Advances in Psychiatric Treatment (2007), vol. 13, 101–110 doi: 10.1192/apt.bp.106.002840 Why, when and how to ask about childhood abuse John Read, Paul Hammersley & Thom Rudegeair Abstract Subscribers to the medical model of the causation of madness and distress emphasise the role of genes and can severely underestimate the impact of traumatic events on the development of the human mind. This bias persists despite the worldwide popular wisdom that mental illness arises when bad things happen to people. Childhood physical and sexual abuse and neglect are extremely common experiences among those who develop serious mental health problems. Unfortunately, victims are typically reluctant to disclose their histories of abuse and practitioners are often reluctant to seek it. We explore the nature and extent of the problem and the apparent reasons for the pervasive neglect of this important area of care. Then, on the basis of our experience in New Zealand, we provide guidelines on asking patients about childhood abuse and describe an ongoing initiative in the UK to further advance our understanding of the impact of abuse and our skills to detect it and treat survivors. Mental health experts do not have a proud history that there is such a thing as ‘acquired vulnerability’ when it comes to understanding how often very bad and that this can be ‘due to the influence of trauma, things happen to children. Just three decades ago specific diseases, perinatal complications, family a prominent psychiatric textbook reported that the experiences, adolescent peer interactions, and other prevalence of incest was one per million (Henderson, life events that either enhance or inhibit the develop- 1975). ment of subsequent disorder’ (Zubin & Spring, 1977: The reductionistic ‘biogenetic’ paradigm that p. 109). until recently dominated mental health services There seems to be a growing awareness of how and research (Bentall, 2003; Read et al, 2004a) did far the pendulum had swung away from a genuine not encourage a focus on the psychosocial causes integration of the biological and the psychosocial. of mental health problems. Issues such as poverty, The realisation that brain differences, usually cited isolation, discrimination, dysfunctional families and as evidence of biological phenomena, can be caused violence were relegated, in the bio-psychosocial by adverse events – especially during childhood or stress–vulnerability model, to mere triggers or (Read et al, 2001a) – has assisted this process. There exacerbators of a vulnerability usually presumed is also a greater understanding of the role of the to be genetic in origin (Read, 2005). However, pharmaceutical industry in promulgating simplistic the research1 summarised here on the prevalence physiological explanations and highly profitable and effects of childhood abuse is an example of a chemical solutions. Last year the President of the resurgence of interest in ‘psycho’ and ‘social’ factors. American Psychiatric Association advised that ‘As we Perhaps we are beginning to remember that the address these Big Pharma issues, we must examine originators of the stress–vulnerability model stated the fact that as a profession, we have allowed the bio-psycho-social model to become the bio-bio-bio model’ (Sharfstein, 2005). 1. We have not exhaustively referenced here every result It is not sufficient, however, that researchers are discussed. Instead, we have cited only key studies or reviews. paying more attention to the psychosocial causes A full list of references is available from J.R. of human distress. Clinicians need to reflect in their John Read is a senior lecturer in psychology at the University of Auckland (Psychology Department, University of Auckland, Private Bag 92019, Auckland, New Zealand. Email: [email protected]) and a member of the Executive Committee of the International Society for the Psychological Treatments of Schizophrenia (http://www.isps.org). Paul Hammersley is programme director for postgraduate studies in family and individual cognitive–behavioural therapy for psychosis at Manchester University, UK. He has written and lectured extensively on the relationship between childhood trauma and psychosis, and is a member of a multidisciplinary team offering training on how to ask about childhood abuse and researching the effectiveness of that training. Thom Rudegeair is clinical director of the psychiatric in-patient unit servicing central Auckland. He trained in the USA, earning a PhD in zoology (evolutionary theory) from the University of Florida, then an MD and psychiatry credentials from the University of Massachusetts. His current research interests include formulating an evolutionary model of ‘madness’ focusing on the role of childhood trauma and developmental derailment. 