Abstract
In Australia, at least one in every five women has experienced sexual violence since age 15. Research consistently links sexual violence with poor mental health, persisting long after the crisis period. Trauma-informed mental health support is therefore critical. This article draws on interviews with 29 women who had experienced sexual violence to understand their experiences accessing mental health services in Australia. Our findings suggest that, constrained by a biomedical model of care, mental health practitioners’ understanding of trauma generally, and sexual violence particularly, may be lacking. Further, women struggle to navigate a “maze” of services.
Sexual violence (SV) in adulthood is prevalent globally (World Health Organization, 2013). Broadly defined as any non-consensual sexual act or attempted sexual act (Dartnall & Jewkes, 2013), it encompasses a range of behaviors including rape, coercion or threats to obtain sex, and forced participation in or consumption of pornography (Dartnall & Jewkes, 2013). SV can affect people of any age, sexual orientation, or gender identity; however, the vast majority is perpetrated by men against women, primarily by a current or previous cohabiting partner (World Health Organization, 2013). In Australia, national prevalence data indicates that around one in every five women has experienced SV since the age of 15 (Australian Bureau of Statistics, 2017), although it is likely that the true prevalence is much higher (Australian Institute of Health and Welfare, 2020).
Research consistently demonstrates strong associations between SV in adulthood and a range of mental health issues (Chen et al., 2010; Dworkin, 2020; Dworkin et al., 2017; Rees et al., 2011). These include post-traumatic stress disorder (PTSD), anxiety, depression and eating disorders, as well as substance misuse and suicidal ideation (Campbell et al., 2009; Dworkin, 2020). These impacts are not limited to the immediate crisis period but can persist for years after SV has occurred (Tarzia et al., 2017; Townsend et al., 2022). Many victim/survivors have also experienced childhood sexual abuse or other co-occurring forms of violence (Rees et al., 2011; Salter et al., 2020), leading to cumulative or complex trauma that is difficult to address (Herman, 1992). Indeed, systematic reviews confirm that poor mental health relating to SV can be more severe and long-lasting than for other types of traumas (such as road accidents, natural disasters or physical assaults) (Dworkin, 2020). In part, this may be due to shame and self-blame (Bhuptani & Messman-Moore, 2019; Bhuptani & Messman, 2021; Tarzia, 2020a; Vidal & Petrak, 2007). SV is an embodied trauma; violence enacted on and in the body (Cahill, 2001). Victim/survivors have described it as uniquely dehumanizing and degrading (Tarzia, 2020a). These profound emotional impacts can impede recovery and worsen mental health symptoms (Bhuptani & Messman, 2021). Counteracting these feelings through non-judgmental, empathetic support that validates women's experiences is critical (Martsolf et al., 2010; Rees et al., 2019; World Health Organization, 2014; Wright et al., 2021). While for some women, friends and family can provide this support, many turn to professional services.
In Australia, psychological support for victim/survivors of SV can be provided through specialist sexual assault centers delivering a feminist model of counseling (National Association of Services Against Sexual Violence, 2021). In addition to recovery from trauma signs/symptoms, a feminist model of counseling may also address issues of power/abuse of power, self-blame, and the broader structural context of SV (Egan, 2019). These government-funded services, while considered to represent best practice, typically have long waiting times, offer a limited number of sessions, and are not necessarily suitable for all women (Smith et al., 2015; Sweeney et al., 2019). For example, women who do not label their experiences as “sexual violence” (Harned, 2005; Tarzia, 2020b) may be less likely to utilize these specialist services. Furthermore, in Australia, sexual assault services cannot prescribe medications or clinically manage co-occurring mental health symptoms. Consequently, the reality is that women often seek psychological support via the mental health service system.
The mental health service landscape in Australia is complex and is composed of a range of services delivered in diverse settings. Some services are funded by federal, state, or even local governments (Australian Institute of Health and Welfare, 2022), including mental health care accessed through public hospitals, residential mental health services, community mental health services and some general practitioners (family doctors) (Australian Institute of Health and Welfare, 2022). Many mental health professionals such as psychologists and psychiatrists, on the other hand, are available privately on a fee-paying basis (although government subsidies exist for a limited number of visits and/or via particular initiatives) (Australian Institute of Health and Welfare, 2022). The dominant framework across most of these services is the recovery model (Department of Health and Ageing, 2013). This model focuses on choice, rights, dignity and respect, partnership and communication. It prioritizes the individual's hopes and goals for recovery and their ability to manage their own illness and treatment (Department of Health and Ageing, 2013). Alongside the recovery model, the principles of trauma-informed care have been considered to be a key part of best practice in Australia for several decades (Sweeney et al., 2018; Victorian Government, 2021). Trauma-informed care expects that clinical services are able to identify the needs of service users with a history of trauma and employ practices that promote healing and recovery and avoid re-traumatization (Reeves, 2015; Sweeney et al., 2018). Trauma-informed services should operate from the assumption that any patient could have a history of abuse and violence, whether or not they disclose or whether it is the reason for their presentation (Harris & Fallot, 2001).
