HISTORICAL CHILD SEXUAL ABUSE ANNUAL MEDICAL PSYCHOTHERAPY CONFERENCE, LEEDS 2016 DRS JO STUBLEY AND MARIA EYRES

Transcription

1 Individuals Services Society HISTORICAL CHILD SEXUAL ABUSE ANNUAL MEDICAL PSYCHOTHERAPY CONFERENCE, LEEDS 2016 DRS JO STUBLEY AND MARIA EYRES

2 Aims of workshop Overview Questions Discussion Outcomes

3 Banality of Evil Hanna Arendt coined the phrase in her work Eichmann in Jerusalem, Report on Banality of Evil where she described his action as not attributable to the deeds of the madman alone but to the context of the society around him It came to indicate the culture of submission to authority, where no questions are asked about the morality Bauman argued further that one of the civilization's features is its moral indifference, with modern society cutting its members off from their ability to empathize

4 Current Context around HCSA seems to reverberate with some of those sentiments where no questions were asked and no authority questioned Jimmy Savile Scandal Operation Yewtree 2012 Giving Victims a voice complaints spanning 55 years, age range 8 47 y.o. Rotherham, Derby and Oxford inquiries into child sexual exploitation National Taskforce on Sexual Violence, CSA and Exploitation OCC Inquiry into Sexual Abuse in the family environment Multiple Police Inquiries into HCSA Operation Whistle (Jersey), Wiltshire investigation into Heath, Operation Midland

5 Current Context cont Independent Inquiry into Childhood Sexual Abuse 2014 Justice Goddard Aims expose institutional past failings and make future recommendations for child protection measures Beginning Roman Catholic and Anglican Churches, Local councils including Rochdale and Nottinghamshire

6 Avoiding the evil; mandatory reporting; a search for the concrete container? 2013 Working Together to Safeguard Children D of Education. Mandatory Reporting not the answer. Safeguarding Guidance is already crystal clear. Subsequent events >politicians on all sides called for a change to the law Amendment to the Serious Crimes Bill 2014 brought before the Lords withdrawn and government committed to consultation. Likely to offer to consultation (April 2016) mandatory reporting and failure to act. Addition of mandatory reporting on HCSA?

7 Historical Psychoanalytic / Psychiatric Context Freud s seduction theory Freud VS Ferenczi Masson in 1970 s Recovered / False Memory syndrome Debate Ritual Satanic Abuse / Dissociative Identity Disorder Complex Trauma / Borderline Personality Disorder

8 Complex Trauma Judith Herman 1992 PTSD Re experiencing, hyper arousal and avoidance and numbing AND Dissociation, somatisation, identity disturbance, revictimisation and affect dysregulation? ICD 11 / DSM V PTSD with dissociative Links with Van der Kolk s Developmental Trauma Disorder

9 Definitions of CSA Tends not to be an event but a process that evolves over time systematic, repeated, normalised Russell 1986 hierarchy of severity Perpetrator gender, family member, known to child, age sibling, peer on peer, Diversity experience, impact, outcome, age of child, relationship to abuser, duration, resilience, support network Research only began in earnest in mid 1980s issues re data collection, prevalence rates, false positives or negatives, barriers to disclosure

10 Government consultation of definition of Childhood Sexual Exploitation (CSE) Feb 2016 CSE is a form of child abuse It occurs if anyone under the age of 18 is persuaded, coerced or forced into sexual activity in exchange for, amongst other things, money, drugs/alcohol, affection or status. Consent is irrelevant, even where the child may believe they are voluntarily engaging It doesn't t always involve physical contact and may occur online

11 Epidemiology Adverse Childhood Experiences (Felitti 2002) > patients San Diego California 28% reported physical abuse, 21% CSA 40% reported 2 or more ACE; 12.5% 4 or more Cumulative ACE scores high correlation with numerous mental and physical health problems as adults

12 The 2007 National Survey of Psychiatric Morbidity Uncomfortable talk M 7 % F 14 % Sexual touching M 5% F 11% Non consensual intercourse M 1% F 3% No effect of social class and ethnicity Lower rates reported by those over 65

