IN PART ONE of our Speak or Survive investigation, we spoke to survivors of sexual abuse about their experience of coming forward and what changes they want to see, as well as talking to agencies including Tusla, the HSE and groups who provide therapy and advocacy for victims of sexual crimes.
Today, we explore how those who suffered the most traumatic and sustained abuse – particularly childhood sexual abuse – have had poor mental health outcomes in a system that is not structured to adequately support them.
Noteworthy has identified that:
Despite international evidence showing that survivors of childhood sexual abuse can suffer severe trauma and lifelong fallout, many adults in need of psychological supports are not getting appropriate supports in psychiatric institutions.
Some survivors of childhood sexual abuse say that they feel the response to their trauma has been to place them in mental health facilities, sometimes involuntarily in accordance with the 2001 Mental Health Act.
Children who are sexually abused face waiting lists of over a year for therapeutic support.
Tusla is not categorising how many allegations of sexual abuse are deemed “unfounded” and there is widespread concern among advocacy groups that some children may be being returned to abusive situations in which they are not eligible for therapeutic supports.
In 2018, a report commissioned by the National Women’s Council highlighted that 25% of women had experienced a form of physical and sexual violence since turning 15.
In 2013, a sample study of male and female Irish psychiatric inpatients found that 29% reported being raped before entering the institution while an overlapping 26% reported other types of sexual abuse or humiliation, also outside the institution. Part 5 of the Commission to Inquire into Child Abuse’s report extensively detailed a link between childhood sexual abuse and later mental health problems.
This supports international evidence suggesting that around half of all female mental hospital patients had been sexually abused as children or adolescents, but that hospital staff were usually unaware of this and that only 20% believed they had been adequately treated for sexual abuse. Irish studies have found a link between childhood sexual abuse and adult depression.
Since its establishment in 2000, the National Counselling Service has seen over 40,000 referrals to its service which provides free counselling and psychotherapy to adults who had experienced abuse in childhood.
“While a majority of clients (at the NCS) report sexual abuse as the reason for seeking counselling, this form of abuse rarely occurs in isolation,” said a spokesperson for the HSE. Citing extensive academic research, the spokesperson acknowledged a strong link between childhood sexual abuse and adverse mental health in later life, with victims vulnerable to post-traumatic stress disorder and suicidal ideation.
“The majority of NCS clients present with symptoms of post-traumatic stress [and] approximately 50% experience mental health difficulties for which they attend community mental health teams,” the HSE spokesperson said.
Yet it is precisely because survivors of abuse often present in a psychologically-vulnerable state that many of Noteworthy’s interviewees felt they had been “written off” by those from whom they sought help.
Involuntary admission to psychiatric units
Alice*, who was sexually abused by her father and again when in foster care, has spent 22 years seeking to have the abuse addressed and acknowledged by the HSE, An Garda Siochana and Tusla. We relayed Alice’s fight for justice in part one of this investigation yesterday here.
Alice believes that part of the health system’s response to her claims and the fallout from the trauma she endured has been to medicate and institutionalise her on various occasions, sometimes involuntarily and for a period of months, rather than provide her with appropriate therapeutic support.
“In the late 1990s, [the local health board] were investigating the abuses in the foster home, and I was working with them but they weren’t helping me,” said Alice. “I was self-sabotaging and drinking. On a night out with my friends, I left them to throw myself into the canal but instead I decided to go to the Garda station and report the abuse. I was crying and distraught and told them I was suicidal. I was told I’d be done for public order if I didn’t stop.”
Alice said there was no follow-up from the Garda following her visit to the station that night; an internal report into Alice’s case, published by Tusla this year, supports this claim.
Antipsychotic drugs
Alice’s medical records show that during one involuntary psychiatric admission she tried to “abscond” and was “put into seclusion”. “They dragged me back and put me into a seclusion room that was like a cell. I clawed at the door begging them to listen to what I was saying.”
She was put on risperidone, an antipsychotic drug. “When I screamed out, they’d say it was a feature of my mental illness. They didn’t seem to have experience of people suffering from trauma. I was told that it was for my safety but it felt like punishment.
“How can you prove that you are not insane – just traumatised? You succumb to them and start to think: maybe they’re right, maybe it’s me that’s the problem.”
As documented in part one of this series, Tusla has publicly apologised for admitted failings in her case dating back to at least as far 1987. All of this compounded the experience of being sexually abused as a child, Alice said.
“Of course it is hard to cope sometimes. How could anyone?”
