S2045796019000131jed 598..602 Epidemiology and Psychiatric Sciences cambridge.org/eps Editorial Cite this article: Sweeney A, Perôt C, Callard F, Adenden V, Mantovani N, Goldsmith L (2019). Out of the silence: towards grassroots and trauma-informed support for people who have experienced sexual violence and abuse. Epidemiology and Psychiatric Sciences 28, 598–602. https://doi.org/10.1017/ S2045796019000131 Received: 29 October 2018 Revised: 16 February 2019 Accepted: 19 February 2019 First published online: 12 April 2019 Key words: Health service research; psychiatric services; sexual assault; trauma Author for correspondence: Angela Sweeney, E-mail: asweeney@sgul.ac.uk © Cambridge University Press 2019 Out of the silence: towards grassroots and trauma-informed support for people who have experienced sexual violence and abuse A. Sweeney1, C. Perôt2, F. Callard3, V. Adenden4, N. Mantovani1 and L. Goldsmith1 1Population and Health Research Institute, St Georges, University of London, Cranmer Terrace, London, UK; 2Independent Researcher, Hon. Research Associate, University of Bristol Centre for Academic Primary Care, Population Health Sciences and King’s College London, London, UK; 3Department of Psychosocial Studies, Birkbeck, University of London, UK and 4Focus-4-1, Merton, London, UK Abstract To experience sexual violence and abuse is to experience silence. This commentary explores some of the ways in which psychiatry reinforces the silencing of sexual violence survivors. We argue that current psychiatric responses to sexual violence typically constitute iatrogenic harm including through: a failure to provide services that meet survivors’ needs, a failure to believe or validate disclosures; experiences of medicalisation and diagnoses which can delegit- imise people’s own knowledge and meaning; ‘power over’ relational approaches which can prevent compassionate responses and result in staff having to develop their own coping strat- egies; and poorly addressed and reported experiences of sexual violence within psychiatric set- tings. We argue that these multiple forms of silencing have arisen in part because of biomedical dominance, a lack of support and training in sexual violence for staff, inconsistent access to structured, reflective supervision, and the difficulties of facing the horror of sexual violence and abuse. We then describe community-based and grassroots responses, and con- sider the potential of trauma-informed approaches. Whilst this paper has a UK focus, some aspects will resonate globally, particularly given that Western psychiatry is increasingly being exported around the globe. Introduction trauma matters. It shapes us. It happens all around us. It destroys some of us, and it is overcome by many of us. To ignore it is to ignore who we are in all our complexity (Filson, 2016). Inter-personal trauma has at its core the abuse of power (see Lovett et al., 2018). This paper focuses on power abuses that manifest as sexual violence in all its subtleties and complexities, whilst understanding that many survivors have experienced multiple forms of abuse over long periods meaning that their experiences often do not map neatly onto the distinct categories used in research and practice (Perôt and Chevous, 2018). We also write in the knowledge that it can take people many years to understand that what they have experienced constitutes sexual violence. Estimates of the prevalence of childhood sexual abuse (CSA) range from one in 20 to as high as one in four, with girls disproportionately affected (Felitti et al., 1998; Radford et al., 2011). Globally, it is estimated that 35% of women have experienced sexual or intimate partner violence, and that women are more likely to experience repeated and severe violence compared with men (Oram et al., 2017). Experiencing sexual violence is linked to significant mental dis- tress (Khadr et al., 2018), with CSA in particular linked to psychosis (Bebbington et al., 2011). Unsurprisingly, current and previous rates of sexual violence amongst people in contact with psychiatric services are high (e.g. Grubaugh et al., 2011; Mauritz et al., 2013; Khalifeh et al., 2015). Given that sexual violence is so commonplace and so impactful, what is psychiatry’s response? Mainstreaming silence: psychiatric services and sexual violence The idea that people, predominantly girls and women, are too mad, too bad and too sad to be believed has been used to silence people since time immemorial (Watts, 2018). Silence typically characterises the experience of sexual violence, particularly in childhood. It is a silence that is demanded and coerced by perpetrators, and sanctioned by families, commu- nities and society. Sexual violence survivors have long described the way in which psychiatry can reinforce this silence, causing further harm to an already shattered self (e.g. Smith et al., 2015; Bond et al., 2018). Collectively, we may recognise the silencing of the