101 Read et al practice this long-overdue swing of the pendulum that those who had suffered ‘moderate’ abuse during back towards a more central, evidence-based childhood were 11 times more likely, and those who position. We describe here what we have learned had suffered ‘severe’ childhood abuse 48 times more about one way of doing this: asking patients about likely, to have ‘pathology level psychosis’ than people childhood abuse and responding well when the who had not been abused as children (Janssen et al, answer is ‘yes’. 2004). Not everyone is convinced that there is enough evidence to conclude that childhood abuse is a risk The prevalence and effects factor for psychosis and schizophrenia (Spataro et of child abuse al, 2004; Morgan et al, 2006; Read et al, 2006b). We are convinced by the research and by what we hear A review of 46 studies (n = 2604) of female in-patients in our clinical work when we ask people with these and out-patients, most of whom had psychoses, diagnoses about their lives. This fact, however, is revealed that 48% reported having been subjected largely irrelevant to the purposes of the current to sexual abuse and 48% to physical abuse during article. Psychiatrists do not have to be convinced of childhood. The majority (69%) had been subjected a causal relationship to each and every diagnostic to one or the other (or both). The corresponding category to understand the importance of asking the figures for men (31 studies, n=1536) were: childhood people they are trying to help what has happened sexual abuse, 28%; childhood physical abuse, 50%; in their lives. either one or the other (or both), 59% (Read et al, 2005). Childhood abuse has been shown to have a causal Public beliefs role in many mental health problems, including and expectations depression, anxiety disorders, post-traumatic stress disorder (PTSD), eating disorders, substance A recent review (Read et al, 2006c) found that the misuse, sexual dysfunction, personality disorders public in 16 countries believe that psychosocial and dissociative disorders (Mullen et al, 1993; Boney- factors such as childhood abuse, loss, poverty McCoy & Finkelhor, 1996; Kendler et al, 2000). and problematic families play a greater role in the Psychiatric patients subjected to sexual or physical causation of mental health problems than do genes, abuse during childhood have earlier first admissions, brain dysfunction or chemical imbalance. This is also longer and more frequent hospitalisations, spend true for patients and their relatives (Read & Haslam, longer in seclusion, receive more medication, are 2004). more likely to self-mutilate, and have higher global A study of Londoners (Furnham & Bower, 1992) symptom severity (Mullen et al, 1993; Lipschitz et al, found that the most endorsed causal models for 1996; Read et al, 2001b). They are far more likely to schizophrenia were ‘unusual or traumatic experi- try to kill themselves than are psychiatric patients ences or the failure to negotiate some critical stage of who have not suffered such abuse (Lipschitz et emotional development’ and ‘social, economic and al, 1996; Read, 1998). One study, of 200 adult out- family pressures’. Furthermore, participants ‘agreed patients, found that suicidality was better predicted that schizophrenic behaviour had some meaning and by childhood abuse than by a current diagnosis of was neither random nor simply a symptom of an depression (Read et al, 2001b). A general population illness’. In a more recent London study, only 5% of study found that women who had been sexually people diagnosed with schizophrenia believed the abused as children were between 8 and 25 times cause of their problems to be a mental illness and more likely (depending on the severity of the abuse) only 13% cited other biological causes, whereas 43% to have tried to kill themselves than women who had cited social causes such as interpersonal problems, not been abused (Mullen et al, 1993). stress and childhood events (McCabe & Priebe, There is now also strong evidence that childhood 2004). sexual and physical abuse are related to the symptoms This public belief in psychosocial causes has of psychosis and schizophrenia, particularly halluci- proved resilient to efforts, eagerly supported by the nations and paranoid delusions (Ross et al, 1994; Read pharmaceutical industry, to persuade the public to & Argyle, 1999; Read et al, 2001a, 2003, 2004b, 2006a; adopt a more biological understanding of human Hammersley et al, 2003; Bebbington et al, 2004; Read distress. We should note, in passing, that the ‘mental & Hammersley, 2006). Recent large-scale general illness is an illness like any other’ approach to public population studies controlling for possible mediating education, intended to reduce