“How did you get here?”
The relationship between traumatic life events and serious mental health problems
In a recent discussion with the veteran Irish uses rights campaigner Ita O’Keefe, she explained to me how one of the comforts she found in her many years in the Irish psychiatric system was the sympathy and understand she found on Irish admission wards, not from the staff but from other in-patients.
She told me “someone would always come up to you and ask what’s happened to you”. This immediate recognition that the traumas of life are significant contributors to serious mental health problems is a common theme amongst service users. The conclusion to the many lectures I’ve conducted with Peter Bullimore from The Hearing Voices Network tends to follow the same pattern. Peter will end the lectures (usually delivered to staff), by telling them that the most important question you can ask anyone using mental health services is “How did you get here?”
This is not a reference to car, bus or taxi, the question is a simple one.
“What happened in you your life to bring you to this point?”
The situation in the health service is that the users of the service often want to talk about life events, whilst those in power are far more concerned with genetics, family history, biological illness and medication. This state of affairs is not confined to the United Kingdom. John Read the New Zealand psychologist has collected some memorable quotes from service users in Auckland, New Zealand. “There were so many doctors, nurses and social workers in your life all asking the same thing mental, mental, mental, but not asking you why.”
“My life went haywire from thereon in. I just wish they would have said “what happened to you? What happened?” but they didn’t.” (Hammersley 2004)
The general public are in little doubt as to who they agree with when it comes to the issue of traumatic life events. In studies conducted all over the world asking the general public about causes of metal illness, environmental factors and traumas are consistently rated to be far more significant than biological or genetic factors. For example a survey conducted with the American general public (Link 1999) showed that 91% cited stressful circumstances as a cause of schizophrenia, a finding that has been replicated in countries as diverse as Ireland, Australia, India and Mongolia (Read 2006). To sum up, most service users, the majority of staff and most of the population of the world share the opinion that stressful life events are an important contributory factor in the development of psychosis. The answer is yes and the evidence is growing. Much of the research evidence to date has focused on the relationship between child abuse and psychosis. Before reviewing this evidence two important points need to be made.
Firstly, child abuse is not the only trauma that an individual can experience. Traumatic events in adulthood can be equally significant, as can humiliation experiences such as bullying, or situations involving extreme loss. In addition there is growing evidence (Bentall et all 2006), that those who experience psychosis are in a particularly difficult position, in that they can be further traumatised both by their own often terrifying symptoms, and also through the experience of repeated hospitalisation.
Secondly, it would be incorrect to suggest that the relationship between childhood trauma and subsequent adult psychosis is 1:1. Many people experience child abuse and do not develop psychosis, similarly many people who have distressing psychosis experiences report no history of abuse. This research evidence should not be misinterpreted and used as a stick with which beat families.
There is little doubt in anyone’s mind that child abuse can have severe and lasting consequences. There is robust evidence linking child abuse to a wide range of problems from depression and anxiety to alcohol and drug misuse. Until recently the dominance of bio-genetic models of psychosis meant that the analysis of child abuse in sufferers of adult psychosis was relatively unexplored. Some studies had been conducted (see Read 2006) for a review, but these were often small and poorly controlled, usually because of financial restrictions. However as interests in the field grew some much larger studies with stronger scientific design were published. The first complete systematic review of the evidence linking child abuse to psychosis was completed by John Read and colleagues in 2006. (Read at al 2006), and the results were startling, and prompted Oliver James the British psychologist to state in the Guardian “The psychiatric establishment is about to experience and earthquake that will shake it to its intellectual foundations and may trigger a landslide.”
The review of over 40 studies drawn from an initial sample of over 13,000 concluded.
- There is a strong relationship between symptoms indicative of psychosis and child abuse and neglect.
- This relationship is as least as strong as with other mental health problems.
- There is a particularly strong relationship between sexual abuse and auditory hallucinations.
- The relationship appears to be casual with a dose effect (i.e. the worse the trauma the more likely the psychosis).
It’s beyond the scope of this article to cover all the findings of the original review. Instead I have decided to present in a little more detail finding from three o the more interesting papers.
Janssen et al (2004)
This study looked at a general population sample of 4045 people in Holland. One problem with attempting to analyse previous experience of child abuse in someone with a psychosis, is that there is a tendency for some scientist to question weather or not there can be believed and trusted to give an accurate account. (Despite the fact that there is no evidence what so ever that someone diagnosed with psychosis is more likely to ‘invent’ childhood trauma). To get round this the researches interviewed people with no history of psychosis about their childhood experiences and then waited for two years before re-interviewing them. The authors had hypothesised that over the course or two years some people in the group of 4045 would begin to show some evidence of psychosis and thus they would be able to determine if it was the participants who reported child abuse who subsequently ‘crossed over’ into psychosis. The results were an unequivocal yes. It was indeed the participants reporting abuse, who made the transition, and there was a clear dose effect, men who reported severe abuse as children were 40 times more likely to develop psychosis than their non-abused counterparts.
Bebbington et al (2004)
This was a large scale study of 8580 British adults conducted by Paul Bebbington and colleagues from the Institute of Psychiatry. The participants were asked if they has ever had any psychotic experiences and were also asked about child abuse in the form of nine different ‘victimisation experiences’ including physical and sexual abuse, bullying and time in a children’s institution. The psychosis group was 15.5 times more likely to have suffered from sexual abuse than those without any mental disorder; in addition abuse in childhood was more closely related to psychosis than neurotic disorders and drug or alcohol use. A very similar study (Whitfield et al 2005) was conducted with 17,337 participants from California which found almost identical results; the relationship between abuse and hallucinations in this study was so strong that the authors concluded that hallucinations should be viewed as a marker for previous trauma.
Hammersley at al (2003)
I have selected this study not just because I have written it (honestly), but because it looks at a different group of participants. In this study just fewer than a 100 participants with a diagnosis of bipolar disorder were asked about adverse childhood experiences by experiences therapists , at the same time data related to psychotic experiences was collected by trained research assistants who were unaware that trauma data was being collected. The results in this very different group of participants were the same. Those reporting abuse were more likely to report psychotic symptoms, there was a clear dose effect and the strongest relationship was between sexual abuse and auditory hallucinations. Thus it appears that diagnosis is irrelevant, the association between childhood abuse and psychosis in adulthood is a cross-diagnosis phenomenon.
To return to the original point, the answer to the question ‘how did you get here?’ for many service users, who experience psychosis, is, via a series of highly unpleasant life events. The reluctance of the psychiatric establishment to accept this and respond appropriately is a scandal. Continuing to miss-diagnose and medicalize trauma, and offer little more than medication as a response is no longer acceptable, and is one of the reasons why we formed CASL (the Campaign for the Abolition of the schizophrenia Label).
Can things improve? I think so, consider the following quote. “There is widespread concern at the over-medicalization of mental disorders and the over-use of medication. Financial incentives and managed care have contributed to the notion of a ‘quick fix by taking a pill, and reducing the emphasis on psychotherapy and psychological treatments. There is much evidence that there is less psychotherapy provided by psychiatrists than 10 years ago. This is true despite the strong evidence base that many psychotherapies are effective when used alone or in combination with medications… If we are seen as mere pill pushes and employees of the pharmaceutical industry, our credibility as a profession are compromised.”
If that quote had come from a dissident radical practitioner or from within the service users movement, it would not be a great surprise. In fact the quote is from Dr David Sharfstein last years outgoing president of the American Psychiatric Association. As Bob Dylan once remarked “Times they are a changing.”