07 August 2005
	Help for Adult Victims Of Child Abuse. A non-profit making organisation based in the UK dedicated to provide help, support and information to any adult who is suffering from past childhood abuse.

Just Another "Special Interest Group"? Survivors and National Health Care Reform
By Mary Anne Reilly

Unlike other complex and controversial issues of the day, health care reform isn't important only to so-called special interest groups. In fact, health care reform is of special interest to all of us, regardless of the backgrounds we inherit. The devoted lifelong partner of an elderly person whose medical needs threaten the couple's financial stability and the survivor of sexual child abuse whose employer provides minimal, if any, medical and mental health benefits share a similar nightmare: that their needs cannot or will not be met under the current health care system. Competing Interests Nonetheless, as The New York Times reports, organizations promoting their members' interests are weighing in with their own proposals (Toner, 1993). More than 200 health care reform plans have crossed the desks of Clinton administration advisors thus far, and more than 240 organizations, representing constituencies ranging from insurance agents to drug manufacturing companies, have already spoken with these advisors about their concerns. Furthermore, even though the administration is expected to come up with a proposed health care plan by May 1, we can safely assume that there is no end in sight for these discussions: no fewer than 750 trade associations are said to have a stake in what the future may hold.

Amid all this talk and position paper pushing, can survivors of sexual child abuse and their advocates get a word in edgewise? And if and when we do, what might be the focus of our concerns?

Potential Allies
The good news is that the Clinton administration -- and First Lady Hillary Rodham Clinton in particular -- has gone on the record time and time again on the necessity of focusing on the needs of children, including safety from parental abuse. Tipper Gore, a mental health advisor to the administration who also happens to be the vice president's wife, has a long-standing interest and involvement in children's mental health issues. Health and Human Services Secretary Donna Shalala, like the First Lady, has chaired the board of the Washington, DC-based Children's Defense Fund, an organization focused on issues related to the basic health and economic needs of children.

In addition, the Clinton transition team itself includes other advocates for abused children. National Committee for the Prevention of Child Abuse staff member and transition team member Anne Cohn Donnelly participated in the pre-Inaugural Economic Conference in Little Rock, AR, saying ". . . as we talk about making sure that young children are ready for school, as we concern ourselves with their health and their educational readiness, we also have to concern ourselves with the safety of the environments in which they're growing up."

Potential Sources of Concern
Given this information, what kind of bad news could adult survivors and their advocates possibly expect? One answer could be that there is, or will be, no bad news -- that our needs for medical care, mental health care, and a more integrated approach toward these and other services that we may need in order to heal will be fully met.

The more realistic answer to this question, however, is that our perspective could be lost in the crush of legitimate concerns about skyrocketing health care costs. Survivors' interests and the interests of other trauma victims could also be compromised by policies that offer and apportion treatment primarily to people who exhibit symptoms of narrowly defined -- and far from universally accepted -- types of mental "disorders." Many of these disorders, as described in the Diagnostic and Statistical Manual of Mental Disorders-Revised (DSM III-R), predate much of the research conducted on sexual child abuse and other trauma. Consequently, for this and other reasons, such diagnoses don't recognize the effects of early childhood and other types of trauma on the behavior of children and adults. Fortunately, it can be argued that any examination of the provision and structure of health care services that takes into account survivors' issues can have a significant impact on long-term health care costs. At the very least, such an examination could prevent construction of a well intentioned new system that, in the absence of feedback from survivors and their advocates, would fail to solve problems it didn't know it had.

This article focuses on a variety of health care-related issues of importance to survivors. It is not meant to be comprehensive; however, it is offered as an introduction to issues that need to be addressed as we take the opportunity to make adequate health care accessible to all Americans, regardless of whether they have been victims of trauma.

The Scope of the Problem
Among the many articles policy analysts are reputedly reviewing are two published in the February 1993 issue of the Archives of General Psychiatry. The articles (Narrow et al., 1993; Regier et al., 1993) contain the findings of a National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) survey that was designed to determine how common a variety of mental and addictive disorders, including manic depressive disorder and alcohol addiction, really are among the U.S. population. The ECA survey, conducted in 1980 and 1985, also sought to determine what kinds of services people with these disorders actually use, such as the services of physicians, specialists in mental and addictive disorders, other human service professionals, and voluntary support groups, including 12-step programs.

