The importance of new guidance on the management of disclosures of non-recent (historical) child sexual abuse

Child Sexual Abuse (CSA) is sadly prevalent within the UK, with the Office for National Statistics suggesting that 7.5 per cent of adults having reported experiencing CSA in England and Wales before the age of 16.

The findings of the Independent Inquiry into Child Sexual Abuse (IICSA) unfortunately highlighted the paucity of good practice that has historically faced this population of survivors.

The testimony of over 6,000 survivors as part of the Truth Project arm of IICSA suggests that survivors were more than twice as likely to report disclosing CSA in later life (75 per cent) than at the time of the abuse (28 per cent).

The average time between the first CSA victimisation and contact with a support service was 19 years, and while there is evidence that CSA survivors are over-represented in the mental health populations, it is also clear that even when they do make contact, they often fail to disclose.

Read et al (2016) describe how less than 25 per cent of service users report being asked about the experiences of trauma and abuse in mental health services, and this figure has not improved from their original audit in 1997.

One may suggest that the failures in mental health to address the ubiquity of CSA in adults seeking care in various settings may be linked to Judith Herman's quote:

"The ordinary response to atrocities is to banish them from consciousness."

We have seen this played out in many different ways over the years, including the rise of the False Memory Societies and the response to Karl Beech in broader society.

I believe this is also evident in the ongoing reluctance to accept the reality of the Dissociative Identity Disorder diagnosis, despite growing evidence in both the neurological and epidemiological fields.

However, there is a growing sense of change within this difficult area with multiple intersecting movements within the mental health field allowing for a groundswell of change.

This includes the trauma-informed care approach being more widely adopted, the alternatives to psychiatric medical models including the Power Threat Meaning Framework bringing the question of "what happened to you?" to the foreground and seeing oppression and power as an inherent aspect of mental health difficulties, and the growing voice of survivors themselves and their engagement with and challenge to current structures.

Alongside this, I would also place the Royal College of Psychiatrists' expert reference group working on a position statement for non-recent CSA, a group I currently co-chair. This is the field into which this guidance enters and I would see it as an essential step in this ongoing political and clinical process.

The anxiety that many clinicians from a wide range of backgrounds face when they recognise that a disclosure is possible, is occurring or has begun needs acknowledgement. There is little doubt that training and support in this area to date across many professions has been piecemeal at best.

This guidance clearly, succinctly and thoughtfully addresses the likely concerns and provides a step-by-step guide in helping the clinician recognise possible next steps. There is an appropriate focus on the experience of the survivor whilst delicately balancing this with broader safeguarding concerns.

My only note of caution is that I feel it is important to acknowledge clearly that someone who has experienced CSA may present with any diagnosis, and the evidence base is not yet sufficient to be clear for most diagnostic categories as to whether 'treatment as usual' with evidence-based treatments is the best practice for this particular population.

A significant number of survivors may present with Complex PTSD and a phase-based approach as part of best practice guidance from ISSTD and ISSTS is helpful.

As part of the work undertaken by the college, a search of evidence base guidance was made (NICE and other countries such as Canada, Australia etc.) and there was almost no mention of CSA specifically in any treatment guidance across multiple possible diagnostic presentations, and in our literature review little evidence of how interventions may need to be modified for this population.

What this highlights clearly is the paucity of high-quality research specifically for survivors in terms of what is best practice.

This inevitably brings us back to the need to have clear guidance on facilitating disclosure because without this, the survivor goes unrecognised, and their specific clinical needs may not be identified. This is what makes this guidance so essential in this arena.

I would suggest that this guidance should go hand-in-hand with training in disclosure which needs to include a reflective space for clinicians to consider their own emotional and personal responses to working with possible survivors.

The potential to turn a blind eye to CSA is evident at a societal level as suggested by Herman but it also resides in us all and can be reflected in the way services are set up or managed so that disclosure does not occur.

When it does, it requires the clinician to be emotionally present and available to the survivor, to acknowledge the reality of these atrocities and this requires emotional work. Without the system supporting this, the potential for burnout and vicarious traumatisation is high.

There could not be a more fitting and appropriate time for this impressive document to be published, and I am sure its reach will extend far beyond the psychological profession into many different disciplines within the mental health field.

The authors have sensitively and carefully outlined a compassionate and thoughtful response to the management of disclosures of non-recent abuse in therapeutic settings.

There is real wisdom contained here, acknowledging the complexities of this work whilst providing a clear outline of how one might proceed in these circumstances.