past, of the wives https://www.cambridge.org/core/terms. https://doi.org/10.1017/S2045796019000131 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 00:56:10, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/eps https://doi.org/10.1017/S2045796019000131 https://doi.org/10.1017/S2045796019000131 mailto:asweeney@sgul.ac.uk https://www.cambridge.org/core/terms https://doi.org/10.1017/S2045796019000131 https://www.cambridge.org/core and daughters placed in Victorian asylums. But we deny the silen- cing of the present, for psychiatry is different now, not like the representations of One Flew Over the Cuckoo’s Nest (Kesey, 1962), but benign, expert, well-meaning. We may concede that psychiatry silenced sexual violence survivors in the 1960s, maybe even the 1970s, but surely not now. The experiential knowledge of survivors, shared in conversa- tions, blogs, book chapters and beyond reveals a different story. I broke down completely. My internal distress was mirrored by my exter- nal reality. I was in a seemingly endless nightmare and I was awake … It didn’t take long for the label of ‘paranoid schizophrenic’ to be pronounced over my dead spirit. I was tendered a large dose of Largactil … to appease my reality (Richie, 1996, pp 12). My first contact with mental health services was at the age of 12 or 13. Although I didn’t have the words to explain what had happened to me, after years of silence, and of feeling that I didn’t have a voice, my story was pouring out. I was closed down with medication and changes of topic. I still do not have the words to tell my story. Twenty years earlier, my mum’s trauma had led her to sectioning, ECT and a lifetime of contact with mental health services. I believe that our lives would have unfolded very differently if … staff had been supported to understand and engage with our pain - if we were encouraged to tell our stories instead of being shut down with looks, words, drugs and ECT (Sweeney, 2016). It is only in recent years that mainstream mental health research has established the role of gender-based violence in the develop- ment of significant mental distress (e.g. Bebbington et al., 2011; Khadr et al., 2018); this partially explains the paucity of research eliciting survivors’ views of support needs and services. Sexual violence survivors may justifiably expect that psychiatric services have a long-held fundamental understanding of trauma and sex- ual violence, how it impacts on people and survivors’ subsequent support needs. It often comes as a shock when survivors attempt to access help and realise that not only is there very little well- funded support available, but that the response of psychiatry can be actively harmful (Smith et al., 2015; Bond et al., 2018). This can leave desperate people with a choice between harmful help, or no help (Jensen, 2004 quoted in Russo, 2018, p. 10). Further, asking for help with nothing changing can replicate dam- aging early experiences (e.g. see Smith et al., 2015). What do we mean when we describe psychiatric help as harm- ful? It is not uncommon, even in the #MeToo era, for sexual vio- lence survivors to be disbelieved by psychiatric services, to be explicitly told ‘You were not abused, you have a mental illness’ (see also Hughes et al., this issue). Russo writes, ‘psychiatry is one of the best preventions of truth … becoming a mental patient was a good solution for everyone, except for me’ (2002). Research has found that mental health staff often fail to validate disclosures because service users have psychiatric diagnoses (Mantovani and Allen, 2017), and frequently use ‘alleged’ when recording disclo- sures in medical notes (Trevillion et al., 2014), a subtle form of silencing. Alongside inflicting immense psychological damage, denying sexual violence jeopardises criminal proceedings and risks keeping people in abusive situations. Connected to this, the power and authority of biomedical psy- chiatric interpretations of mental distress can delegitimise peo- ple’s own knowledge: I knew that what I was experiencing made sense, given what had taken place in my life. Even then I understood my reactions as sane responses to an insane world. I was told, ‘Whatever else might be going on with you is not relevant – it’s your mental illness that matters’. This drove me into a frenzy, for now help was just another perpetrator saying, ‘You liked it, you know you did; that wasn’t so bad; it’s for your own good.’ I was diagnosed and described as ‘lacking insight’ – ensuring that I would never be able to legitimately represent my self or my own experi- ences (Filson, 2016, pp. 21). Whilst experiences of diagnosis are idiosyncratic, receiving a diag- nosis can operate as a powerful signifier that it is you who are the problem, not your experiences, reinforcing silence. The label ‘per- sonality disorder’, for instance, locates the problem within the individual and de-legitimses the search for meaning in one’s responses to, and interaction with, the social world (Coles, 2013). Watson has observed, ‘What messages is society giving to abusers when victims are given disorders as the explanation for distress?’ (2018). Similarly, Shaw and Proctor comment: I cannot understand how the vast majority of perpetrators of sexual vio- lence walk free in society; whilst people who struggle to survive its after effects are told they have disordered personalities (cited in Coles, 2013). Prominent psychiatrist and trauma researcher Judith Herman argues that help is always harmful when it mimics the original trauma by taking power away from the survivor (1997). Everyday experiences of using psychiatric services can re-trauma- tise survivors and actively prevent healing. Consider the use of restraint and forcible injection, which can physically re-enact rape and sexual assault. Agenda, a UK-based non-governmental organisation, has found that one in five women and girls admitted to UK psychiatric units experience physical restraint, including repeated and face down, and that women and girls are more likely to be restrained than men and boys (2017). It was horrific… I had some bad experiences of being restrained face down with my face pushed into a pillow. I can’t begin to describe how scary it was, not being able to signal, communicate, breathe or speak. Anything you do to try to communicate, they put more pressure on you. The more you try to signal, the worse it is (MIND, 2013). The damage inflicted by ‘power over’ responses to distress also takes subtler forms, including overt and insidious pressures to accept prescriptions, treatments and diagnoses that may conflict with people’s own beliefs and needs. This replication of invalida- tion, coercion and force can be hugely damaging, not only to sur- vivors but also to staff, particularly those who are themselves survivors: research suggests that there are significant trauma rates amongst health and social care staff (e.g. Bracken et al., 2010; Esaki and Larkin, 2013; McLindon et al., 2018). This is because the organisational expectation that staff will use ‘power over’ relational approaches can erode staff compassion (Sweeney et al., 2016), with pessimism – rather than hope – protecting staff from feelings of helplessness (Chambers et al., 2014). Biomedical dominance, insufficient support and training in sexual violence and trauma-informed approaches, and inconsistent access to structured, reflective supervision can act as further bar- riers to compassionate responses to sexual violence survivors (see Sweeney et al., 2018). Furthermore, it is difficult for staff to face and accept the scale and horror of sexual violence and abuse with- out support (see Sweeney et al., 2018). Bond and colleagues (2018) interviewed 28 CSA survivors, and found: All the survivors who spoke to us described numerous encounters with support services that demonstrated an innate lack of empathetic Epidemiology and Psychiatric Sciences 599 https://www.cambridge.org/core/terms. https://doi.org/10.1017/S2045796019000131 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 00:56:10, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms https://doi.org/10.1017/S2045796019000131 https://www.cambridge.org/core understanding, professional knowledge and expertise in how best to pro- vide appropriate support for adult survivors of CSA. Sexual violence within psychiatric settings Perpetrators of sexual violence are able to operate in institutions where organisational cultures reinforce silence; where there is a ‘conducive context’ (Lovett et al., 2018). Following a recent investigation into the aid sector, the UK House of Commons International Development Committee concluded: the delivery of aid, whilst providing lifesaving resources to people and communities in crisis, can also be subverted by sexual predators into a channel through which they can magnify their power and use possession of those resources to exploit and abuse some of the most vulnerable people in the world. We must not turn away from the horror of it. We have a duty to confront it (2018, pp. 75). Psychiatric service users are also vulnerable to institutional sexual exploitation and violence, not least because psychiatric labels can undermine claims to truth and rationality (Roper, 2016; Rose, 2017). The few studies that have been conducted into sexual vio- lence on inpatient wards are deeply troubling. A survey of 50 women in Australia found that 45% had been sexually assaulted whilst an inpatient, and of the 61% who reported this to staff, the overwhelming majority (85%) found the response unhelpful (VMIAC, 2013). One participant commented ‘If the assailant is not a patient but a nurse or doctor who can you trust or turn to for help?’