Making the links: violence, trauma and mental health.
Violence and trauma, including childhood abuse, sexual abuse, and intimate partner violence, are common in Canada. It is conservatively estimated that half of all Canadian women and one-third of Canadian men have survived at least one incidence of sexual or physical violence. Although both boys and girls are affected by family violence, four out of five victims of family-related sexual assaults (79%) are girls.
Heather Pollett writes in The Connection Between Violence, Trauma and Mental Illness in Women that the relationship between trauma and mental health is a complex one; not all people who experience abuse, either in childhood or adulthood, inevitably develop a mental illness, and not everyone who has been diagnosed with a mental illness has experienced abuse. Yet research has established a strong association between trauma, violence and mental health. Those reporting a history of childhood physical abuse have significantly higher rates of anxiety disorders, alcohol dependence and antisocial behaviour, and are more likely to have one or more disorders than were those without such a history.
Childhood history of abuse
Research by H. MacMillan et al. (2001) found that women with a history of physical abuse have "significantly higher lifetime rates of major depression and illicit drug abuse/ dependence than did women with no history." This association was not found in men. For men the prevalence of disorders tended to be higher among those who report exposure to sexual abuse, but only with associations to alcohol dependence. Therefore, the relationship between a childhood history of physical abuse and lifetime psychopathology (mental illness or disorder) varies significantly by gender. A similar relationship has been seen between a childhood history of sexual abuse and lifetime psychopathology.
Epidemiological studies have also shown that the risk of developing Post Traumatic Stress Disorder (PTSD) among those exposed to violence is approximately twofold higher in women and that women often experience a characteristic cluster of symptoms that has been named "complex PTSD." Vulnerability factors may include: women's greater likelihood of exposure to assaultive violence, societal influences, gendered meanings ascribed to traumatic experiences, and hormonal influences.
Reasons for disclosure
The reasons men and women do not disclose personal trauma such as experiences of childhood sexual violence may differ as well; studies have shown that males report difficulty disclosing because they fear being viewed as homosexual and as victims, while women's difficulties centre on feeling conflicted about responsibility, and they more strongly anticipate being blamed or not believed.
Effects of violence and treatment
For women, problems most commonly associated with the experience of violence include: depression, anxiety, posttraumatic stress disorder, personality disorders, dissociative identity disorder, psychosis, and eating disorders. For men, childhood maltreatment has been associated with problem alcohol use. Women make three to four times more suicide attempts than men (though men succeed more often than women). The Ontario Canadian Mental Health Association has found that there is a significant correlation between a history of sexual abuse and the lifetime number of suicide attempts, and this correlation is twice as strong for women as for men.
Pollett writes that individuals who have experienced violence, like others dealing with mental health problems, face mental health treatments that are primarily based on the biomedical model (focused on biological and genetic factors of mental health instead of social determinants such as poverty, housing, stigma and past experiences of violence). Women who require mental health services often receive inappropriate diagnoses and treatment or are denied services because their behaviour is misunderstood or stigmatized.
She also writes that borderline personality disorder (BPD), for example, is diagnosed in women at three times the rate of men. Women with this diagnosis may be more often in crisis situations and access health resources more frequently than men because BPD is considered difficult to treat. It has been shown that if the symptoms of BPD are not recognized as trauma-related and treated as such, these women may be at increased risk for violence or even suicide. Misdiagnosis and inappropriate mental health treatment can also reinforce self-destructive behaviours such as drug and alcohol use.
Violent criminal behaviour
Men and women who do not receive appropriate care for trauma, mental health and addictions problems may end up falling through the cracks and end up within the correctional system. A study found that the pathways between childhood abuse and neglect and violent criminal behaviour are different for men and women; for men childhood maltreatment has both a direct effect on aggressive behaviour and an indirect one, through alcohol, while for women, only the indirect path was found.
In Canada, 82% of federally sentenced women have reported past sexual and/or physical abuse, and the rate increases to 90% for Aboriginal women. The Elizabeth Fry Society reports that more federally sentenced women than men have received a diagnosis of mental illness and their issues tend to be different. For instance, women in federal correctional institutions have a higher rate of self-mutilation and attempted suicide than their male counterparts.
Substance use and mental health problems frequently co-occur among people who are survivors of violence, trauma and abuse, often in complex, indirect, mutually reinforcing ways. Many women identify substance use as a way to cope with gender-based abuse and trauma. Nancy Poole writes in Gender does matter: Coalescing on women and substance use that alcohol problems have been found to be up to 15 times higher among women survivors of partner violence than in the general population. Yet service providers and policy-makers have not always acted on these connections; services with a primary mandate for domestic violence and sexual assault have often not served women with substance use problems, adding to women's vulnerability. Addiction services also must integrate work on trauma, provide information on the connections with addiction recovery and offer individual and group programming.
Effective models of care
The lack of gender-specific responses to the linked issues of violence, trauma, substance use, and mental health problems has resulted in significant costs for service systems: women and men with trauma histories are likely to repeatedly use emergency rooms, mental health inpatient units, and/or end up in the criminal justice system as they cope with symptoms in a context of unresponsive health and social policies and programs. A study found that women who reported a history of childhood sexual trauma were more likely to visit emergency rooms and had annual total health care costs which were significantly higher than women without such a history (these costs were still observed after excluding the costs of mental health care). It has also been shown that adult women victims of sexual trauma use higher levels of health care (more physician visits and higher outpatient costs) when compared to women who have experienced other forms of violence.
The application of a gender-based analysis has assisted health systems and communities in developing evidence-based models that provide effective, integrated, gender-specific care to women and men for violence, trauma, substance use, and mental health issues. For example, the Women, Co-occurring Disorders and Violence Study (funded by the US Substance Abuse and Mental Health Services Administration) found that women-centred, integrated services that provide linked supports for women with trauma, substance use, and mental health problems were more effective in facilitating recovery than usual care, and cost no more to provide. Similarly, the Warriors Against Violence Society in Vancouver has used gender-specific and culturally relevant programming to effectively and compassionately assist Aboriginal men, youth, and families to identify and respond to the root causes of violence against women and children in Aboriginal communities.
The Ad Hoc Working Group on Women, Mental Health, Mental Illness and Addictions is coordinated by the Canadian Women's Health Network and the Centres of Excellence for Women's Health. The Group includes researchers, NGO representatives and front-line community workers in women's mental health, mental illness and addiction from across Canada.
For more information, see the report Women, Mental Health and Mental Illness and Addiction in Canada: An Overview on the Canadian Women's Health Network website: www.cwhn.ca