Reasonable responses to unreasonable behaviour?: medical and sociological perspectives on the aftermaths of sexual violence - Liz Kelly, CWASU, London Metropolitan University

Reasonable responses to unreasonable behaviour?: medical and sociological perspectives on the aftermaths of sexual violence Liz Kelly CWASU June 2011

Overview
Pick up on theme of tensions between sociological and medical framings, definitions and contexts
Two key questions
How are ways of understanding the impact of sexual violence mediated by medical/therapeutic discourses and social contexts?
Are there alternative sociological framings which offer opportunities for new thinking in health policy and for practitioners?

Starting points 1
Most victim-survivors do not make an official report or disclose to health sector – but they do tell someone and seek support
Often delay contacting formal agencies
The responses of informal network members and professionals either compound impacts or alleviate them, be a gateway into further support or a barrier
Other keynotes all focus on DV/IPV, this one on SV
Health – unlike in some other countries has been a reluctant partner in responses to VAW

Starting points 2: Language in discourse
Medical/psychological
Effect
Trauma
Healing
Recovery
Syndromes
/disorders
Sociological
Impacts and consequences
Empowerment
Embodiment
Meaning
Resistance
Harm
Social suffering
Multiple narratives – stories of harm but also coping/survival

Wider context
Policy shift at national and some local levels
integrated approach to violence against women and girls (VAWG) begun by Labour government in Nov 2009, rooted in gender inequality and human rights
Approach and framing re-affirmed by coalition govt
Neo-liberalism and new public management
Measurement, ‘evidence’ based
Fits with a health research models, but ongoing debates about what counts as evidence
Variations in funding base – drug companies and health provider funding, versus small budgets for social science
Valorisation of quantitative, controlled trials
When do women’s voices and lives count?

Evidence on sexual violence and mental health
Short term impacts
Shock, fear, anxiety, withdrawal, distrust
Longer term
Depression, self-harm, eating disorders, sleep disturbance, self-blame, self-medication/substance misuse, panic attacks, flashbacks, fear and anxiety, shame and self-blame
Sense of safety in the world is undone – shrinks women’s space for action (Jordan, 2008)
Negative social reactions associated with poorer psychological outcomes (Ullman 1996, Filipas and Ullman 2001, Banyard et al, 2002)
Higher rates of mental health impacts than physical violence (McFarlane et al, 2005)
SV in childhood – penetrative and repeated assaults are associated with more severe/disabling mental health impacts

The trauma framing

Rape Trauma Syndrome (RTS)
Burgess and Holmstrom (1972) – 146 women – attending hospital post assault
Marks the early recognition of rape as social problem, its effects and the need for crisis intervention
Trauma model based on their research
Acute phase (initial impact and immediate effects)
- expressed reaction
- controlled reaction
Disorganisation phase (re-experience assault)
Reorganisation phase
- emotional legacies
- disruptions to lifestyle
- establish new routines and capacities
Later writings highlight ‘compounded reaction’ – that recent assault amplifies any past or current histories of psychological, psychiatric difficulties

Post Traumatic Stress Disorder (PTSD)
Superseded RTS as a model
Developed following experiences of Vietnam War veterans
Describes a cluster of symptoms observed in the aftermath of trauma – entered DSM III in 1980
‘ Experienced an event outside of the range of usual human experience and would be markedly distressing to anyone ‘(added 1987)
Amended DSM IV (1994) - event that involves actual or threatened death or serious injury or threat to physical self or others; responses include intense fear, helplessness or horror
Widely used to measure impact of sexual violence in research
many studies find changes in PTSD at intervals following assault
evidence base limited to assaults disclosed to formal agency
Interventions focus on alleviation of ‘symptoms’, ‘recovery’

Judith Herman – Trauma and Recovery (1992)
Combines psychological and sociological
Links the trauma of sexual violence with social devaluation of women and children, both cause and consequence of SV
Identified changes in arousal, emotion, memory, and cognition
Challenges the use of psychiatric diagnoses of women, especially personality disorders
‘ Complex post-traumatic stress disorder’ – to accommodate that changes self (not just sel;f-worth/self-esteem) and ‘being in the world’
Need to find meaning in order to ‘recover’
Activism as strategy that helps some women

Critiques of trauma model
Problematising ‘recovery’ (Kelly et al, 1996; Reavey & Warner, 2001) – is not an illness but a life changing event
Contested concept – can validate as ‘real problem’, open pathways to therapeutic support and become part of everyday vocabulary (Ussher, 2010) BUT as diagnostic label fails to recognise the social context
No recognition of that being part of a social group is relevant –to the violence and its meanings – gender/class/ethnicity/disability
‘ language of psychology rather than the language of survivors’ (Humphreys & Joseph, 2004: 566)
Embedded in clinical psychology - but most victim-survivors do not access this, use grass roots specialised services
Has become a narrative with ‘master status’ (Frank, 1995) – against which all accounts are judge - ‘trauma talk’ to be recognised
Loss of survival and resistance
Ethnocentric in the framework – distress expressed differently across cultures

Feminist engagements
Have used strategically (Burstow, 2003)
Contributed to the development of trauma discourse
Attempt to add social location into
Viewing sexual violence as ‘outside of usual human experience’ is to challenge its normalisation, and to introduce women’s lives into ‘human experience’
HOWEVER, the underlying assumption is that social life is safe is belied by prevalence studies on the extent of sexual violence
Part of feminist argument has been that violence is everyday, mundane and world is not safe
If apply PTSD formulaically then women’s continued anxiety and fear appears irrational and to be lessoned
Can the concept of trauma be used in non-medicalised way?