. A recent investigation by England’s Care Quality Commission found that on inpatient psychiatric wards over a 3-month period in 2017, there were reports of 29 rapes, 273 sexual assaults and 184 acts of sexual harassment, the majority against service users (2018). The report also concluded that recording rates may be low, partially due to staff desensitisation through the regularity of incidents (see Hughes et al., this issue, for further discussion). Police recording of sexual assaults on psychiatric inpatient wards has also been found to be inadequate (Foley and Cummins, 2018). Whilst the UK has a policy of gender seg- regation on inpatient psychiatric wards, this cannot protect people from sexually violent staff, or perpetrators of the same gender. Out of the silence: grassroots and community-based responses The UK has few statutory services for sexual violence survivors (Coy et al., 2009; Allnock et al., 2012; Hawkins and Taylor, 2015; Kennedy and White, 2015), with National Health Service trauma clinics often excluding experiences of childhood abuse. This, coupled with experiences of statutory iatrogenic harm, means that many survivors are seen in community-based special- ist sexual violence services (Bond et al., 2018). Despite survivors’ generally reporting positive experiences of these services (Bond et al., 2018), they are often underfunded, resulting in long waiting lists, session fees and time-limited therapy (Smith et al., 2015). It is also uncommon for the sector’s specialist expertise to impact on psychiatric services: indeed, there are concerns that the direction of influence runs the other way, with a psychiatric ‘creep’ into anti-violence services, such as the increasing tendency to establish separate services for the ‘mentally ill’ (Rubinsztajn, 2016). Survivors who have experienced pathologisation and iatrogenic harm often move away from helper–helpee roles, connecting instead through mutual peer support (e.g. Filson and Mead, 2016). Some survivors have established organisations fostering peer support, self-help, activism, campaigning and education, often simultaneously. In the UK, these include Survivors’ Voices (co-established/led by CP, http://www.survivorsvoices.org), Butterfly (established by VA, http://focus-4-1.co.uk/projects-ser- vices/) and The Survivors’ Collective (www.survivorscollective. co.uk). There are also important transnational sources of influ- ence and inspiration. Endeavours like these are often run with lit- tle or no funding, reliant instead on the passion and commitment of key members. In reflecting on a Berlin-based survivor-led sexual violence project, Rubinsztajn observes: how powerful it can be when people realise that everybody else in the pro- ject is a survivor … It’s then, maybe for the first time, that the person is consciously in a space with other survivors and can physically grasp that they’re not alone in their experience … you find yourself among likeable, tough and funny people who have gone through similar things and decided not to bear those experiences and consequences on their own any- more, not to stay silent anymore (emphasis added, pp. 128). Carr writes of, ‘the persistent argument from service users, survi- vors, their organisations and communities … that we must have independent organisations, arenas and power bases from which to think and do for ourselves’ (2018). Rubinsztajn also voices con- cerns that survivor-led sexual violence projects can come to mimic the mainstream services they critique; she describes the lack of a single ‘we’ in survivors’ needs and perspectives, with some experiences highlighted and others unspoken, such as of racism. Adopting an intersectional approach is a shared core standard for a number of women’s anti-violence services, bench- marking good practice (Imkaan et al., 2016). The hope of trauma-informed approaches The behaviours and thoughts that experts in some cultures label psychotic or schizophrenic are usually understandable reactions to our life events and circumstances. So rather than ask, ‘What is wrong with you?’ and ‘What shall we call it?’ It is more sensible, and useful, to ask, ‘What hap- pened to you?’ and ‘What do you need?’ (Read, 2018). Trauma-informed approaches may be a way of enabling all ser- vices – community and statutory alike – to come closer to meeting survivors’ needs, as well as improving staff experiences (e.g. see Sweeney et al., 2018). Trauma-informed approaches are an organ- isational change process that can be described as: a strengths-based framework that is grounded in an understanding of, and responsiveness to, the impact of trauma, that emphasises physical, psycho- logical and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment (Hopper et al., 2010). The aim then is to improve experiences, relationships and environments for staff and service users. Whilst concepts like ‘strengths-based’ and ‘empowerment’ can seem almost meaning- less because of their overuse, they are hugely significant in this context, intended to reverse the ‘power over’ abuses that are at the heart of sexual violence and iatrogenic harm (see Butler et al., 2011; Sweeney