Trauma, Women’s Mental Health, and Social Justice

Pitfalls and Possibilities

Emma Tseris

• Publisher: Routledge
• Year: 2019
• Topic: Social Sciences
• eBook ISBN:
  9781351608220
• Subtopic: Sociology
• Index: Social Sciences

This book argues that while notions of trauma in mental health hold promise for the advancement of women's rights, the mainstreaming of trauma treatments and therapies has had mixed implications, sometimes replacing genuine social change efforts with new forms of female oppression by psychiatry. It contends that trauma interventions often represent a "business as usual" approach within psychiatry, with women being expected to comply with rigid treatment protocols, accepting the advice given by trauma "experts" that they are mentally unstable and that they must learn to manage the effects of violence in the absence of any real changes to their circumstances or resources. A critique of trauma treatment in its current form, Trauma, Women's Mental Health, and Social Justice recommends practical steps towards a socio-political perspective on trauma which passionately re-engages with feminist values and activist principles.

1 Introducing a critical perspective on trauma

A “trauma-informed” approach to understanding people experiencing mental distress has – in the space of a couple of decades – moved from being a little-known, activist notion, to a paradigm that has been eagerly embraced within mental health services. Though not inevitable, trauma is viewed as a common and understandable response to violence and a range of other overwhelming experiences, and the concept of trauma has garnered mounting influence within human service practice, policy, research, and education contexts. Far from its original positioning as a peripheral concept, contemporary mental health policy documents, funding proposals, and service delivery statements are now imbued with notions of “trauma-informed care”. The turn towards trauma has been described as offering “a ‘new generation’ of transformed mental health and human service organisations and programs” (Bateman, Henderson, & Kezelman, 2013, p. 4), and the vast majority of scholarship on trauma-informed practices has taken a highly optimistic view of its benefits – particularly in terms of its capacity to offer a compassionate and contextualised perspective on mental health presentations, through its consideration of the life events that may lead to mental distress. Trauma-informed practices are routinely compared favourably in comparison to conventional mental health service provision. While the latter emphasises the assessment and management of symptoms, trauma work – it is argued – allows for a socio-contextual analysis of the origins of emotional distress. This book differs in the analysis that it offers relating to trauma-informed mental health services, providing a more careful reading of the trauma paradigm, and examining in particular its implications for women (while acknowledging that trauma discourses also hold many implications for other individuals and communities, including refugees and asylum seekers, people experiencing poverty, and people experiencing various forms of violence and discrimination other than or in addition to gendered oppressions). While there have been extensive medical and psychological investigations into trauma that have examined its causes, treatments, and the possibility of recovery, there has been limited critical analysis that has situated trauma as a socially constructed concept, allowing for an exploration of its underlying assumptions and relations of power.

While trauma-informed practices are used rather broadly within mental health services, thus affecting a wide range of mental health service users, this book contends that turning a spotlight onto women’s experiences of the trauma paradigm is a valid focus. The psychiatric profession has a very long history of disproportionately labelling women as mentally ill, leading to a range of mental health interventions specifically designed to control and manage women’s perceived mental dysfunctions – a bias that continues to this day (Ussher, 2011). In addition, a significant amount of attention within trauma literature centres on the effects of rape, domestic violence, and child sexual assault – experiences that are clearly gendered due to women and girls being so disproportionately affected (Moulding, 2015). When considering the turn to trauma within mental health policy and service provision contexts, women as a group have been particularly affected; for example, trauma-informed therapeutic support is often recommended as a “best practice” response to women when experiences of sexual assault and other gender-based violence have been disclosed. This is an important shift: after decades of ignoring women’s social experiences, and viewing mental and emotional distress as arising due to purely biological processes, ideas about the importance of negative life events in shaping women’s lives are becoming increasingly more widely accepted within psychiatric settings. Rosenthal, Reinhardt, and Birrell (2016) note that a “trauma-informed” approach is underpinned by a number of assumptions:

• Human experiences of an overwhelming or devastating nature leave predictable and understandable marks on survivors’ minds and bodies.
• While mainstream mental health services have usually viewed such difficulties as mental health disorders, they should instead be seen as causally linked to the events that have occurred.
• When the connection between events and distress is not made, mental health service users are pathologised by the mental health system, as they are seen as “disordered” individuals, while their social contexts are ignored.