Last December, the Director of Public Prosecutions informed Alice that her father and the abuser from the foster home would not be prosecuted due to insufficient evidence. “I was wailing. I felt like my insides were being ripped out. Nobody made any follow-up call to check if I was alright. I went into a state of trauma. My GP prescribed some Xanax.”
Alice’s GP recommended that she be admitted to hospital for bedrest. He gave her a referral letter explaining her documented history of child sexual abuse and she willingly presented herself to the hospital. An admitting doctor carried out an assessment during which, she said, he quizzed her on her relationship with her parents.
“He asked me if I was suicidal and, when I said I was not, he told me I would not be admitted because I was not a danger to myself. Then I was given a prescription for Clonazepam, a drug I hadn’t ever taken before. I said I wanted support, not drugs. He said this is not the place for me.”
Lack of confidence in the HSE
Mick Finnegan, whose claims that he was abused as a boy by a senior volunteer in the St John’s Ambulance were investigated and described as “founded” by Tusla in July this year, said he was severely traumatised both by the abuse and how it was allowed to happen. His alleged abuser denies all allegations, and has said he will challenge the Tusla finding.
Mick went to England when he was 18 and, for many years, lived on the streets.
“I got help with the NHS,” he said. “Without them, I think I’d be dead: the mental health services for victims of sexual crimes in Ireland are outsourced to underfunded charities.”
Mick’s lack of confidence in Ireland’s ability to correctly care for victims of sexual crime is echoed by Dr Stuart Neilson, who spoke to Noteworthy about his experience of being treated in a mental health setting in Ireland.
In 2018, there were 2,390 involuntary admissions to mental hospitals and other approved settings, according to the Mental Health Commission. Figures from the Health Research Board suggest that men may make up approximately 67% of involuntary admissions.
Stuart suffered sexual abuse while at boarding school in England as a child in the 1970s. He moved to Ireland from England in 1998 and has experience of being involuntarily admitted to a mental hospital in this country.
The abuse Stuart endured at school, combined with his Asperger’s Syndrome, made Stuart vulnerable. He spoke out publicly when the scale of child sexual abuse by children’s TV presenter Jimmy Savile – who had visited his school in the 1970s but was not Stuart’s abuser – began to emerge.
In 2015, Stuart received a letter from the chairman of the school’s governors which said: “I understand that your own time at the school was not happy – or at least that there were unhappy incidents in it.”
The sexual crimes – and the fallout from them – took a heavy toll on Stuart. “I’m 56 years old, married to a supportive wife and have great kids, but I still won’t get in a car, meeting or lift with one man. I’ve been an inpatient in psychiatric units five times. One of these was an involuntary admission after a suicide attempt and, on another occasion, I was told I would be sectioned if I did not stay voluntarily.
“These mental hospitals are full of people who have been sexually assaulted. It’s so common: between one in four and one in five people have had similar experiences [of sexual crimes].” Stuart said that there were no programmes specifically equipped to deal with sexual assault.
Most of the therapy was group sessions and Stuart felt that it was never the right environment for him to explain what had really brought him there. “I was being treated for social anxiety without them having any understanding of what I was anxious about.”
Stuart’s medical records for the years 2012-17 in Ireland, obtained through a subject access request and seen by Noteworthy, indicate that he was prescribed chlorpromazine, a conventional antipsychotic which treats psychosis (where a patient struggles to distinguish between what is real and what is not), schizophrenia, mania and bipolar disorder, as well as pregabalin, which is used in the treatment of epilepsy and anxiety.
“No intervention, other than drugs, has ever been offered for the impact of child sexual abuse,” said Stuart. “When I was in the hospital, a doctor recommended I attend [a HSE-funded counselling service dedicated to helping survivors of sexual abuse].”
Treatment – but on whose terms?
In appointment letters, the HSE told Stuart that “it is necessary for you to attend the outpatient clinic in order to remain on waiting lists to attend other members of the community mental health team such as the social worker, psychologist etc.”
“Treatment is purely on their terms, and is all or nothing,” said Stuart. “My HSE treatment consisted of six assessments per year by trainee psychiatrists, without access to a consultant. Repeating my history from the beginning to at least two – and usually more – psychiatric trainees every year was very wearing and often extremely upsetting.”
In his medical records, a psychiatrist records that “Stuart has been contacted by Gardaí to provide a written statement re abuse he suffered…This has been very difficult and past trauma has resurfaced. Wife is supportive. Attends [a service provided by an autism charity] key worker and counsellor alternate weeks, feels it very useful.”
