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and the emergence of a new, trauma-based paradigm
From the age of 13 to her recent death at the age of 32, my daughter Anna was viewed and treated by the mental health system as "severely and chronically mentally ill." Communication about who she was, how she was perceived and treated, and how she responded took place through her mental health records. A review of 17 years of these records reveals her being described in terms of diagnoses, medications, symptoms, behaviors, and treatment approaches. She was consistently termed "noncompliant" or "treatment resistant." Initially recorded childhood history was dropped from her later records. Her own insights into her condition were not noted. When she was 22, Anna was reevaluated after a suicide attempt. For a brief period, she was rediagnosed as suffering from acute depression and a form of post-traumatic stress disorder. This was the only time in her mental health career that Anna agreed with her diagnosis. She understood herself not as a person with a "brain disease" but as a person who was profoundly hurt and traumatized by the "awful things" that had happened to her.
What happened to Anna?
Anna was born in 1960, the third of five children, a beautiful healthy baby with a wonderful disposition. At the age of about 2 1/2, she began to scream and cry inconsolably. At age 4, we took her to a child psychiatrist who found nothing wrong with her. When we placed her in nursery school, her problems seemed to lessen.
That Anna was being sexually abused and traumatized at the time is clear now, verified in later years by her own revelations and by the memories of others. Her memories of abuse by a male babysitter were vivid, detailed, and consistent in each telling over the years. They were further verified by persons close to the perpetrator and his family, one of whom witnessed the perpetrator years later in the act of abusing another child.
Evidence that Anna was betrayed and sexually violated at an even earlier age by another perpetrator, a relative, came to light eventually through the revelations of a housekeeper in whom Anna had confided at the time. She had told this woman that a man "played with her where he wasn't supposed to" and that the man "hurted her." This abuse was kept secret for nearly 30 years. Anna remembered trying to tell us, as a little child, what was happening, but there was no one to hear or respond. When she told me a man "fooled" with her, I assumed she meant a young neighborhood boy and cautioned his parents. When we took her to a physician, she experienced the physical examination as yet another violation: "I remember the doctor you took me to when I told you. He did things to me that were disgusting (pointing to her genital area)."
The trauma Anna experienced was then compounded by the silence surrounding it. She tried to communicate with her rage, her screams, and her terror. She became the "difficult to handle" child. Her screaming and crying was frequently punished by spankings and confinement to her room. No one then could see or hear her truth; sexual abuse did not "exist" in our minds. When later, as a young girl, she withdrew within herself, somehow different and apart from her peers, we attributed it to her artistic talent or independent personality. We did not see or attend to the terror, dissociation, loneliness, and isolation expressed in her drawings, nor did we heed the hints of trouble expressed by her behaviors. Two grade school psychologists were alone among the professionals we encountered in sensing the turbulence underneath her silence. "Anna is confused about her sexual identity," one reported. "You must help her." The other wrote, "It would seem that Anna has suppressed or repressed traumatic incidents."
Chaos and parental conflict existed in Anna's family from the age of 11 to 13. Although her four brothers and sisters survived the multiple geographic moves, alternative lifestyles, disintegration of their parents' marriage, and episodic violence and alcoholism, Anna did not. She "broke" at age 13. A psychiatrist prescribed Haldol to "help her sleep." She suffered a seizure in reaction, requiring emergency hospitalization. Thus was she introduced to the mental health system.
Anna's invisibility in the mental health system
Anna was a client of the mental health system for 19 years, until the age of 32. For nearly 12 of those years, she was institutionalized in psychiatric hospitals. When in the community, she rotated in and out of acute psychiatric wards, psychiatric emergency rooms, crisis residential programs, and locked mental facilities. Principle diagnoses found in her charts included borderline personality with paranoid and schizo-typical features, paranoia, undersocialized conduct disorder aggressive type, and various types of schizophrenia including paranoid, undifferentiated, hebephrenic, and residual. Paranoid schizophrenia was her most prominent diagnosis. Chronic with acute exacerbation, subchronic, and chronic courses of schizophrenia were identified. Symptoms of anorexia, bulimia, and obsessive compulsive personality were also recorded. Treatments included family therapy; vitamin and nutritional therapy; insulin and electroconvulsive therapy; psychotherapy; behavioral therapy; art, music, and dance therapies; psychosocial rehabilitation; intensive case management; group therapy; and every conceivable psychopharmaceutical treatment including Clozaril. The use of psychotropic drugs comprised 95% of the treatment approach to her. Although early on there were references to dissociation, her records contain no information about or attempts to elicit the existence of a history of early childhood trauma.
Anna was 22 when she learned, through conversation with other patients who had also been sexually assaulted as children, that she was not "the only one in the world." It was then that she was first able to describe to me the details of her abuse. This time, with awareness gained over the years, I was able to hear her.
Events finally became understandable. Sexual torture and betrayal explained her constant screaming as a toddler, her improvement in nursery school, and the reemergence of her disturbance at puberty. It explained the tears in her paintings, the content of her "delusions," her image of herself as shameful, her self-destructiveness, her involvement in prostitution and sadistic relationships, her perception of the world as deliberately hurtful, her isolation, and her profound lack of trust. I thought with relief and with hope that we now knew why treatment had not helped. Here at last was a way to understand and help her heal.
The reaction of the mental health system was to ignore this information. When Anna or I would attempt to raise the subject, a look would come into the professionals' eyes as if shades were being drawn. If notes were being taken, the pencil would stop moving. We were pushing on a dead button. This remained the case until she took her life, 10 years and 15 mental hospitals later.
