Looking at the correlation between physical and mental health problems and a history of sexual abuse will require us to reassess how we analyze and diagnose physical and mental illness. This, of course, will take time and cost money.
But the time taken may well save us money in the end. As Judith Lewis Herman, M.D., author of Trauma and Recovery, has said, the suffering of many seemingly different populations with seemingly different needs may have a common source. The battered woman who remembers her childhood abuse during her third visit to the emergency room, the combat veteran who suffers from Post-Traumatic Stress Disorder (PTSD) that has its roots in early terror, the homeless woman who cannot feel safe in any place that resembles a home, and the teenage runaway with Human Immunodeficiency Virus (HIV) all have different stories to tell.
In fact, stories like these have been recounted in the offices of physicians and mental health professionals and in community shelters throughout this nation: people with traumatic life histories use such services and use them regularly (Bryer et al., 1987). The challenge to all of us is to find the thread of common experience that many victims of trauma share and weave it into a strong and supportive cloth, a new social safety net, that gives as many people as possible a fighting chance today — and tomorrow.
Physicians, mental health professionals, survivors, and other service providers need to share the knowledge we have gained from our individual and collective work to show whether paying attention to the effects of victim costs less money than ignoring it. With health care costs a constant concern and the threat of violence an everyday source of societal stress, there is ample reason for conducting a deeper examination of the causes and effects of the trauma we encounter each day.
There is also reason to think that the Clinton administration would be interested in doing so. Earlier this year, Attorney General Janet Reno indicated that she understood the necessity of providing immediate care for victims of abuse and creating opportunities for long-term protection from and prevention of abuse.
In fact, the former Dade County, FL, prosecutor has a history of linking victims and perpetrators of family violence with relevant mental health care programs. Reno appears aware that early and careful intervention could result in long-term savings for judicial systems that are currently over-burdened with cases involving family violence and other criminal behavior that may be linked to a history of family violence. During the Senate hearings that preceded her confirmation as Attorney General, Reno said that “until we focus on violence in the family, we are going to continue to have violence in the streets.”
Some Numbers But what exactly is the price we pay by sticking with the status quo? One cost estimate is noted by author Murray Strauss (1987), Director of the University of New Hampshire’s Family Research Laboratory. Strauss alludes to one statistic, based on his study of the incidence of interfamily homicides in 1984 alone, that put the cost of such homicides at $1.7 billion. Such data, he is quick to assert, are misleading because the percentage of actual homicides is small in relation to the total number of violent incidents involving families. Furthermore, that amount, in Strauss’ view, cannot begin to include the costs of the violence that preceded the death of an adult or child in that comparatively small population.
“The true accounting of the cost of family violence,” Strauss writes, “must also include the cost of providing mental health and social services to victims and the cost of treating aggressors.” Some of these costs are beginning to be tabulated. While an associate professor in the Department of Psychiatry at the University of Manitoba, Canada, Colin A. Ross, M.D., calculated the lifetime psychiatric health care costs of 15 women who had been diagnosed with multiple personality disorder (MPD). The research, which assessed the cost of care both before and after the women had been diagnosed, indicates that the mental health care costs for women before being diagnosed with MPD are quite high ($2,769,997.50 in Canadian dollars). Projections are that accurate diagnosis and treatment of WD (which DSM III-R recognizes as a potential effect of sexual child abuse) would produce a “net saving of $84,899.44 per patient over 10 years” (Ross and Dua, 1993).
Such projections were made on the basis of data showing that women in the study had spent an average of 98.77 months in the Canadian mental health care system before being diagnosed with MPD. By contrast, the average time they spent in the system after diagnosis came to 31.5 months. Ross, now director of the Dissociative Disorders Unit at Charter Hospital in Dallas, TX, and associate professor of psychiatry at Southwestern Medical Center at Dallas, further contends that the savings per person could increase to more than $250,000 if openness to and earlier diagnosis of MPD were to occur in the mental health system. He states that “If these women had been diagnosed before age 10, when, according to retrospective history they all had alter personalities, and their abuse stopped, the overall saving to the taxpayer for social services might have been in the order of $10,000,000.”
In the press of health policy-related lobbying, other organizations have also produced estimates of the costs of mental illness. According to USA Today (Healy, 1993) the Rockville, MD-based Institute for Behavior and Health (IBH) estimates that anxiety disorders cost the nation $46.6 billion in 1990. About three-fourths of those dollars, the study says, are losses due to reduced productivity, worker absenteeism, and disability — not the cost of medical care itself.
Such research, though far from complete, has a variety of implications. Some of the data show that abused children — including those who have been sexually abused — have two to three times more difficulty in making friends (Strauss, 1987). Many are much more likely to produce failing grades, display “disciplinary” problems, have drug and alcohol problems, and wind up in jail.
Ross also points to the possible long-term effects of growing up in a violent home. While noting that his sample included no males diagnosed with MPD, he indicated that additional studies suggest that the “burden to the taxpayer of undiagnosed MPD in males is born largely through the criminal justice system” (Ross and Dua, 1993).
As Strauss and Ross propose, mental health and non-medical costs may far outweigh the cost of treating injuries themselves. These kinds of costs are especially familiar to the millions of survivors who may never have seen the inside of a county jail cell but who continually struggle to finance their way out of the prison of their pain.
As the IBH study suggests, that price is paid in the form of missed work time and troubled personal lives. Survivors also pay a price by pouring what seems like more than their share of would-be disposable income into services that societal ignorance of the effects of abuse largely obliges them, rather than individual and institutional perpetrators, to pay.
-Mary Anne Reilly
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.