Despite an emphasis on trauma-informed care in theory, research suggests that, in practice, trauma-informed care can be delivered inconsistently (O’Dwyer et al., 2019; Quadara, 2015; Salter et al., 2020; Watson et al., 2020; Xiao et al., 2016). Although research in this area is lacking, a small body of Australian literature explores the perspectives of mental health service providers on delivering care for survivors of SV. For example, a study by McLindon and Harms regarding the experiences of Australian mental health workers found that the majority had not received sufficient training in responding to SV (McLindon & Harms, 2011). O’Dwyer et al. (2019) similarly found that staff in psychiatric inpatient units in Victoria had a poor understanding of SV and the needs of women consumers, often engaging in practices that victim/survivors considered re-traumatizing. Hegarty et al. (2016) found that various organizational barriers could prevent the delivery of trauma-informed care for women experiencing SV and/or family violence, and that a “holistic” model of care was lacking. Internationally, studies in the mental health setting predominantly focus on responses to childhood sexual abuse (Hepworth & McGoway, 2012), or domestic violence (Trevillion et al., 2012) and the nuance of how clinicians address SV experienced in adulthood is largely unexplored.
From the perspective of victim/survivors of SV, only four studies have explored experiences accessing services in Australia (Hegarty et al., 2016; Rees et al., 2019; Salter et al., 2020; Watson et al., 2020). Of these, only one (Watson et al., 2020) focused specifically on the mental health context, foregrounding the perspectives of 11 women who had spent time in a psychiatric inpatient unit and experienced gender-based violence. Participants reported a lack of trauma-informed care, neglect of past trauma and failure to maintain safety to prevent further gender-based violence. Their study, however, was not focused exclusively on SV. Similarly, although Hegarty et al. (2016) and Rees et al. (2019) did focus on victim/survivors of SV, their studies were not restricted to mental health settings, but rather, explored service provision more broadly. Salter et al. (2020) explored service provision for victim/survivors of complex trauma, including, but not limited to, survivors of SV in adulthood. Thus, to our knowledge, there are no studies exploring the perspectives of women victim/survivors of SV accessing mental healthcare in Australia. Internationally, there is a more robust literature base exploring general help-seeking after SV, as outlined in a systematic review by Lanthier et al. (2018) on responses to delayed disclosure in healthcare settings. The review found that some women encountered blaming, minimizing or disbelieving responses from health practitioners with a lack of emotional support. On the other hand, responses that were validating and offers of tangible aid were perceived as helpful (Lanthier et al., 2018). However, of the 23 articles included in their review, none focused on mental health services. A subsequent study by Starzynski et al. (2017) is, to our knowledge, the only one to specifically address the experiences of women victim/survivors of SV in the mental health system, although some recent work (Sorrentino et al., 2021) has examined the perspectives of victim/survivors of domestic violence. The findings of Starzynski et al., based on interviews with 15 women in the USA, confirm the critical importance of trust-building between victim/survivors and mental health practitioners; negative, blaming or unprofessional responses were perceived as unhelpful and distressing (Starzynski et al., 2017).
It is clear that the voices of victim/survivors of SV have been largely absent from research into the specific context of mental health services (Hughes et al., 2019; Sweeney et al., 2019). Yet, in recent years, there has been greater emphasis placed on the value of lived experience and co-design in the delivery of healthcare interventions and systems reform (Tarzia, Humphreys et al., 2017; Victorian Government, 2021). This article seeks to address this gap in knowledge by drawing on qualitative in-depth interviews with women recruited from health and specialist services in Victoria, Australia. The key research question guiding our analysis was: “What are the experiences of women victim/survivors of SV when accessing and using mental health services in Australia?”
Method
This article presents the findings of a secondary analysis of 29 in-depth, unstructured interviews undertaken as part of a broader project on trauma-informed care in health settings for women experiencing SV and mental health problems (Hegarty et al., 2016). The interviews aimed to explore women's pathways to safety and care after experiencing SV and mental health issues, including exploring their experiences of health service access. The analysis undertaken for this article focused more specifically on women's engagement with mental health services and their experiences. The sample size was guided by numerous factors, including: the focus of the research questions for the original study, the method of data collection (narrative interviews), demographic diversity within the sample, diversity of experiences accessing services, the depth and richness of the data obtained from participants, and the scope of the project itself (Braun & Clarke, 2019b). Thirty-three interviews were undertaken for the original study, however, two were subsequently excluded from analysis (the participants had misinterpreted the study aims but this only became evident once the interview had commenced). A further two participants had chosen not to access any mental health care due to distrust of the mental health system. These participants were also excluded since our focus was not on barriers to access.