Stuart said: “This psychiatrist seems to have simply fitted whatever I said into their own understanding of residential child sexual abuse inquiries. It is extremely tiring to keep repeating the same history, only to see they weren’t really listening anyway. This sounds unduly negative and critical of the service. The staff were not at all equipped to help; they are devoted and caring, but hugely under-resourced. Trainee psychiatrists have no authority to provide anything other than pharmaceutical interventions.”
A HSE clinical psychologist speaks
Under condition of anonymity, we have spoken to an experienced HSE clinical psychologist who has worked with inpatients and outpatients at an Irish psychiatric hospital. We refer to this person as Dr X.
Upon Dr X’s advice, Noteworthy also asked the HSE what procedures or therapies are offered (eg CBT, psychotherapy) where the person’s trauma or psychological illness is primarily or exclusively a result of sexual crimes. They did not respond to this question.
The HSE explained, in detail, how the NCS functions. The HSE said that the waiting times to attend counselling at the NCS vary throughout the country depending on several factors including staffing levels, but that it can vary from 6 to 12 months. “For some clients the wait may be longer when they have additional specific requirements in terms of appointment time, location, counsellor etc. Covid-19 has impacted on service provision significantly.”
There is no requirement to ask about a history of sexual abuse in Irish mental hospitals.
“They are mandated in the UK, although of course there is a difficulty around that being a tick-box question and the reality that you often need to establish a trust relationship before someone will disclose,” said Dr X.
Research shows that up to 60% of victims never disclose their abuse, the HSE said, with male victims even less likely to disclose and, even then, often after some significant delay.
Dr X notes: “Anecdotally, there are huge rates of sexual abuse that are not reported to clinicians, or reported and written down as though as they’re as relevant as what car the patient drives. If someone presents with an illness, such as schizophrenia, clinical depression or obsessive compulsive disorder, we tend to treat the illness, whereas what we need is a more trauma-informed approach – but we are leagues from that. There is no specific treatment for child sexual abuse.”
The World Health Organisation has only recently included complex post-traumatic stress disorder in its list of diagnoses.
“Before this, we had a diagnosis of post-traumatic stress disorder, but someone with a history of ongoing traumatic stress disorder does not typically present as a typical case of PTSD,” said Dr X.
“PTSD is more applicable to a single event of major trauma rather than the clinical issues you see in someone subjected to sustained sexual childhood abuse, which can have interpersonal, intrapersonal, metabolic and neurological effects on the developing brain.
“Survivors can become hypoaroused – underaroused and dissociated as a survival strategy for a child so terrified that their mind almost leaves their body, which becomes reflexive in later life – or hyperaroused, using drugs, alcohol or deliberately self harming.
“Borderline personality disorder, substance misuse disorder, schizophrenia are among the diagnoses given.”
Abigail’s story
Another abuse survivor with whom Noteworthy has had extended contact is Abigail*. When Noteworthy first spoke to Abigail*, she had just been released from an involuntary admission to a psychiatric unit.
Indeed, she has been in and out of psychiatric care for over 20 years.
“I’m scared to keep speaking about what happened to me because they’ll lock me up,” she said at the time.
Abigail’s story is difficult, fragmented and complex. Sometime around late 2014 or early 2015, she made a complaint to gardaí alleging that she had been sexually abused by a babysitter when she was a child.
Gardaí sent a file to the Director of Public Prosecutions on Feb 10, 2015 and that office requested further records from gardaí on May 5, 2015, according to records seen by Noteworthy. At the end of that month, she was informed that the DPP would not be proceeding with a prosecution due to insufficient evidence being available to secure a conviction that would be safe beyond reasonable doubt; this was confirmed in writing from the DPP on September 15, 2015.
Approximately a year later, she made a further statement to gardaí at a station. Over six pages, she detailed how a relative had groomed and sexually abused her over a four-year period, beginning when she was eight years old and ending when she was about 12.
Noteworthy has been able to verify that Abigail met with a garda shortly after this statement was made about the relative, during which the garda explained the process to her.
Abigail’s sister accompanied her to this meeting because the sister alleged that she had witnessed some of the childhood sexual abuse from the relative.
Speaking out – and being dismissed
What is striking about Abigail’s story is how she feels her past attempts to speak out about her abuse had led her to be dismissed as a child and young adult with mental health issues. Her troubles, she said, all stem back to her experience of childhood sexual abuse.
She claims that when she first tried – as a child – to relay the abuse as a child to her mother, she was “locked away”. The Gardaí came to take me to [a psychiatric ward]; my mother rang them to take me. I’ve been in and out of psychiatric care, I was put on medication that I subsequently became addicted to, and when I was right [well], I would fight for my custody of my daughter.