Believing herself to be "bad," "disgusting," and "worthless," as child sexual abuse victims often do, she hurt, mutilated, and repeatedly revictimized herself. She put cigarettes out on her arms, legs, and genital area; bashed her head with her fists against walls; cut deep scars in herself with torn-up cans; stuck hangers, pencils, and other sharp objects up her vagina; swallowed tacks and pushed pills into her ears; attempted to pull her eyes out; forced herself to vomit; dug her feces out so as to keep food out of her body; stabbed herself in the stomach with a sharp knife; and paid men to rape her.
Again and again, as victims of sexual assault often do, Anna sought relief through suicide. She tried to kill herself many times-slashing her wrists, attempting to drown herself, taking drug overdoses, poisoning herself by spraying paint and rubbing dirt into self-inflicted wounds, slitting her throat with a too-dull razor, and hanging herself from the pipes of a state hospital. Many of the mental health professionals she encountered were highly skilled in their disciplines. Many genuinely cared for Anna, and some grew to love her. But in spite of their caring, her experience with the mental health system was a continuing reenactment of her original trauma. Her perception of herself as "bad," "defective," a "bad seed," or an evil influence on the world was reinforced by a focus on her pathologies, a view of her as having a diseased brain, heavy reliance on psychotropic drugs and forced control, and the silence surrounding her disclosures of abuse.
Just 4 days after her 32nd birthday, after another haunted sleepless night, she hung herself, by her T-shirt, in the early morning bleakness of her room in a California state mental hospital. She was found by a team of three night staff who were on their way in to give her another shot of medication.
The wall of silence
The tragedy of Anna's life is replicated daily in the lives of many individuals viewed as "chronically and severely mentally ill." Unrecognized and untreated for their childhood trauma, they repeatedly cycle through the system's most expensive psychiatric emergency, acute inpatient, and long-term institutional services. Their disclosures of sexual abuse are discredited or ignored. As happened during their early childhood, they learn within the mental health system to keep silent.
Clinicians who acknowledge the prevalence of traumatic abuse and recognize its etiological and therapeutic significance are deeply frustrated at being denied the tools and support necessary to respond adequately. Sometimes, as Anna's psychologist did, these clinicians leave the mental health system entirely, deciding they can no longer practice with integrity within it.
The biological paradigm = the inability to see
Although rehabilitative, psychotherapeutic, and self-help approaches operate within the system, the dominant paradigm within which these approaches are subsumed is clearly that of biological psychiatry. Thomas Kuhn, in his analysis of the history and development of the natural sciences, brought the concept of "paradigm" into popular usage. He viewed paradigms as the conceptual networks through which scientists view the world. Data that agree with the scientists' conceptual network are seen with clarity and understanding. But unexpected "anomalous" data that do not match the scientific paradigm are frequently "unseen," ignored, or distorted to fit existing theories.
In the field of mental health, a biologically-based understanding on the nature of mental illness has for years been the dominant paradigm. It has determined the appropriate research questions and methodologies; the theories taught in universities and applied in the field; the interventions, treatment approaches, and programs used; and the outcomes seen to indicate success.
Paradigmatically understood, the mental health system was constructed to view Anna and her "illness" solely through the conceptual lens of biological psychiatry. The source of her pain, early childhood sexual abuse trauma, was an anomaly-a contradiction to the paradigm-and, as such, could not be seen through this lens. Her experience did not match the professional view of mental illness. It did not fit within the system's prevailing theoretical constructs. There was no adequate language available within the professions to articulate or label it. There were not reimbursement mechanisms to cover its treatment. It was not addressed in curricula for professional training and education, nor was there support for research on the phenomenon. There were no tools-treatment, rehabilitation, or self-help interventions-for responding to it. And there was no political support within the field for its inclusion. Screened through the single lens of the biological paradigm, Anna's experience could not be assimilated. It had to be unseen, rejected, or distorted to fit within the parameters of the accepted conceptual framework.
As a result of this paradigmatic blindness, conventionally accepted psychiatric practices and institutional environments repeatedly retraumatized Anna, reenacting and exacerbating the pain and sequelae of her childhood experience.
The emerging trauma paradigm
Although paradigm shifts mark the way to progress and opportunity, they are always resisted initially. They cause change, disrupt the status quo, create tension and uncertainty, and involve more work. Resistance to a sexual abuse trauma paradigm has existed for more than 130 years, during which time the etiological role of childhood sexual violation in mental illness has been alternately discovered and then denied. In 1860, the prevalence and import of child sexual abuse was exposed by Amboise Tardieu, in 1896 by Sigmund Freud, in 1932 by Sandor Ferenczi, and in 1962 and 1984, by C. Henry Kempe. Each exposure was met by the scientific community with distaste, rejection, or discreditation. Each revelation was countered with arguments that in essence blamed the victims and protected the perpetrators. Freud, faced with his colleagues' ridicule of and hostility to his discoveries, sacrificed his major insight into the etiology of mental illness and replaced his theory of trauma by the view that his patients had "fantasized" their early memories of rape and seduction. Today, 100 years later, in spite of countless instances of documented abuse, this tradition of denial and victim blame continues to thrive.
Psychiatrist Roland Summit refers to this denial as "nescience" or "deliberate, beatific ignorance." He proposes that "in our historic failure to grasp the importance of sexual abuse and our reluctance to embrace it now, we might acknowledge that we are not naively innocent. We seem to be willfully ignorant, 'nescient'".
At this point in history, however, multiple and divergent forces are confronting nescience with truth. Although these forces will continue to meet resistance, they appear to be forming a powerful movement that will help to protect children from adult violation and will promote acceptance of a trauma-based paradigm recognizing the pain of individuals like my daughter and offering them "the radical prospect of recovery".
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