The results of that survey are striking. Researchers is covered that mental disorders affect more than 28 percent of the U.S population in any given year. They also concluded that 72 percent of those who had been diagnosed received no care at all during that period.

The Limits of Diagnostic Definitions
The results of the ECA survey received their share of media attention, largely because they indicated that a sizable percentage of the population suffers from mental disorders and that a large majority of those sufferers receive no treatment whatsoever. But there's more to those results than is immediately apparent from news reports on the subject. None of the DSM III-R disorder categories included in the ECA survey, for example, state that a history of sexual child abuse could be a relevant or "predisposing" factor in the lives of those diagnosed with disorders. Add to that the fact that the survey was conducted before the subject of sexual child abuse captured significant professional, not to mention public, attention, and you have results that do little more than hint at the prevalence and nature of mental health problems in the United States.

Surveys of this type may provide little information on the nature of problems surrounding the accessibility and delivery of adequate mental health services. This occurs, in part, because traditional diagnostic categories alone cannot be used to evaluate the reasons why participants exhibit symptoms that characterize them as having one kind of disorder, a series of disorders with no readily identifiable cause, or no disorder at all.

Focusing on whether there has been a history of trauma, however, may give health care providers a clearer idea of who needs the services, why they need them, and how those needs can best be met. This is not the time to launch into a discussion of complex diagnostic issues involving the definition of disorders, or even, frankly, the use of the word "disorder" when describing responses to trauma. But it is important to increase policy makers' awareness that the use of definitions, such as some of those appearing in the DSM III-R, cannot, in themselves, either adequately discern an individual's need for services, or persuade society that such services are addressing real needs.

Quality of Care
As can be expected, the type and quality of care offered to users of mental health services are also of great concern to survivors. Although the comparative merits of the health care models currently under scrutiny (see "Accessibility to Care," page 13) are not the focus of the discussion here, it appears that some sort of managed-care or managed-competition model may well become the model of the future. In that case, it makes sense to look at some of the issues that might be raised by the adoption of such models.

Some proposals that suggest limits on the length of care have surfaced; these may do little to assist survivors in the short -- much less the long -- term. For example, the Jackson Hole Group, a collection of health care policy analysts and industry leaders, has suggested that the Clinton administration propose coverage limiting users of mental health services t  approximately 20 outpatient visits and one 30-day inpatient visit per year. According to The New York Times, the Group has also presented an alternative: an annual limit of $10,000 for both types of services per year (Pear, 1993).

It's safe to say that economic realities will produce much support for such cost cutting measures. Viewed in this context, the current managed-care approach to the delivery of health care services, which features some of the limits described above, may appear to be a relatively simple, efficient way to provide needed services on a tight budget. Unfortunately, virtually no one in the field of treatment for the effects of sexual child abuse currently believes that 20 weeks of care could adequately equip adult survivors with many of the tools necessary to function effectively at home and in the workplace. Infact, it's unlikely that survivors who are fully aware of their own histories would successfully establish a relationship of trust -- vital for successful therapeutic intervention -- in such a short period of time. Furthermore, it seems even more futile to suggest that those struggling with a past they cannot yet fully remember could possibly come to terms with their own histories -- and begin to use that knowledge to enhance their lives and contributions to society -- in a matter of weeks.

There may be times when short-term intervention is a valid and preferred option, when a few months of therapy can turn someone's life -- or at least a situation that threatens someone's sense of stability -- completely around. But there is mounting evidence (see "Assessing the Cost of Trauma, page 14, and "Revictimization: Examining Its Occurrence in the Lives of Survivors," Moving Forward, Volume 1, Number 6) that a primary source of many of the "disorders," addictions, and social problems we encounter today represent the combined effect of childhood trauma and societal denial of its impact on victims. If that is the case, then such proposed limits on care cannot and will not meet the needs of many consumers of mental health care. 

In fact, cost-containment measures such as rigid limits on length of treatment may turn out to be no more than Band-Aid solutions to mental health service cost-related problems. Unless and until "faster" and more effective ways can be found to empower individuals with such a history, chances are slim that narrowly focused cost-cutting efforts will alleviate the problem of escalating health care costs.