Because I do not like to think that the man who raped me infected me with a mental illness, I resist calling the effects of overwhelming terror an illness. I claim my sanity, and view my response as human, even appropriate and dignified
Nancy Venable Raine (1999)

Sociological framings

Stigma, spoiled identities
Goffman (1963) 'the process by which the reaction of others spoils normal identity'.
rape is inherently dishonouring, amplified where culture/faith places high value on women’s honour, and silences (Gill, 2009)
Contexts where hymen repair considered necessary treatment, eg Palestine (Shalboub-Kevorkian, 1999:164) and recent discussions in Libya
Implications for telling others – have to manage their responses – emotion work (Hochschild, 1983)
Responses of others – positive: listening and believing emotional support, practical support
- difficult/negative: blame; taking control; distraction; treating differently; egocentric reactions
Time of Silence and Time of Telling (Carlson, 2009)
Complexity of silence (Crisp, 2010; Singh et al, 2010)

Feminist version: Victimism
Redefining rape, demanding recognition of women’s victimisation has led to the creation of a new status - the victim.... Creating the role and status of the victim is the practice I call victimism. A woman who has been sexually assaulted finds she can only be understood if she takes on the role of the victim, she is assigned victim status and then seen only in terms of what has happened to her…. It creates a framework for others to know her not as a person, but as a victim, someone to whom violence has been done.
Victimism is an objectification which establishes new standards for defining experience, those standards dismiss any question of will, and deny that the woman even whilst enduring sexual violence is a living, changing, growing, interactive person…. It denies the reality of women’s circumstances and the very real human efforts they make to cope with those circumstances…. Surviving is the other side of being a victim. It involves will, action, initiative. Any woman caught in sexual violence must make moment-by moment decisions about her survival. (Kathleen Barry, 1979, p38-9)

The relational self
I develop and defend a view of the self as fundamentally relational – capable of being undone by violence. But also of being remade in connection to others … (Brison 2002)
Sexual violence as violation of the body and social relationships (Koss, 2006)
Interrupts capacity for trusting relationships
Requires a rebuilding of the self in a changed context
PTSD underplays the role of re-connecting to social networks (Humphreys & Joseph, 2004)
Positioning as a victim
can lead to feeling ‘tainted’ and defined by men’s violence
victim as passive and a gendered concept (Reavey & Warner, 2001)

The ‘v’ words
Victimisation
Material reality – extent of violence/abuse
To be made a victim
Powers of violence and abuse as control
Corodes confidence and erodes agency
Further harms through responses of others –shame and stigma
To be a victim
To name ones experience
Legal status
Victimhood
As a chosen identity
A critique of feminist analysis – ‘victim feminists/feminism’
Child and Woman Abuse Studies Unit

(Dis)embodiment
Implications of violating boundaries - disrupts
control over body and relationship with body
Coping during assaults: dissociation and leaving the body emotionally when it is impossible to leave physically
Body as ‘crime scene’
Self as embodied – ‘ Nothing can be your body if there is no you ” (Church 1997) – struggling to ‘get the self back’ (Jordan, 2008)
Sexual and physical abuse is experienced through the body and survivors of sexual abuse often describe a disconnection or dissociation such that the ‘true’ self can describe incidents of abuse from a physical and emotional distance. The child’s sense of believing ‘this isn’t happening to me’ may go on to develop into a profound alienation from the life of the body (Scott 2001:177)
Dissociation as disorder or an attempt to manage the unbearable and linked to social/cultural views of women and their bodies?