It is this book’s contention that the trauma paradigm’s construction of an “experience-distress” nexus has both liberating and troubling implications for women who come to the attention of mental health services. This book enthusiastically concurs with Becker-Blease’s (2017, p. 131) claim that while the trauma paradigm without doubt carries much emancipatory potential for women, we must start to “critically engage with the devils in the details” – a task that has become especially urgent given the exponential rise in the popularity of the term “trauma-informed”. While acknowledging the conceptual and practical improvements that trauma discourses have made to the traditional diagnostic model of mental health is important, it is also crucial for mental health workers and researchers who are knowledgeable about the limitations of biological explanations of mental distress to subject any new-found certainties about the causes of distress to critical analysis. Within this age of biomedical psychiatry, it is a refreshing reprieve to come across ideas that are less reductionist or deterministic than those provided by the medical model of mental illness. Nevertheless, it is the stance taken in this book that ideas about the social factors underpinning distress, and the efficacy of therapeutic (as opposed to medical) responses, are not immune from political biases or professional interests. Moreover, the need for critical analysis exists regardless of whether one’s professional training is inside or outside of psychiatry (for example, in sociology, social work, nursing, psychology, or art therapy), and it remains relevant even if a mental health treatment modality is open to accepting socio-contextual explanations of mental distress.

Unfortunately, once conversations about mental health shift from biomedical topics towards an engagement with “social” or biographical factors and their effects, there is often an inherent assumption that the analysis that is being offered is benevolent and free from power relations or biases. Frequently, such analyses interrogate the fallibilities of psychopharmacology, and call for a rise in the number of talking professionals or therapists (for example, Gnaulati, 2018). As will be explored throughout this book, however, therapy is not an innocent endeavour – even if a staunch anti-medication stance is taken, or if the approach used by a worker is to develop an explicitly “collaborative” partnership with service users, or if the work is shaped by a trauma-informed perspective. Rather, therapeutic work is deeply embedded in cultural, socio-political, and gendered processes, and such processes are not neutral. Thus, trauma-informed therapeutic practices should be subjected to sociological critique. As noted by feminist anti-psychiatry academic, Burstow (2018), any position that is formulated within the constraints of mental health discourses – however progressive its intentions – is compromised by the ongoing constraints of a mental health focus on locating dysfunctions within service users. Such discourses are shaped by notions of individual pathology and the assumption that distress is solvable through a combination of professional interventions and self-help efforts.

Importantly, in providing a critical perspective on trauma-informed practices, the intention of this book is not to undermine the feminist efforts that have led to the development of trauma-informed practices within mental health services, nor to deny the improvements that trauma-informed practices have made possible. Rather, this book has emerged out of a concern that at times the trauma paradigm is being positioned as having resolved the inadequacies of a psychiatric explanation of distress (particularly women’s distress), leading to an inability to fully examine the socio-political implications of the turn to trauma within mental health services. It also attempts to address the question of whether the feminist underpinnings of the trauma paradigm can retain their influence as trauma discourses are utilised within mainstream mental health services. Therefore, it is not the intention of the book to assume a position of lofty theorising, in which the limitations of current mental health practices are determined, without offering any useful alternatives. Worse still, I do not wish to overlook the multitude of ways in which feminists working within the walls of mental health services have tirelessly advocated for a system that not only acknowledges women’s experiences, but that highlights gender inequality and gender-based violence as fundamental to the assessment of women’s mental health presentations. Trauma-informed practices have been an important, and at times, central component of these feminist efforts.