13 Impact on the Individual Physical Somatisation Chronic pain and unexplained illness Somatoform Hypochondriasis, Body Dysmorphic Disorder Frequent or recurrent infections, severe eczema and other skin conditions Auto immune Disorders CFS, ME, SLE, R Arthritis Increase risk Obesity, Type 2 Diabetes, Hypertension, Heart Disease, Respiratory Disease, Cancer

14 Impact on the Individual Psychiatric Personality Disorders BPD ( Zannarini et al 1997, % report CSA) ASPD, Narcissistic Depression, Bipolar Disorder, Anxiety, Social Anxiety, OCD, PTSD, Dissociative Disorders, Eating Disorders, Substance Misuse and Addictions, sexual dysfunction Psychotic disorders Self harm and Suicide

15 Impact on the Individual Psychiatric Cont d Australian Twin Studies Kendler et al 2000 significant odds ratio for sexually abused twin especially for drug and alcohol dependence and bulimia nervosa Dinwiddie et al 2000 major depression, panic disorder and alcohol dependence Nelson et al 2002 depression, attempted suicide, conduct disorder, alcohol dependence, social anxiety, rape as an adult and divorce

16 Impact on the Individual Psychiatric Cont d Cutajar et al 2010a Child sexual abuse involving penetration has, in particular been identified as a risk factor for developing psychotic and schizophrenic syndromes Fergusson et al 2008 Christchurch longitudinal study Estimates of the Population Attributable Risk (PAR) suggested that the elimination of CSA within the cohort would have reduced overall rates of mental health disorder in adulthood by 13% The study also emphasizes the increased risk for suicidality

17 Impact on the Individual Psychiatric Cont d Read 1997 Review of 15 studies from showed 64% of women psychiatric patients report either physical or sexual child abuse The study also found abused men were significantly more suicidal than their nonabused counter parts

18 Impact on the Individual Social Relationships with others Domestic violence, marital breakdown Education and employment Forensic crime and delinquency, substance abuse Care giving capacities

19 Impact on Services Medical, Psychiatric and Social care needs coordination and linking across boundaries Repetition Compulsion / attachment styles impact on engagement with services and push for action rather than containment Disclosure delayed / absent treatment of symptoms without formulation / understanding Treatment requires stability of attachment short term interventions problematic

20 Impact on Services Disclosure Read and Fraser % of psychiatric inpatients disclosed trauma when asked; 8% volunteered disclosure without being asked Felitti and Anda % reduction in doctor s office visits and11% reduction in ER visits if asked about ACEs as part of standard medical assessment (444, 000 patients)

21 Impact on Society Morbidity / Mortality Cost to NHS, social care and forensic / police services financial and styles of engagement, complex co morbidity Trans generational transmission attachment research of unresolved trauma Cycles of abuse and deprivation

22 What has already been done The Academy of Medical Royal Colleges produced a report on Child Sexual Exploitation Jay report highlighted the importance of awareness of the effects of sexual exploitation on children, young people and adults

23 Q1 How do we get involved? What is our role as individuals? What is the role of the Faculty? What is the role the College(s)?

24 Q2 How do we work with the impact of HCSA on the workers? Help others to recognize the effect Reflective spaces

25 Q3 Diagnosis and treatments, services and pathways; do they need reformulating? How helpful are the psychiatric diagnostic classificatory systems in the light of emerging evidence on HCSA; do they mimic the fragmentation of the mind in the aftermath of trauma? Do we need to re design psychiatric services to move away from diagnostic based interventions which offer limited pieces of work towards a model based on individual formulations or trauma based and relational interventions?

26 Q4 Training What prevents medical / psychiatric training from adequately addressing this issue in training for detection, aiding disclosure, engagement and management of HCSA related problems and presentations? What do we need to put in place to make it work?

27 Q5 Research priorities What research questions should we be asking? Epidemiology Resilience Evidence based practice Service issues