Sexual Abuse in the Lives of Women Diagnosed withSerious Mental Illness

Maxine Harris, Christine L. Landis, Maxine Harris, Christine L. Landis

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781317710622
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Although a substantial amount of media and professional attention has been devoted to the incidence of sexual abuse in the population at large, the plight of those who have suffered abuse and are seriously mentally ill has largely been ignored. Adding to the existing literature on trauma, this book exposes the prevalence of physical and emotional abuse among severely mentally ill patients, and includes case studies that reveal its tragic and devastating impact. Offering chapters on theory and assessment of abused women, this book explores services that are available to them, discusses treatment (including inpatient and cognitive-behavioral approaches), and addresses recommendations for the improvement of both policy and research.

Chapter One
Modifications in Service Delivery

Maxine Harris

INVESTIGATIVE reporting within the popular press has brought to light the incidence of childhood sexual abuse trauma, domestic violence and sexual intimidation and harassment within the general population of women. More recently, scientific researchers have turned their attention to discovering the rates of sexual abuse trauma in the lives of women diagnosed with serious mental illness (Beck and van der Kolk, 1987; Craine et al., 1988; Rose et al., 1991). Before clinicians and program planners begin making alterations in treatment protocols to address sexual abuse trauma in the lives of women with severe mental illness, two definitional issues must be addressed. First, what do we mean by sexual abuse trauma? Second, how do we define the population of women diagnosed with severe mental illness?

Although distinctions can be made between sexual abuse trauma, which occurs in childhood (when cognitive and emotional schemas for understanding self and others are first forming) and abuse which occurs in adulthood as rape or domestic violence, many recent attempts to establish prevalence rates tend to aggregate sexual abuse which occurs in childhood with abuse which occurs later in adulthood (Jacobson, et al., 1987). This tendency to combine the two types of abuse may stem from the fact that women sexually abused in childhood are more likely to be victimized as adults, resulting in substantial overlap between the two groups (Muenzenmaier, et al., 1993). The tendency to group childhood and adult survivors of sexual trauma may also stem from a recognition that similar treatments apply regardless of when the trauma occurred (Herman, 1993). For the purposes of this chapter, “sexual abuse trauma” will be used to refer to sexual assault experiences sustained during childhood and/or adulthood.

The designation “severe or chronic mental illness” also requires some clarification. It is generally accepted that such labeling does not refer exclusively to diagnosis, but rather that it takes into account both the duration of a person’s psychiatric symptoms and the extent to which those symptoms impair level of functioning (Bachrach, 1988). It is unclear, however, what role, if any, a history of sexual abuse trauma might play in a woman’s being labeled as “severely” or “chronically” mentally ill. One study of female psychiatric inpatients suggests that those with a history of abuse are more likely than a nonabused cohort to have severe, psychotic-like symptoms, to be diagnosed as having borderline personality disorder and to have suicidal symptoms (Bryer, et al., 1987). It may well be, although it remains to be proven, that sexual abuse trauma is one route to patienthood for at least some women who come to be diagnosed as severely mentally ill.

Although it is true that more research needs to be done before we fully understand the role that sexual abuse trauma plays in the lives of women diagnosed with severe mental illness, those studies that have been done reveal prevalence rates from 34% in case management clients (Rose, et al., 1991) to 51% in state hospital psychiatric patients (Craine, et al., 1988). Clinicians and program planners need to begin modifying treatment interventions to accommodate the special needs and vulnerabilities of trauma survivors. Treatment services for clients diagnosed with severe mental illness generally include: case management, residential placement and supervision, inpatient hospitalization, medication management, network intervention and social skills training. Each of these treatment or service interventions must be grounded in an understanding of the trauma experience and adapted to accommodate the vulnerabilities of the trauma survivor. The purpose of this chapter is to suggest a series of clinical and programmatic modifications in customary and usual treatment for persons diagnosed with severe mental illness that might render those treatments more suitable to women who have experienced sexual abuse trauma.

Case management

Case management is a systems and a service intervention designed to coordinate, access and often provide the full range of care that a person with severe mental illness needs in order to live in the community. Regardless of their theoretical orientation, case managers often share a willingness to be flexible and to bend the rules of traditional treatment, a sense of informality and collegiality that extends both to co-workers and clients and a commitment to aggressive outreach (Harris and Bergman, 1993). Paradoxically, these very qualities, so important when engaging deinstitutionalized clients, may pose problems when working with trauma survivors. Trauma survivors are all too familiar with pseudo-intimate relationships in which traditional boundaries are violated and the will of the other is aggressively asserted “for their own good.”