et al., 2016). Fundamental to trauma-informed approaches is ‘seeing through a trauma lens’ – that is, understanding the connections between experiences and coping strategies – and preventing (re) traumatisation. Although further principles have been fairly well described (see e.g. Elliot et al., 2005; Butler et al., 2011; SAMHSA, 2014; Filson, 2016; Sweeney et al., 2016), the approach 600 A. Sweeney et al. https://www.cambridge.org/core/terms. https://doi.org/10.1017/S2045796019000131 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 00:56:10, subject to the Cambridge Core terms of use, available at http://www.survivorsvoices.org http://www.survivorsvoices.org http://focus-4-1.co.uk/projects-services/ http://focus-4-1.co.uk/projects-services/ http://focus-4-1.co.uk/projects-services/ http://www.survivorscollective.co.uk http://www.survivorscollective.co.uk https://www.cambridge.org/core/terms https://doi.org/10.1017/S2045796019000131 https://www.cambridge.org/core is relatively complex and consequently, commonly misunderstood (Sweeney and Taggart, 2018). This increases the risk that where implemented, it could be diluted to the point of worthlessness (Sweeney and Taggart, 2018). Change is required at a systemic level, including staff support, training and reflective supervision (Bloom and Farragher, 2010). Alongside commissioning mean- ingful trauma-informed services (Bush and Brennan, 2018), com- missioners should develop and strengthen peer-led organisations, reinforcing local capacity to engage in service provision, peer sup- port and campaigning (e.g. Bott et al., 2010). Despite widespread interest in, and early implementation of, trauma-informed approaches, there is a lack of underpinning empirical research (see Christie, 2018). And just as there are vast differences between grassroots and mainstream psychiatric ser- vices, so too there are vast differences between survivor-led and mainstream research approaches (e.g. see Russo, 2012). Research led by and co-produced with survivors is needed to understand whether and how services meet survivors’ needs, and to investigate the potential – and potential failings – of trauma-informed approaches. This research should itself be trauma-informed (Shimmin et al., 2017) and occur within an epistemic injustice framework (understanding discrimination and exclusion in knowledge generation and against knowers) (Fricker, 2007), with an understanding of how participation affects survivor researchers, particularly when working in partnerships (Roper, 2016). The Charter for Organisations Engaging Survivors in Projects, Research & Service Development, currently being piloted, aims to provide a quality mark for safe, meaningful and effective sur- vivor involvement in research (Perôt and Chevous, 2018). Closing thoughts Survivors of sexual violence and abuse can feel let down over and over again – that the abuse was able to continue for so long; that perpetrators are able to continue abusing, including within psy- chiatric services; that the criminal justice system is stacked in per- petrators’ favour (as evidenced by low conviction rates, Walby and Allen, 2004); and that the psychiatric system, which should understand and support survivors, is more often harmful and pathologising of individual responses, rather than recognising people’s strengths and remarkable ability to adapt and survive. It is through validation (the act of believing) that a climate of sup- port and recognition for victims and survivors of sexual violence and abuse is created. Our core belief, and one that is worth repeat- ing, is that the expertise about what we need to heal lies with us. Acknowledgements. Angela Sweeney would like to thank Dr Steve Gillard for helpful feedback on and discussions about an earlier draft. Financial support. Angela Sweeney is funded by a National Institute for Health Research Post-Doctoral Fellowship (PDF-2013-06-045). This paper presents independent research partially funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Conflict of interest. None. References Agenda (2017) Briefing on the use of restraint against women and girls. Available at https://weareagenda.org/wp-content/uploads/2017/03/Restraint- FOI-research-briefing-FINAL1.pdf (Accessed 23 October 2018). Allnock D, Radford L, Bunting L, Price A, Morgan-Klein N, Ellis J and Stafford A (2012) In demand: therapeutic services for children and young people who have experienced sexual abuse. Child Abuse Review 21, 318–34. Bebbington P, Jonas S, Kuipers E and King M (2011) Childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in England. British Journal of Psychiatry 199, 29–37. Bloom S and Farragher B (2010) Destroying Sanctuary: The Crisis in Human Service Delivery Systems. New York, NY: Oxford University Press. Bond E, Ellis F and McCusker J (2018) I’ll be a Survivor for the Rest of My Life. Adult Survivors of Child Sexual Abuse and Their Experience of Support Services. Suffolk: Survivors in Transition and University Campus Suffolk. Bott S, Sweeney A and Watkts R (2010) A Commissioner’s Guide to Developing and Sustaining User-Led Organisations. London: Social Care Institute for Excellence. Bracken M, Messing J, Campbell J, La Flair N and Kub J (2010) Intimate partner violence and abuse among female nurses and nursing personnel: prevalence and risk factors. Issues in Mental Health Nursing 31, 137–148. Bush M and Brennan S (2018) Moving beyond adversity. In Bush M (ed.) Addressing Adversity. Prioritising Adversity and Trauma-Informed Care for Children and Young People in England. London: The YoungMinds Trust with Health Education England, pp. 110–122. Butler L, Critelli F and Rinfrette E (2011) Trauma-informed care and mental health. Directions in Psychiatry 31, 197–210. Care Quality Commission (2018) Sexual Safety on Mental Health Wards. Available at https://www.cqc.org.uk/sites/default/files/20180911c_sexual safetymh_report.pdf (Accessed 23 October 2018). Carr S (2018) ‘Where I end and you begin’. A personal commentary on Russo’s ‘Through the eyes of the observed’ #PsychDrugDebate. The Mental Elf. Available at https://www.nationalelfservice.net/populations- and-settings/service-user-involvement/where-i-end-and-you-begin-a-personal- commentary-on-russos-through-the-eyes-of-the-observed-psychdrugdebate/. Chambers M, Gallagher A, Borschmann R, Gillard S, Turner K and Kantaris X (2014) The experiences of detained mental health service users: issues of dignity in care. BMC Medical Ethics 15, 1–8. Christie C (2018) A Trauma-informed Health and Care Approach for respond- ing to Child Sexual Abuse and Exploitation Current knowledge report May 2018. Chanon Consulting and Department for Health and Social Care. Coles S (2013) Borderline personality disorder: abandon the label, find the per- son. Available at https://blogs.canterbury.ac.uk/discursive/borderline-personal- ity-disorder-abandon-the-label-find-the-person/ (Accessed 23 October 2018). Coy M, Kelly L and Foord J (2009) Map of Gaps 2. The Postcode Lottery of Violence against Women Support Services in Britain. London: End Violence Against Women in partnership with Equality and Human Rights Commission. Elliot D, Bjelajac P, Fallot R, Markoff L and Glover Reed B (2005) Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women. Journal of Community Psychology 33, 461–77. Esaki N and Larkin H (2013) Prevalence of adverse childhood experiences (ACEs) among child service providers. Families in Society: The Journal of Contemporary Social Services 94, 31–7. Felitti G, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V, Koss M and Marks J (1998) Relationship of child abuse and household dys- function to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine 14, 245–58. Filson B (2016) The haunting can end: trauma-informed approaches in heal- ing from abuse and adversity. In Russo J and Sweeney A (eds), Searching for a Rose Garden: Challenging Psychiatry, Fostering Mad Studies. Monmouth: PCCS Books, pp. 20–24. Filson B and Mead S (2016) Becoming part of each other’s narratives: inten- tional peer support. In Russo J and Sweeney A (eds), Searching for a Rose Garden: Challenging Psychiatry, Fostering Mad Studies. Monmouth: PCCS Books, pp. 109–117. Foley M and Cummins I (2018) Reporting sexual violence on mental health wards. The Journal of Adult Protection 20, 93–100. Fricker M (2007) Epistemic Injustice: Power and the Ethics of Knowing. Oxford, New York: Oxford University Press. Grubaugh A, Zinzow H, Paul L, Egede L and Frueh B (2011) Trauma expos- ure and posttraumatic stress disorder in adults with severe mental illness: a critical review. Clinical Psychology Review 31, 883–899. Epidemiology and Psychiatric Sciences 601 https://www.cambridge.org/core/terms. https://doi.org/10.1017/S2045796019000131 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 00:56:10, subject to the Cambridge Core terms of use, available at https://weareagenda.org/wp-content/uploads/2017/03/Restraint-FOI-research-briefing-FINAL1.pdf https://weareagenda.org/wp-content/uploads/2017/03/Restraint-FOI-research-briefing-FINAL1.pdf https://www.cqc.org.uk/sites/default/files/20180911c_sexualsafetymh_report.pdf https://www.cqc.org.uk/sites/default/files/20180911c_sexualsafetymh_report.pdf https://www.cqc.org.uk/sites/default/files/20180911c_sexualsafetymh_report.pdf https://www.nationalelfservice.net/populations-and-settings/service-user-involvement/where-i-end-and-you-begin-a-personal-commentary-on-russos-through-the-eyes-of-the-observed-psychdrugdebate/ https://www.nationalelfservice.net/populations-and-settings/service-user-involvement/where-i-end-and-you-begin-a-personal-commentary-on-russos-through-the-eyes-of-the-observed-psychdrugdebate/ https://www.nationalelfservice.net/populations-and-settings/service-user-involvement/where-i-end-and-you-begin-a-personal-commentary-on-russos-through-the-eyes-of-the-observed-psychdrugdebate/ https://www.nationalelfservice.net/populations-and-settings/service-user-involvement/where-i-end-and-you-begin-a-personal-commentary-on-russos-through-the-eyes-of-the-observed-psychdrugdebate/ https://blogs.canterbury.ac.uk/discursive/borderline-personality-disorder-abandon-the-label-find-the-person/ https://blogs.canterbury.ac.uk/discursive/borderline-personality-disorder-abandon-the-label-find-the-person/ https://blogs.canterbury.ac.uk/discursive/borderline-personality-disorder-abandon-the-label-find-the-person/ https://www.cambridge.org/core/terms https://doi.org/10.1017/S2045796019000131 https://www.cambridge.org/core Hawkins S and Taylor K (2015). The Changing Landscape of Domestic and Sexual Violence Services. All-Party Parliamentary Group on Domestic and Sexual Violence Inquiry. Bristol: Women’s Aid. Available at www.rapecri- sis.org.uk. Herman J (1997) Trauma and Recovery. New York: Basic Books. Hopper E, Bassuk E and Olivet J (2010) Shelter from the storm: trauma- informed care in homelessness services settings. The Open Health Services and Policy Journal 3, 80–100. House of Commons International Development Committee Sexual exploit- ation and abuse in the aid sector Eighth Report of Session 2017–19. 23 July 2018. Available at https://publications.parliament.uk/pa/cm201719/cmse- lect/cmintdev/840/840.pdf. Imkaan, Rape Crisis England & Wales, Respect, SafeLives and Women’s Aid (2016) Sector Sustainability Shared Standards: Shared Values That Apply Across the VAWG Sector. Bristol: Women’s Aid. Kennedy K and White C (2015) What can GPs do for adult patients disclos- ing recent sexual violence? British Journal of General Practice 65, 42–4. Kesey K (1962) One Flew Over the Cuckoo’s Nest. New York: The Viking Press. Khadr S, Clarke V, Wellings K, Villalta L, Goddard A, Welch J, Bewley S, Kramer T and Viner R (2018) Mental and sexual health outcomes following sexual assault in adolescents: a prospective cohort study. The Lancet Child and Adolescent Health 2, 654–665. doi: 10.1016/S2352-4642(18)30202-5. Khalifeh H, Moran P, Borschmann R, Dean K, Hart C, Hogg J, Osborn O, Johnson S and Howard L (2015) Domestic and sexual violence against patients with severe mental illness. Psychological Medicine 45, 875–86. Lovett J, Coy M and Kelly L (2018) Deflection, Denial and Disbelief: Social and Political Discourses About Child Sexual Abuse and Their Influence on Institutional Responses. A Rapid Evidence Assessment. Independent Inquiry into Child Sexual Abuse. London: Child and Woman Abuse Studies Unit, London Metropolitan University. Mantovani N and Allen R (2017) Improving Responses to Domestic Violence in Secondary Mental Health Services in Wandsworth, South West London. A Mixed Methods Study to Assess the Recorded Incidents of Domestic Violence and Abuse (DVA) in Secondary Mental Health Services and to Explore Stakeholders’ Views on Strategies to Address DVA. London: St. George’s University of London. ISBN: 978-1-5272-0938-1. Mauritz M, Goossens P, Draijer N and van Achterberg T (2013) Prevalence of interpersonal trauma exposure and trauma-related disorders in severe mental illness. European Journal of Psychotraumatology 4. doi: 10.3402/ ejpt.v4i0.19985. McLindon E, Humphreys C and Hegarty K (2018) ‘It happens to clinicians too’: an Australian prevalence study of intimate partner and family violence against health professionals. BMC Women’s Health 18, 113. MIND (2013) Mental Health Crisis Care: Physical Restraint in Crisis. A Briefing for Frontline Staff Working in Mental Health Care. London: MIND. Oram S, Khalifeh H and Howard L (2017) Violence against women and men- tal health. Lancet Psychiatry 4, 159–170. Perôt C and Chevous J (2018) Available at http://survivorsvoices.org/charter/ (Accessed 23 October 2018). Radford L, Corral S, Bradley C, Fisher H, Bassett C and Howat N (2011) Child Abuse and Neglect in the UK Today. London: NSPCC. Read J (2018) Making sense of, and responding sensibly to, psychosis. Journal of Humanistic Psychology Available at https://doi.org/10.1177/0022167818761918. Richie B (1996) Afraid to live and afraid to die. In Read J and Reynolds J (eds), Speaking Our Minds: An Anthology of Personal Experiences of Mental Distress and its Consequences. Houndmills, Basingstoke, London, Hampshire: Macmillan Press Ltd, pp. 9–15. Roper C (2016) Is partnership a dirty word? In Russo J and Sweeney A (eds), Searching for a Rose Garden: Challenging Psychiatry, Fostering Mad Studies. Monmouth: PCCS Books, pp. 201–209. Rose D (2017) Service user/survivor-led research in mental health: epistemo- logical possibilities. Disability and Society 32, 773–789. Rubinsztajn Z (2016) Sexual violence in childhood: demarketing treatment options and strengthening our own agency. In Russo J and Sweeney A (eds), Searching for a Rose Garden: Challenging Psychiatry, Fostering Mad Studies. Monmouth: PCCS Books, pp. 127–133. Russo J (2002) In Read J and Reynolds J (eds), Reclaiming