“I don’t know how many times I’ve been in psychiatric care. I was pumped with medication and put into a place that some people still never come out of. It seemed to coincide with when I spoke out about the abuse. I met women of 60 or 70 who were institutionalised. They put me away one time after I went down to request help from a local TD: I had a knock on my door and after a few hours I was back in the ward. The hospital said I had a personality disorder.”
Noteworthy has seen medical documents relating to Abigail’s medications and history of narcotic use.
“I drank heavily and took drugs for years to block out the sexual abuse of my childhood,” she said. “I left school early and went to England when I was 18 to get away. I came back a year later and was put into an alcohol treatment centre. I was messed up over everything, but what I needed was for the abuse to be addressed.
“I was on ecstasy, speed and hash and I’d go out all night and leave my daughter with my cousin or my parents as babysitters. I only did it on weekends, but I was trying to block out the abuse. I was young, naive and vulnerable. My daughter was two and a half when they took her from me and gave her to my parents while I was in treatment.”
A relative paid for private treatment in a rehab centre. “I told them about the sexual abuse but they said they only deal with drugs and alcohol,” Abigail claims. “I told them all but nobody seemed to want to address why I was traumatised.”
On March 27, 2001, when Abigail was receiving counselling as an outpatient, her therapist recorded: “Abigail very tearful and angry. Angry at parents for taking [her daughter] into foster care. Denys [sic] using any drugs or taking alcohol. When I asked about what precipitated this admission, became very angry [and] stated that no one would believe her, the mental health service would only listen to her parents.”
When speaking to Abigail, it is clear that she is wary of state agencies including the HSE and the criminal justice system. We have included her story here precisely because it is complex and because, despite having gathered hundreds of pages of documents and presented Noteworthy with approximately two dozen recordings, she has sometimes struggled to present all the different threads coherently.
Presenting as anything less that coherent
Of approximately 30 survivors we have spoken to – including many women who have gone on to campaign against sexual violence and spoke only on background – at least a dozen say that presenting as anything less than coherent and with carefully structured evidence can lead to a survivor being dismissed.
This, in turn, may exacerbate trauma, according to a HSE clinical psychologist who spoke to us on condition of anonymity.
“I needed support,” Abigail said. “I needed to be believed. I wouldn’t have gone through nearly 40 years of this for nothing. I’ve never been given therapeutic support that addresses what actually happened to me and, at this stage, I don’t even know if I’d accept it. I’ve no faith in the mental health system. I feel I’ve been in a lone battle.”
One big change that would make a huge difference is an advocate, she said. “I wish that, when I’d gone to the Gardaí and made my report, there’d been someone there to support me throughout, keep me informed on what was going and make sure I had support.
“I understand that there has to be due process and I don’t want that overturned – it is right that the defendant gets a fair trial, but they’re supposed to get that fair trial because they are one person against the might of the State. Instead, it feels like the State is against the victims.”
In medical records for both Abigail and Alice, doctors have suggested that they may have a personality disorder but they have not received a formal diagnosis.
“Many with that diagnosis – mostly female – do have histories of significant abuse, and the diagnosis is often made, but problems arise from there: huge gaps in availability of evidence-based interventions and over-reliance on medication to treat symptoms, lack of trauma-informed care and fundamental misunderstanding of the aetiology of difficulties with which this patient group present,” said Dr X.
“In standard care, the frontline treatment for most diagnoses and most patients is medication and dealing with the symptoms rather than causes, and it is tricky because if you have someone who presents as floridly psychotic and is talking of abuse, it can be hard to know what is real and what is not.”
Alice said that, in her case, simple consultation between social workers and clinicians would have prevented her from being disbelieved about her abuse.
Medicating trauma
Cliona Sadlier, executive director of the Rape Crisis Network of Ireland, said that “complex PTSD oftentimes mistaken for mental illness and they are assigned lifelong diagnoses and medicated. There is work that needs to be done. We experience this a lot … When we used to medicate and institutionalise mental illness, we had people come to us to get off the prescribed drugs and get out of the mental health system. Trauma is a rational response to what someone has done to you but the system looks at this and medicates.”
When someone is referred as an inpatient or outpatient, Dr X said, a clinical history is taken in a short period of time, sometimes an hour and sometimes three, depending on the pressure services are under.
“I often hear team meetings in which it is said that the patient had ‘no adverse childhood experiences and I think ‘they didn’t report them but that doesn’t mean it didn’t happen’, because in my clinical experience it can take years for people to acknowledge, even to themselves.