The perceived gap that exists between the research world and the world of human service practice is a critique of the role of academic work that I have reflected upon while writing this book, and I have attempted to avoid the perceived limitations of academic contributions to mental health practice in a number of ways. Firstly, my analysis of trauma-informed practices has been inspired by both informal conversations and formal interviews with mental health service users over the period I have been involved in research (and prior to this as a mental health social worker), who have shared with me their concerns about contemporary mental health provision, their experiences of psychiatric harm, and their ideas about alternative responses to people experiencing distress. In Chapter 5, I report on a research study involving in-depth interviews with women survivors of gender-based violence and their exposure to mental health and therapeutic support. The power differential that exists between mental health service users and workers means that it is usually extremely difficult, and often unsafe for mental health service users to offer a critique or to protest against contemporary service provision. My privileged position enables me to much more freely articulate a critique and to provide a counter-narrative, although it brings up a vast array of difficult questions about how this work might be approached in an ethical manner – for example, it is important that I acknowledge that my name as the sole author of this book invisibilises the expertise of others. Secondly, my ideas have been shaped by numerous discussions with critically minded mental health workers, who have shared with me their understandings of the possibilities and potential limits of trauma-informed practices. Chapter 4’s exploration of the relationships between neuroscience, attachment theory, and trauma discourses came about as a result of conversations with feminist mental health workers expressing their hesitations about the under-examined implications of the turn towards trauma, and their concerns that trauma-informed practices alone cannot be seen as a solution to the individualising effects of the biological framing of mental distress.

Key concepts and debates in the book

The understanding of feminism that is used within this book is that it is a heterogeneous movement, with diverse voices and perspectives, giving rise to lively and useful debates and contestations. At its core, however, “feminism is a movement to end sexism, sexist exploitation and oppression” (hooks, 2000, p. viii). In line with a feminist analysis, gender-based violence is defined as violence against women and children that is specifically constructed by the power relations of hetero-patriarchy (Radford, Kelly, & Hester, 1996). This understanding is grounded in the work of second-wave feminists, who worked tirelessly to generate public awareness about the prevalence of domestic violence, sexual assault, and child abuse, highlighting the deleterious effects of these experiences on women and children. Feminist activism facilitated an awareness of how such experiences are bound by systemic practices of male power and privilege (Reid, 2018), with some women experiencing multiple forms of violence throughout their lifecourse (Cleary & Hungerford, 2015). While not ignoring women’s use of violence, feminist analysis demonstrated that such violence differs in frequency, severity, and intention (Kimmel, 2002). Furthermore, it established that when men are victims of violence, the perpetrator is most often male (Taft, Hegarty, & Flood, 2001); it critiqued pervasive practices of mother-blaming in relation to male-perpetrated violence (Moulding, Buchanan, & Wendt, 2015); and it elucidated the need for maternal violence against children to be viewed in terms of its interaction with co-occurring intimate partner violence (Namy et al., 2017).

Third-wave and intersectional feminism expanded on the work of second-wave feminism by attempting to redress the elevation of particular voices and experiences within the women’s liberation movement (those of white, middle class, able-bodied, cisgender women) at the expense of others. This analysis showed the ways in which feminism was involved in side-lining the experiences of women in some of the most marginalised social locations, while pursuing the agendas of women who already enjoy larger social privileges and resources (Thiara & Gill, 2010). More contemporary perspectives are demonstrating the ways in which the women’s movement has been affected by the neoliberal turn towards individualism and consumption, neglecting its roots as a social movement based on collectivism, with an awareness of the importance of social policy and community change rather than personal aspiration. These failings have led to some people rejecting feminism outright (Crispin, 2017). However, others, such as Roxanne Gay (2014) have argued that while feminism must improve its intersectional analysis of diverse women’s lives, expecting feminism to completely avoid these pitfalls means holding feminism to a higher standard than any other social justice movement. It is important, Gay contends, to avoid conflating the failings and biases of people with the failings of feminism. The approach taken in this book is that the multiple contributions of feminist theories provide a crucial framework to analyse the meanings of trauma perspectives in mental health, and to critically explore their consequences. In developing this analysis, feminist theory is used in conjunction with the tools of poststructuralism and critical mental health theory, which are outlined in Chapter 2.