To avoid replicating the interpersonal dynamics of the abusive relationship, case managers must follow a set of guidelines that substitute structure and predictability for informality and flexibility:

1. Case managers should establish contracts with clients which spell out the obligations and responsibilities of both parties. The limits of the case management relationship should be articulated in these contracts; similarly, the terms under which the relationship will take place should be clarified.

2. Case managers should let clients know what they are going to do in advance of actually doing it. Even simple activities such as filling out a form should proceed with “Now we are going to fill out this form; I will ask you ten questions; the questions will all concern your medical history.” By walking the client through an interaction before it occurs, the case manager makes the encounter predictable and safe.

3. While case managers might do well to ask permission before they intervene with any client, they must ask permission when dealing with the survivors of sexual abuse trauma. Simple activities like making a home visit, riding in a car, or attending a recreational activity need to be agreed upon in advance and need to proceed with the stated consent of the client. Such agreements not only demonstrate respect for the client’s wishes but also give the client control over the interaction.

4. Clients must have the right to say “no” to services. Case managers who are concerned with providing services to disenfranchised, “difficult” individuals sometimes forget that clients should always retain the right to reject services. When case managers foist services on unwilling clients, they risk creating an atmosphere in which a controlling adult asks a vulnerable child to do something that the child knows she does not want to do, in effect replicating the very dynamics of the trauma itself.

Because case management entails a relationship between two people in addition to being a service and treatment intervention (Harris and Bergman, 1987) case managers must be especially mindful of who they are when working with trauma survivors. One must be particularly cognizant of one’s interpersonal style and how that style might be seen by a woman who has experienced abuse. Some variables that need to be considered are:

Degree of openness and friendliness. Because they have been abused in relationships that were supposed to be benign or positive, trauma survivors are naturally distrustful of new relationships. A case manager who is “too open” and “too friendly” may cause a client to ask somewhat suspiciously, “What does he/she want, anyway?”

Tendency toward being hierarchical and authoritarian. Since abusers use power to threaten and intimidate victims, clients are often wary of a case manager who is invested in being in charge. For some clients, any relationship in which a power imbalance exists may be reminiscent of the abuse relationship (Jacobson and Richardson, 1987).

Degree to which one appears self-effacing and fragile. Because trauma survivors have an ambivalent relationship to their own “victim”-selves, they are often disdainful or even rageful toward case managers who appear too vulnerable. The client needs to believe that the case manager is strong enough to handle the powerful emotions that might arise in working together.

Gender. Because most abuse is perpetrated by men toward women, the gender of the case manager is a significant issue (Jacobson, Herald, 1990). Male case managers tend to be feared as potential abusers. Clients may also try to seduce a male clinician, believing that all men are interested only in sex. Female case managers, on the other hand, may be seen as failed protectors and thereby become targets for rageful attacks. In general, it is wise to address issues of gender and the accompanying misperceptions early in the case management relationship. Also, case managers need to be aware of their own emotional reactions when working with trauma survivors. Both peer and individual supervision can be useful in helping case managers recognize and deal with their own feelings and responses.

Residential placement and supervision

At some point in their histories, most individuals who are severely and persistently mentally ill receive assistance in securing and maintaining housing. While housing options range from structured group homes to independent but supervised apartments, they almost always include some support and supervision on the part of residential counselors or clinical case managers (Bebout and Harris, 1991). Because of economic and programmatic realities, however, residents in supervised housing experience a lack of privacy, control and safety. Yet, privacy, control and safety are exactly what trauma survivors need if they are to succeed in residential placements. Moreover, concerns about privacy, control and safety apply equally to independent and group home placements. Regrettably, even on-site supervision does not eliminate the element of dangerousness from some group homes.

Privacy

In most group homes and supported apartments, residents must share not only living but also sleeping quarters. Boundaries are often blurred and a room that serves as a living or dining room by day may convert into a bedroom at night. Lack of secure, private sleeping space becomes especially problematic for a trauma survivor whose bedroom was violated by intruders in the past. It becomes difficult for a clinician to help a client develop emotional and psychological boundaries when her most fundamental physical boundaries are not secured.

Control

In residential programs, rules about when and where people sleep are determined and imposed by residential staff. If an individual is residing in a group home, for example, there will be specific times for sleeping and individuals will be required to sleep in designated bedrooms on assigned beds. While this may seem like a relatively simple requirement, it can be problematic for the survivor of sexual abuse trauma who may have learned that the only safe time to sleep is during the day and that beds are unsafe places in which to sleep.