Madness. Houndmills, Basingstoke, London, Hampshire: Macmillan Press Ltd, pp. 36–39. Russo J (2012) Survivor-controlled research: a new foundation for thinking about psychiatry and mental health. Forum: Qualitative Social Research 13, Art 8. doi: 10.17169/fqs-13.1.1790. Russo J (2018) Talking Point Papers 3. Through the Eyes of the Observed: Re- Directing Research on Psychiatric Drugs. London: McPin Foundation. Available at http://mcpin.org/wp-content/uploads/talking-point-paper-3- final.pdf (Accessed 23 October 2018). SAMHSA (2014) SAMHSA’s Working Concept of Trauma and Framework for a Trauma-Informed Approach. Rockville, MD: National Centre for Trauma- Informed Care (NCTIC), SAMHSA. Shimmin C, Wittmeier K, Lavoie J, Wicklund E and Sibley K (2017) Moving towards a more inclusive patient and public involvement in health research paradigm: the incorporation of a trauma-informed intersectional analysis. BMC Health Services Research 17, 539. Smith N, Dogaru C and Ellis F (2015) Hear me. Believe me. Respect me. #Focusonsurvivors. A Survey of Adult Survivors of Child Sexual Abuse and Their Experiences of Support Services. Suffolk: University Campus Suffolk and Survivors in Transition. Sweeney A (2016) Bringing trauma-informed approaches to the UK. ACES Network Connection 12 October 2016. Available at https://www.acesconnec- tion.com/blog/bringing-trauma-informed-approaches-to-the-uk (Accessed 23 October 2018). Sweeney A and Taggart D (2018) (Mis)understanding trauma informed approaches in mental health. Journal of Mental Health 27, 383–387. doi: 10.1080/09638237.2018.1520973. Sweeney A, Clement S, Filson B and Kennedy A (2016) Trauma-informed mental healthcare in the UK: what is it and how can we further its devel- opment? Mental Health Review Journal 21, 174–192. Sweeney A, Filson B, Kennedy A, Collinson L and Gillard S (2018) A para- digm shift: relationships in trauma-informed mental health services. BJPsych Advances 24, 319–333. Trevillion K, Hughes B, Feder G, Borschmann R, Oram S and Howard L (2014) Disclosure of domestic violence in mental health settings: a qualita- tive meta-synthesis. International Review of Psychiatry 26, 430–444. Victorian Mental Illness Awareness Council (2013) Zero Tolerance for Sexual Assault: A Safe Admission for Women. Victoria: VMIC. Available at http:// www.daru.org.au/wp/wp-content/uploads/2013/05/Zero-Tolerance-for-Sexual- Assult_VMIAC.pdf. Walby S and Allen J (2004) Domestic Violence, Sexual Assault and Stalking: Findings from the British Crime Survey. Home Office Research Study 276. London: Home Office. Watson J (2018) A disorder for everyone blog. Available at http://www.adisor- der4 everyone.com/about (Accessed 18 July 2018). Watts J (2018) The uncomfortable truth is that many psychiatric wards have a culture of sexual assault. The Independent 12 September 2018 (Accessed 23 October 2018). 602 A. Sweeney et al. https://www.cambridge.org/core/terms. https://doi.org/10.1017/S2045796019000131 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 00:56:10, subject to the Cambridge Core terms of use, available at http://www.rapecrisis.org.uk http://www.rapecrisis.org.uk https://publications.parliament.uk/pa/cm201719/cmselect/cmintdev/840/840.pdf https://publications.parliament.uk/pa/cm201719/cmselect/cmintdev/840/840.pdf https://publications.parliament.uk/pa/cm201719/cmselect/cmintdev/840/840.pdf http://survivorsvoices.org/charter/ http://survivorsvoices.org/charter/ https://doi.org/10.1177/0022167818761918 https://doi.org/10.1177/0022167818761918 http://mcpin.org/wp-content/uploads/talking-point-paper-3-final.pdf http://mcpin.org/wp-content/uploads/talking-point-paper-3-final.pdf http://mcpin.org/wp-content/uploads/talking-point-paper-3-final.pdf https://www.acesconnection.com/blog/bringing-trauma-informed-approaches-to-the-uk https://www.acesconnection.com/blog/bringing-trauma-informed-approaches-to-the-uk https://www.acesconnection.com/blog/bringing-trauma-informed-approaches-to-the-uk http://www.daru.org.au/wp/wp-content/uploads/2013/05/Zero-Tolerance-for-Sexual-Assult_VMIAC.pdf http://www.daru.org.au/wp/wp-content/uploads/2013/05/Zero-Tolerance-for-Sexual-Assult_VMIAC.pdf http://www.daru.org.au/wp/wp-content/uploads/2013/05/Zero-Tolerance-for-Sexual-Assult_VMIAC.pdf http://www.daru.org.au/wp/wp-content/uploads/2013/05/Zero-Tolerance-for-Sexual-Assult_VMIAC.pdf http://www.adisorder4everyone.com/about http://www.adisorder4everyone.com/about http://www.adisorder4everyone.com/about https://www.cambridge.org/core/terms https://doi.org/10.1017/S2045796019000131 https://www.cambridge.org/core Out of the silence: towards grassroots and trauma-informed support for people who have experienced sexual violence and abuse Introduction Mainstreaming silence: psychiatric services and sexual violence Sexual violence within psychiatric settings Out of the silence: grassroots and community-based responses The hope of trauma-informed approaches Closing thoughts Acknowledgements References