The term “discourses” is used within the book to refer to the myriad ways in which people act upon and make meaning within the social world: “discourses are more than language – they are ways of behaving, interacting, valuing, thinking, believing, speaking – discourses are ‘ways of being in the world’” (Locke, 2004, p. 7). Despite there being a variety of discourses available within the social world, certain discourses are more dominant and influential than others. Powerful groups have excessive capacities to perpetuate their views of the world, resulting in the propagation of dominant discourses, leading to the most powerful knowledges with the largest “subscription” base becoming hegemonic discourses (Locke, 2004). Meanwhile, the “local” understandings of marginalised groups become “disqualified” knowledges, and are treated as though they lack legitimacy (Foucault, 1980). For example, mental health discourses (the practices, language, concepts, and understandings of the mental health professions) are currently the dominant means through which a large proportion of human problems are understood, leading to other explanations of human experience being rendered invisible. In this way, notions of mental health and mental illness can be viewed as socially constructed – while the existence of human suffering and “madness” is not in dispute, medical understandings are culturally and historically situated knowledges, which are therefore open to contestation. Within the book, I use the term trauma discourses in order to argue that the “taken-for-granted” status that is often afforded to trauma and trauma-informed practices within mental health settings is problematic. In other words, trauma should not be viewed as an objective concept, but rather as a paradigm that has arisen within particular socio-political and professional contexts, which has been informed by a number of assumptions that should be viewed with a critical analysis – for example, ideas about the centrality of therapeutic mental health interventions after violence. This is not the same as arguing that trauma and trauma-informed practices have never been helpful for women; rather, while the concept of trauma is helpful in some circumstances, this book argues that its utilisation at other times is hazardous and limiting; that claims about its universal relevance are unwarranted; and that caution is required as the trauma concept gains more and more traction within mental health settings.

The terms “trauma-informed practices”, the “trauma concept”, and “trauma paradigm” are used to refer to the broad – and increasingly contested – bod(ies) of knowledge that explore the effects of a range of adverse life experiences on mental wellbeing across the lifecourse. Trauma is defined within mainstream mental health settings as the psychological effects of exposure to actual or threatened death, serious injury, or sexual violation (American Psychiatric Association, 2013), with some authors advocating for a broader definition that can incorporate additional experiences, for example emotional abuse, which are not life-threatening but are frequently humiliating and oppressive (Briere & Scott, 2015). Another significant contestation relating to definitions of trauma is that the term trauma is not only used to describe the psychological effects of particular events, but it is also commonly used to describe overwhelming events or stressors themselves – for example, “the trauma [event] has caused a trauma [reaction]”. Consequently, an unhelpful elision has emerged, with trauma sometimes being used to describe both an event and its effects (Gilfus, 1999). This overlapping usage is confusing, and it unhelpfully contributes to the notion that adverse events and trauma are inevitably connected. It also means that “trauma” is sometimes used as a euphemism or replacement word for violence, which has de-politicising effects (Tseris, 2018). Within this book, then, care is taken to separate acts of violence from ideas about their negative and long-lasting effects. To do this, I have avoided using the term “trauma” or “traumatic event” when referring to experiences of violence or abuse, using it only when discussing the potential effects of such experiences (although p...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgements
• List of abbreviations
• 1 Introducing a critical perspective on trauma
• 2 Interrogating biomedical dominance: critical and feminist perspectives on mental health
• 3 The mainstreaming of trauma in mental health: radical critique, or business as usual?
• 4 Symptoms or social justice? Contested understandings of trauma
• 5 Dysfunctional and responsible: women’s accounts of therapeutic responses to gender-based violence
• 6 De-therapising trauma: negotiating the contested trauma concept
• Index