosis and CBT for PTSD  (Callcott & Turkington, 2006; Smith, et al., 2006). 
Callcott and Turkington (2006) base their recommendations for the treatment of trauma in psychosis on the idea, proposed by Kingdon and Turkington in 1999, of five subgroups on the schizophrenia spectrum: sensitivity disorder, catatonia, anxiety psychosis, drug-induced psychosis, and traumatic psychosis (as cited by Callcott & Turkington, 2006). The label of traumatic psychosis is not necessary for treatment, however, since Smith et al. (2006) do not use the label yet make strikingly similar recommendations. Whether or not a co-occurring diagnosis of PTSD can be made, both Callcott and Turkington (2006) and Smith et al. (2006) recommend combining CBT for PTSD with CBT for psychosis in treatment. Which treatment is emphasized in the combination depends on whether client also qualifies for PTSD, whether a link appears between the trauma and the psychosis, and whether the client makes any such link themselves (Callcott & Turkington, 2006).
CBT for traumatic psychosis can help clients identify and clarify links between voice content and sexual trauma (Callcott & Turkington, 2006). In the case of “James,” CBT helped him to understand that what he had previously experienced as “out of the blue” hallucinations were vivid flashbacks from previous sexual and physical assaults (Smith, et al., 2006). In the case of Harriet mentioned above, CBT helped her come to the conclusion that she had indeed been raped by a babysitter her father had hired, but that her father himself had not abused her (Callcott & Turkington, 2006). In the case of “Tanya,” hallucinations appeared to serve as a channel for emotions that she did not permit herself to experience about sexual abuse perpetrated by her stepfather (Callcott & Turkington, 2006). Although Tanya was able to describe her sexual abuse with an astonishing lack of emotion, she was terrified by other violent images, such as an image of her having stabbed her neighbor and being covered in blood— an event that had not actually occurred (Callcott & Turkington, 2006).
Like many other therapies, CBT for traumatic psychosis is “best delivered after a period of engagement with good support in place and the cooperation of relatives and professional carers” (Callcott & Turkington, 2006). Clinicians allow ample time to work with the client to collaboratively develop an understanding of experiences that is neither psychotic nor completely biological (Smith, et al., 2006). Once this formulation of the psychotic experience is developed, it may or may not include sexual or other trauma (Smith, et al. 2006). Either way, this approach is more empowering than the promotion of “insight” into a purely biological perspective in schizophrenia, which is linked to depression in clients (Smith, et al., 2006; Watson, et al., 2006). In treatment, CBT for traumatic psychosis places less emphasis on reliving traumatic experiences and a greater emphasis on changing related schemas than CBT for PTSD does (Callcott & Turkington, 2006). Reliving trauma is not always appropriate in traumatic psychosis, but happily it is usually unnecessary (Smith, et al., 2006).
Sexuality Post-Trauma
People with psychotic disorders experience sexual and intimacy needs related and unrelated to any trauma that may have occurred. Some of the sexual challenges in this population are:

very limited social access and social skills; poor self-image and confidence; limited self-care; poverty and its links with prostitution and exploitation; sexual abuse in childhood and adulthood; the sexual content of positive symptoms; sexual disinhibition and the risk to self and colleagues; the adverse effects of psychotropic medications on libido; the secondary effects of medication, including disabling extrapyramidal signs; the results of institutionalization and stigmatization; hospital policies and the expression of sexual need in institutional settings; education and consent; safe sex and contraception; and homelessness. (McCann, 2000, p. 133)

Other concerns that may be encountered include problems experienced by the general population, such as struggles with gender identity, homosexuality, pseudohomosexual anxiety, and the paraphilias. Additionally, it is assumed that sexual trauma experienced by people with psychosis leads to sexual problems that largely do not differ from those of other people with similar trauma (McCarthy & Breetz, 2010).
However, research on sexuality in psychosis is scarce (McCann, 2010). Out of four studies this student found regarding the sexual needs and concerns of people with psychotic disorders (McCann, 2010; McCann, 2000; Harley & Boardman, 2010; Raja & Azzoni, 2003), only one study mentioned sexual trauma as a possible factor (McCann, 2000, see quote above), but this study did not explore this factor in interviews with subjects. In one more general study cited by McCann (2010), researchers using the Camberwell Assessment of Need deliberately rated all 173 mentally ill respondents as having zero need for sexual expression, due to the researchers’ discomfort in asking!
According to McCann, “there is a general assumption that people with schizophrenia ‘don’t do sex’” (2000, p. 133). However, “people are sexual beings all the time, whether they are healthy, ill, or disabled” (McCann, 2000, p. 134). Frequency of partnered sex is low in schizophrenia, particularly among men (Harley & Boardman, 2010). Yet 90% of people with psychosis reported needs in relationship to sexual expression and 83% reported needs related to intimate relationships (McCann, 2010). In contrast, only 10% of key staff rating the same clients reported their clients having needs related to sexual expression, with 43% reporting their clients having needs related to intimate relationships (McCann, 2010). 
Research demonstrates that people with psychotic illness can be safely and effectively interviewed about their sexual needs and behavior (McCann, 2000). No exacerbation of symptoms has been observed in clients who were asked, and many patients are happy to have the opportunity to discuss the fundamental issues of sex and intimacy (McCann, 2000). “Encouragement to openly discuss, explore and experience satisfactory sexual functioning and relationships is consistent with improving… quality of life and with the recovery model” (Harley & Boardman, 2010, p. 765). 
It is sad to think about the high rate of unacknowledged and untreated sexual trauma among people with psychotic disorders, but the good news is that clinicians can do something about it. By overcoming concerns about addressing it and learning the facts, clinicians can be prepared to ask clients with psychosis about sexual trauma and respond to disclosures about it. By studying CBT for traumatic psychosis and therapy for related sexuality concerns, clinicians can become prepared to treat people with this dual challenge. Through further research, training, and education, clinicians treating psychosis can be empowered to better support a well-rounded recovery of the people they serve. 


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