In most housing arrangements, residents do not have complete control over who is allowed to come into the home. While one may be able to control one’s own visitors, in a shared apartment or a group home one may have no control over the visitors of one’s roommates.

Safety

Because of the lack of affordable housing, most residential programs operate in marginal neighborhoods. It is difficult to feel safe where break-ins, rapes and murders are a daily occurrence.

To provide clients with much needed privacy, control and safety, residential planners must be mindful of the following guidelines:

1. Clients need private sleeping quarters. When economic realities prevent private bedrooms, room dividers and screens should be used to demarcate individual sleeping space. All residents should be helped to respect the privacy of roommates.

2. Residents should be allowed to maintain idiosyncratic sleeping patterns that feel safe to them. At the same time, they must be helped to respect group norms.

3. Rules about visitors and proper conduct within the home should be established to accommodate the needs of the most vulnerable house member. Whenever possible, needs for privacy should be considered and discussed when matching housemates.

4. Clients should be presented with a range of housing options and allowed to choose that which feels most safe.

5. Extra precautions such as door locks and window bars should be installed to help residents feel safe, even in those circumstances in which residential staff deem the precautions to be unnecessary.

6. Whenever possible, planners should establish creative public/private partnerships to develop or subsidize more safe, affordable housing.

Inpatient hospitalization

Most adults diagnosed with severe mental illness will experience at least one inpatient stay over the course of their psychiatric treatment. Hospitalization is often indicated for the survivors of sexual abuse trauma who are suicidal, homicidal, psychotic, drug-addicted, self-mutilating or otherwise decompensating (Courtois, 1988). However, because many women labeled as being chronically mentally ill have experienced sexual abuse or intimidation while being institutionalized, clinicians need to consider carefully how inpatient hospitalization will be used in the treatment of adult survivors of sexual abuse trauma who are diagnosed with severe mental illness (Geller and Harris, 1994).

Before assuming that the hospital is a safe place, the clinician must understand the role which hospitals have played in the lives of individual survivors. In some cases women were hospitalized and labeled as “crazy” when they first spoke of the abuse (Geller and Harris, 1994). The hospital, rather than being a place of treatment, was an instrument of control and punishment. Many women who were hospitalized for long stays at public hospitals were abused while hospitalized (Geller and Harris, 1994). The hospitalization thus became the site of more trauma.

When the need for inpatient, structured hospitalization does arise, clinicians need to carefully consider alternatives to traditional inpatient treatment as well as strategies for reframing inpatient treatment to render the hospitalization safe as well as therapeutic.

1. The alternative of using community-based and professionally staffed crisis beds should be considered. The need for a structured and safe environment is real; however, individuals can receive support and safe haven in environments other than hospitals.

2. When a hospitalization becomes necessary, it should, if possible, be voluntary and under the control of the patient herself. It is often useful to establish contracts with chronically mentally ill survivors of sexual abuse trauma in which the client determines when and if a hospitalization will occur.

3. The rationale for an actual admission should be made explicit to the client as should the conditions for her release from the hospital. This explicit contracting makes the hospitalization a predictable experience rather than a frightening descent into a world over which the client has no control. Such contracting requires close coordination between the inpatie...

Table of contents

• Cover Page
• Half Title page
• New Directions in Therapeutic Intervention
• Title Page
• Copyright Page
• Contents
• Introduction to the Series
• Preface
• Contributors
• Part I Theory and Assessment
• Chapter One Modifications in Service Delivery
• Chapter Two Homeless, Addictions and Mental Illness
• Chapter Three Assessment of Trauma in Women Psychiatric Patients
• Part II Treatment
• Chapter Four A Cognitive-Behavioral Approach
• Chapter Five A Social Skills Approach to Trauma Recovery
• Chapter Six Inpatient Treatment of Psychiatric Women Patients with Trauma
• Part III First Person Accounts
• Chapter Seven A Historical Perspective on Victimization
• Chapter Eight On Being Invisible in the Mental Health System
• Chapter Nine As Told To …
• Chapter Ten The House on Phillips Avenue
• Part IV Policy and Research
• Chapter Eleven A Question of Illness, Injustice, or Both?
• Chapter Twelve Treatment Research on Sequelae of Sexual Abuse
• Chapter Thirteen Prevalence and Impact of Sexual and Physical Abuse
• Part V Special Issues
• Chapter Fourteen Care of Clinicians Doing Trauma Work
• Chapter Fifteen Sexual Trauma and African American Women
• Chapter Sixteen Spirituality in Trauma Recovery
• Chapter Seventeen Trauma and Trauma Recovery for Dually Diagnosed Male Survivors
• Index