“A lot of survivors will never come into contact with the mental health services at all, and there can be a huge difference between someone who experienced a single event or a smaller number of events outside the family and who has a supportive and loving family and someone who suffers sustained childhood sexual abuse within the family.”
In three years of training towards their clinical PhD, Dr X said, they had about one day to explore this area. Noteworthy asked the HSE what specialised training is given to HSE psychiatrists and clinical psychologists to support patients who make a disclosure, what are the training competencies and who sets them. They did not respond to the question.
Dr X said: “There is a growing momentum behind the acknowledgement of the impact of adverse childhood experiences but services are still not designed to respond to it. The HSE said that “approximately 50% of NCS clients experience mental health difficulties for which they attend community mental health teams, with suicidal ideation and suicide risk the most common presenting difficulty amongst NCS clients. The NCS works jointly with mental health services to support clients and coordinate provision of care.”
“For a survivor of sexual abuse to be placed on a ward in a mental health facility can be terrifying and potentially retraumatising especially if they’re in a mixed gender facility with people displaying erratic, unpredictable or potentially aggressive behaviour,” said Dr X.
“It feels like there is an intellectual acknowledgement on the part of many in this profession that sexual abuse is the big issue for many of the patients we see, but sometimes they are not joining the dots between that and the patient’s current presentation.”
In 2019, a one-night census of Irish psychiatric units and hospitals found that “one-third of all in-patients on census night had a primary admissions diagnosis of schizophrenia, 16% had a diagnosis of depressive disorders, 10% had a diagnosis of organic mental disorders and almost 8% had a diagnosis of mania.”
It is unclear if the census questionnaire specifically raised the issue of a PTSD approach, but there was no reference in the resulting report to PTSD or trauma-informed approaches.
Are child abuse victims still being failed? The expert view
In Australia, the Blue Knot Foundation is widely regarded as providing a high – if not gold – standard of care for adult survivors of childhood sexual abuse. “They provide excellent guidelines for GPs, mental health teams and the public, from one-page infographics to more detailed treatment guidelines,” said Dr X. “But they’re well-funded; we have nothing like that here.”
Because severely traumatised or addicted patients cannot get the benefit of standard therapies provided by rape crisis centres, some people in institutional settings, who were sexually abused as children, are effectively not being treated for the root of their trauma.
But the problems extend beyond adult survivors to children who are raped and sexually abused today.
https://public.flourish.studio/visualisation/3710250/
Before Covid-19, Children at Risk Ireland (CARI), a charity which provides therapeutic supports to victims of sexual abuse up to the age of 18 and supports children showing sexually harmful behaviour before the age of 12, had a waiting list of 85 children. By April, that had grown to 114 children. As of July 31, 2020, there were 165 children on the waiting list. Waiting times are at least a year.
“This means that there is a real risk of placement breakdown,” said Eve Farrelly, executive director of Cari, which relies on donations and some Government funding. “Children thrown off their normal developmental trajectory face a lifetime of struggle and fighting demons. We are still storing up problems for the future and repeating the same patterns.”
Cari only sees children who are not at continued risk of sexual abuse. Some referrals are self-referrals, others come from Tusla.
In 2018, One in Four was forced to close its waiting list to adult survivors of childhood sexual abuse due to a lack of resources.
“Our waiting lists are now long, but they are not closed,” said Deirdre Kenny, director of advocacy at One in Four. “We have seen them increase during the pandemic as people have had time to reflect, and our services are being provided online with a slow shift back to face-to-face. But investment is sorely needed, and society as a whole needs to properly recognise the extent to which people can be impacted by sexual violence.”
Of course you have to allow that some cases are correctly handled, said Sadlier. “But when something like sexual crime is too uncomfortable for us, we sometimes turn on the witness – and institutions do that to protect themselves against their own failures. If the system fails it must explain itself, so perhaps it is easier to turn on the witness and say they are mad and bad.”
*Names have been changed. Note: Tusla was established in 2014 and took over HSE social care files, which in turn the HSE had taken responsibility for when it took on the duties of regional health boards in 2005. For legal purposes, however, Tusla is responsible for historic allegations and so, where child abuse allegations take place prior to 2014, we nonetheless refer to Tusla.
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This investigation was carried out by Peter McGuire for Noteworthy and edited by Susan Daly. It was proposed and funded by you, our readers. Noteworthy is the investigative journalism platform from TheJournal.ie. You can support our work by helping to fund one of our other investigation proposals or submitting an idea for a story. Click here to find out more >>
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