Revealing hidden issues

One year since the publication of British Psychological Society guidelines on responding to disclosures of non-recent sexual abuse, we spoke to one of its authors, Consultant Clinical Psychologist Dr Khadj Rouf, about the many people the guidelines have reached and her concerns about cuts to services for survivors.

Rouf (Oxford Health NHS Foundation Trust) and her colleagues have so far reached three of the four UK nations speaking at conferences about the guidelines. These sessions, which have included presentations from academics, clinicians and survivors, have raised important discussions about the importance of survivor-focused services, including the need for routine enquiry about child sexual abuse (CSA) in clinical practice, the dangers of misdiagnosing the after-effects of trauma and the need for more psychologically informed practice.'I was pleased to see audience members from a range of backgrounds raising important issues around the complexities of responding to disclosures,' Rouf said. She one of her co-authors, Benna Waites, will finish their four nations tour in spring 2018 at a special day-long Division of Clinical Psychology Wales event.

Rouf, a survivor herself, said the conferences had emboldened her to share her own stories and artwork (e.g. 'Untitled, 1988', above), which she created as a teen a few years after she disclosed her own abuse. She said she wanted to share the work to show the depths of despair survivors can feel, but also to give a message of hope that recovery is possible. However, she expressed deep concern over the direction in which many services are heading. 'I'm very troubled by the national picture of shrinking state provision for vulnerable people… many charities and third-sector organisations are caught in a precarious funding position. I needed quite a lot of state support when I disclosed as a teenager, including social services, psychology, the police, legal aid and state benefits, as we were suddenly plunged into difficult financial circumstances. I also benefited from a full grant, which allowed me to take up a place at Oxford University. I am not sharing this for pity or praise, but because I am concerned that survivors coming after me may not get access to the kinds of services which helped me so much.'

A 2015 report by the Children's Commissioner Anne Longfield said that while prevalence of CSA could be as high as 11 per cent, only an estimated one in eight survivors come to the attention of statutory authorities. The NSPCC's most recent figures also show an increase in the number of child sexual abuse cases (which could, of course, reflect an increasing willingness to come forward). Are the services there to support them?

There are signs of certain groups within psychology moving towards having more of a focus on trauma and taking a lifespan approach in helping people, but without funding it is difficult to get these ideas off the ground. 'Those trauma-informed services seem so exciting, but we need to make sure there's consistency. How secure is the funding across the state and third sector? There are sexual abuse and rape crisis centres up and down the country which are overwhelmed at the moment. There's a precarious situation for some services in terms of what money they can count on. There are some really exciting examples of what could be achieved out there, but there needs to be secure and sustained funding.'

Rouf is a passionate believer in psychology and the role of psychologists in helping survivors, and said that psychologists should be ambitious as a profession: 'If psychologists see a gap in the services in their local area, I'd say call it out, step up and get involved. There's a vital role for psychologists to play across all parts of society because we're coming into contact with the public. We have a vital role to play in safeguarding, and psychologists can help in ensuring there are individual, systemic and group interventions.'

Rouf also emphasised that the published guidelines could be useful to a diverse range of healthcare professionals and psychologists – not just those working in clinical settings but academics as well. 'During the conferences all kinds of people were interested in getting involved. Disclosures can occur in sexual health settings, cancer services, pain clinics and forensic settings. We divide ourselves into specialities, and maybe we have to do that, but people don't live their lives like that. Disclosures can occur in settings such as schools, but also in unexpected settings, such as when people are doing research at university. All psychologists need to be aware of their safeguarding responsibilities and how to respond.'

John Slater, a survivor who has also spoken at all the conferences and shared his poem (see the online version of this piece), co-runs a male survivor peer support group in the Exeter area called Momentum. The group gives men of all ages and backgrounds a safe place to meet, talk and feel their emotions. Slater is an advocate for services making routine enquiries into clients' history of sexual abuse. He also wants to see evidence-based and trauma-focused services, and he's concerned that many services' referral thresholds or critical criteria exclude people who are struggling deeply but 'not enough' to receive help. 'Many people with difficulties relating to childhood sexual abuse will find the issues around abuse will not be dealt with in a Depression and Anxiety Service as this is outside their remit, and yet the criteria are not met for secondary services.' Slater said while there were excellent and helpful services and projects in the statutory and voluntary sectors, the provision was patchy, underfunded and struggling for financial support: 'The system is not geared to the needs of survivors, despite the large numbers in services. Much can be down to what is in your area, if you are a man or a woman, or the individual innovation of staff to run programmes. The scope for staff to be innovative and respond to need is reducing. I believe the vast majority of survivors' needs are not met and only a restructuring to a trauma-informed approach will give any chance of that occurring.'

Another recurring issue for survivors is the lack of consistency in approaches to CSA across healthcare providers: 'Survivors tell me they are concerned that with long-term contact with services, attitudes to CSA are not consistent. One worker being understanding, the next person avoiding and not relating to the issue. One person mentioned the great help they got from their therapist, but felt that was undermined by a lack of appreciation and understanding of the effects and process of trauma on them from their mental health worker. They would like to see a better understanding of CSA by all, not just some, of the staff they meet.'

Slater said: 'Apart from routine enquiry being a helpful step in itself, it will place an onus on mental health services to demonstrate action to such disclosure, making a Trust more accountable to survivors… Routine enquiry, if done well, will also provide the evidence needed regarding the extent of childhood sexual abuse so it can no longer be a hidden issue of unknown scale.'

Critical Criteria

I lost my job I lost my career 
I lost my worth I lost my mind 
But I did not meet your critical criteria

You plied me with lithium for years 
When I tried to discuss, it was always next time 
For I did not meet your critical criteria

I see a psychiatrist and fill in those repetitive endless forms
As you fill in those tick boxes 
Am I here for you or for me? 
I don't know, all I know is 
I did not meet your critical criteria

What rag rating did you give this human being 
Made of flesh and blood 
Too complex for Primary care I am told 
But still I did not meet your critical criteria

How many fall down this dark condemning gap? 
My partner ironed my shirt and made me shave 
So I did not meet your critical criteria

I have learnt to hide my shame with a smiling mask 
What a pleasant man! 
But he does not meet our critical criteria

I held myself to keep me there and stared out into the past at my pain
I should have stared at the floor 
So I did not meet your critical criteria

I have been in hospital three times 
Afraid of the men carrying the coffin to my room 
Too scared of the world to go on the walk outside of the grounds
But today I look to you for help - 
Ah, eye contact, you do not meet the critical criteria

I cut myself as I did as a child but I could not tell you for the shame
So I did not meet your critical criteria

The GU therapist said "he needs more help to work this through
Our interventions are limited. I write to you as he is in your care"
We would like to consider but he does not meet our critical criteria
But wish him luck in his search for help

What more could I have asked for as I sit here utterly alone
So much I did not tell, you never asked 
The rope, the gag, the sticks, I was only 9 
You never helped me past the fear 
But then I did not meet your critical criteria.

("Operating conveniences" without regard for the spirit.)

John Slater

- If you have been affected by any of the issues discussed in this article contact The Survivor's Trust (0808 801 0818) or Samaritans (116 123). If you are concerned about a child, call the NSPCC on 0808 800 5000.