Resistance, Harm and Social Suffering
Resistance seldom asked about in research or practice
Different to resilience, which emphasises aspects of personality and behaviour that mitigate impacts
Physical/cognitive/emotional resistance (Kelly, 1988; Jordan, 2005)
withholding a part of self
retaining a sense of control
Discussing can enable women to positively reassess (Jordan, 2008)
often discount themselves as ‘unsuccessful’ but remembering and reframing helps shift self-blame
Harm/s as alternative to effects/impacts, comes from a human rights perspective, and adopted by some criminologists ‘social harm’ (Dorling et al, 2008)
‘ Social suffering’ from Bordieu (1999) and developed by Veena Das (2001), links the social, cultural and individual – the burdens of violence in everyday lives

RECENT RESEARCH ON RESPONSES

Specialist services
Rebecca Campbell (2008) : where there is no specialist provision many victim-survivors experience ‘secondary victimisation’: the majority of reported cases are not prosecuted; many do not receive complete medical care, and most do not have access to quality support services
Unacknowledged sexual violence can compound impacts over time – need to provide safe spaces that enable naming,
Minority women and lesbians are less likely to access support, so outreach and appropriate responses necessary
Most significant in positive coping – perceived control over process and body (Frazier et al, 2004)
Practice of FMEs in SARCs
What enables women to access and receive support - ‘normalisation’, validation, respect and dignity’ (Campbell, 2008 )

Specialist services 2
Services that women deem most helpful in 3 countries
were specialist SV services and RCCs in particular
(Fry, 2007; Kingi and Jordan, 2009; Lievore, 2005)
Ongoing project (Ullman and Townsend , 2007) with 1000 victim-survivors: 16% accessed RCCs, 79.3% found it helpful, higher than any of the 10 formal and informal sources of support being studied.
Patterson (2009) RCCs most responsive to victim-survivors and attempt to offer the most holsitic services
Under-resourcing of sexual violence services noted in recent US research (Macy et al, 2010) and in the Australian Plan to Reduce VAW (2009)
Means do not have capacity to meet needs (p75), reach certain communities
As disclosures and reporting of VAW increases, the gap between demand and needs being met will only grow… the first door should be the right door ( p75, 79).
Westminster and GLA invested in expanding RCCs, but cuts in public expenditure mean will remain fragile eg history of provision in Liverpool

What women think
Support for specialist women’s organisations in WNC focus groups (2010, including A Bitter Pill to Swallow to inform the Alberti review) even though not asked
Value – safety, holistic support, when and for as along as need it, and empowerment approach
We need more appropriate services for vulnerable women ... The Havens [SARCs in London] only accept people within one year. Some times it can take many years to come forward. You feel you are on your own if there are no services to support you (p87)
The second time round when I was raped again I went to the Haven, they were fantastic, they made me tea, took my statement, gave me clean clothes, let me have a shower.... the doctor that examined me was perfect, brilliant, she was female (p85)

Food for thought
I’ve had really bad experiences with psychiatrists. I’ve been
suicidal and I’d been trying to tell them about some of the domestic violence I had suffered – I hadn’t even got to my sexual abuse as a child. and the psychiatrist said to me ‘well you’re good at picking them aren’t you... it is alright for your husband to want sex’... and then diagnosed me with OCD (p87)
I don’t want to be given drugs and be locked up in wards just because I have been abused. I want human responses to human distress which recognises my experience as a woman is often different from men (p88)
I’m a mental health patient, when I go to the psychiatric hospital I am abused by the staff. There’s a lot of homophobia ... I got attacked in hospital and that staff didn’t take any notice. One nurse said to me ‘you’re butch , you can defend yourself (p89-90)
I would rather be raped again than enter the mental health system. when I was sectioned I was put in a mixed ward which included sex offenders. I was threatened with shards of glass; the psychiatrist did not believe me.. Trust and most importantly consent were completely absent, it was totally disempowering... I would never, ever disclose if I went back (p90)

RCCs: The whole place self
From Fiona Elvines MA dissertation,
drawn from an interview with SERRIC
The approach is standing alongside and working with
to rebuild a self fragmented by violence
active participants in exploring what violence meant and means for their whole selves – not just a story of abuse, a collection of effects
‘ Relational self’
Women only has significance here – who women can relate to/with
Create new meanings ‘in conversation’
Empowerment means extending women’s space for action, including the power to speak out, resist, be part of a collective movement against sexual violence and for women’s equality

Basis for progress and dialogue?
Good outcomes from the perspective of victim-survivors (drawn from RAE for Stern review)
being believed and acknowledged
access to information and options
complete medical care
feeling in control of what happens to their body and case
access to specialist services
practical and emotional support
access to female practitioners
Implications for health sector
Audit own responses using these as indicators
Recognition of the model sdeveloped in Rape Crisis Centres, and subsequently SARCs

Susan Brison
I develop and defend a view of the self as fundamentally relational – capable of being undone by violence, but also of being remade in connection with others… [the] tension between living to tell and telling to live, that is between getting (and keeping) the story right in order to bear witness and being able to rewrite the story in ways that enable the survivor to go on with her life (pxi-ii) [Aftermath, 2002]

Reasonable responses to unreasonable behaviour?: medical and sociological perspectives on the aftermaths of sexual violence - Liz Kelly, CWASU, London Metropolitan University

by British Sociological Association on Sep 20, 2011

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Reasonable responses to unreasonable behaviour?: medical and sociological perspectives on the aftermaths of sexual violence - Liz Kelly, CWASU, London Metropolitan University — Presentation Transcript