In their search for relief, survivors who are misunderstood or given inadequate care, for example, are likely to make return visits to a variety of medical and mental health care systems. Their journeys invariably lead them, their physicians, and their therapists to "reinvent the treatment wheel" over and over again. The repetitive nature of this exploration is frustrating and costly for all concerned. In fact, this often chaotic process not only affects consumers and service providers but also unnecessarily burdens employee health care plans and -- in cases that involve government-funded benefits -- all of us.

Somatization Issues
Another issue of genuine concern to survivors involves what the NIMH-sponsored ECA survey cans "somatization disorders." According to the DSM III-R definition somatization disorders are "recurrent and multiple somatic (physical) complaints, of several years' duration, for which medical attention has been sought, but that are apparently not due to any physical disorder." One of the recent Archives of General Psychiatry articles describing the ECA survey findings states that this is a relatively rare disorder treated in a large majority of cases (64 percent) by general physicians (Narrow et al., 1993).

This finding warrants further examination for several reasons. According to James Morrison, M.D. (1989), by the late 1980s only two of the 75 somatization-related articles published since the 1950s had provided data on patients' histories of childhood sexual abuse. This is significant because the ECA survey, conducted in 1980 and 1985, was based on DSM III definitions of somatization that do not make the connection between somatic complaints and a history of sexual abuse.

A number of other studies and papers on somatization have been published since then. In one such report, the authors note that several studies have found that a large group of women seek physicians' care for chronic headaches and gynecological complaints (Walker et al., 1988). Although these and other physical symptoms are less severe than some of those referred to in DSM Ill-R (e.g., blindness, paralysis, and dizziness), the authors cite studies that suggest a "strong association" between a history of somatic complaints and a family history of alcohol abuse and other trauma.

The findings of the more recent studies indicate that the results of the ECA survey significantly underestimate the impact that a tendency to misdiagnose (or failure to recognize) somatic complaints in patients may have on current perceptions of the scope of somatization-related problems. These developments certainly point out the necessity of investigating this topic further. And, evidence that Americans receive more mental health services from physicians than from mental health professionals (43 percent versus 40 percent, respectively, in the ECA study) underscores the need for physicians to be fully educated about survivor-related medical issues. The recent efforts of the American Medical Association (see "Medical Community Takes Notice of Survivors' Health Concerns, " Moving Forward, Volume 1, Number 2; and "Survivors Have a Stake in Developing Domestic Violence Guidelines," Moving Forward, Volume 1, Number 3) and the American Academy of Family Physicians in this regard are important first steps. But the findings of the ECA survey indicate that any attempt to reform the system without addressing the need for concentrated efforts in educating physicians about trauma-related issues would be incomplete.

Conclusion
Understanding the linkages between a history of family violence -- and, specifically, sexual child abuse -- with physical and mental health problems is vital for the future of our nation. Unfortunately, however, incorporating that understanding into a reformed health care system will not, in and of itself, stop the violence that takes place behind dosed doors and thrives on secrecy.

But an attempt to do so can begin to break down the barriers to understanding that prevent action from being taken to protect the lives of people of all ages -- and to take down the barricades, erected long ago, that prohibit millions from receiving the assistance they need to lead fully functioning and productive lives.

References
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Healy, Michelle (1993). Undiagnosed mental disorders
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Morrison, James (1989). Childhood sexual histories of women
with somatization disorder. American Journal of Psychiatry, 146 (2),239-241.

Narrow, William E., et al. (1993). Use of services by
persons with mental and addictive disorders: Findings from the National
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Pear, Robert (1993). White House plan would cover costs of
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Regier, Darrel A., et al. (1993). The de facto mental and
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health reform trail The New York Times, March 20, p. Al and A8.
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Mary Anne Reilly, a freelance writer and editor, has published articles in a variety of publications including Newsday and The Texas Observer. She served as a consultant to the American Medical Association's taskforce that prepared the Diagnostic and Treatment Guidelines on Child Physical and Child Sexual Abuse. A former social services professional, she is an associate editor for Moving Forward. Associate editor Stu Philipp, author Marge Elder, and the Clearinghouse on Child Abuse and Neglect contributed research to this article.

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