Recruitment and Data Collection
Women were recruited from a large tertiary women's hospital, a clinical mental health service and a specialist sexual assault service using flyers, posters and cards placed in the waiting room and via referrals by practitioners. Advertising materials called for adult women with experience of “unwanted sexual contact” and “emotional health issues” to participate in an interview about health service use. Interested women were able to contact the research team directly for more information, after which the study plain language statement and consent form were sent to them. After provision of informed consent, a research assistant arranged a convenient time to speak to the interviewer (LT) either in person or via telephone. No eligibility criteria were applied other than women needed to be over 18 years of age and have sufficient English skills to take part in an interview.
After a preamble introducing the topic of SV and mental health problems, the interviews began by asking, “Can you tell me about your experiences accessing health services and what was good or bad about that experience?” Subsequent follow-up questions were different for each interview and dependent on what the woman said, but some examples included: “How did that make you feel when…” and “What would you like to see services do to improve?”. Unstructured interviews typically involve very little input from the researcher; the aim is to allow the participant to guide the narrative (Corbin & Morse, 2003; Low, 2019) and to create a conversation-like atmosphere. It is a flexible style of interviewing that generally requires skillful use of both verbal and non-verbal encouragement in order to keep the participant talking and to maximize the richness of the data. Twenty-seven interviews were undertaken face-to-face at The University of Melbourne. This was helpful for building rapport and for managing participant distress. However, the six interviews undertaken via telephone were also able to be carried out sensitively and empathetically. Indeed, some researchers suggest that the additional distance can be helpful when speaking about traumatic topics (Mealer, 2013). Overall, the interviews lasted between 30 minutes and 2 hours. They were audio-recorded and then transcribed verbatim for analysis.
Data Analysis
Interviews were analyzed using Braun and Clarke's reflexive thematic analysis (Braun & Clarke, 2006, 2021) and focused on women's experiences accessing mental health care. In their 2019 paper, Braun and Clarke state that thematic analysis should be considered a foundational method for qualitative analysis, and define it as “a method for identifying, analysing and reporting patterns (themes) within data” (Braun & Clarke, 2019a, p. 79). They outline a number of key steps in performing thematic analysis; the first step being the researcher thoroughly familiarizing themselves with the data. The researcher should then be able to generate codes for the data (codes refer to a feature of the data that the researcher considers notable) which are grouped together iteratively to form themes. The themes are then reviewed and refined, then defined and named, and finally the report is written, with clear evidence stated for each of the themes (Braun & Clarke, 2006). A key aspect of Braun and Clarke's method is its reflexivity (Braun & Clarke, 2019a). Researchers are encouraged to reflect on and embrace their own subjectivity—recognizing that all qualitative analysis is by its nature a product of interpretation (Braun & Clarke, 2019a). The lead author for this article, SI, was a student undertaking her honours year under the supervision of LT and EM. Her background is in biomedicine. Author EM has a social work background and works part-time as a counsellor in a specialist sexual assault service in addition to her resarch work. LT is a sociologist who has worked in sexual and domestic violence research for nearly a decade. The authors thus approached the analysis from a range of displinary perspectives, with varying degrees of expertise and a mix of research and practice experience with survivors of SV. At the same time, all authors approach the topic of SV from a feminist framework that prioritises trauma-and-violence informed care for survivors.
Interviews were analyzed by author SI, with input from LT, following Braun and Clarke's steps as outlined above. Coding was facilitated by the software program QSR NVivo. After descriptive coding was performed, codes were reviewed and combined based on the underlying meanings and common elements, creating interpretative codes. The process was repeated to reach the overarching themes. These codes and themes were reviewed multiple times by SI, LT and EM. Having multiple researchers review the themes, as well as the careful documentation of the analysis using NVivo, ensured rigor and trustworthiness of the data. Verbatim participant quotes have been used in the Results section to demonstrate how themes were reflected in the data.
Ethical and Safety Issues
This article is the result of a secondary analysis of qualitative data; however, it is important to note that the safety and wellbeing of women participating in the original study was carefully considered. Although the topic was potentially distressing, robust protocols were put in place to ensure that participants were supported throughout the process of recruitment and interviewing. All women were provided with resource cards with links to relevant services on completion of the interview irrespective of distress. Their time and contribution was recognized with the provision of electronic gift vouchers.
At initial contact with participants, the researchers requested “safe” contact details (phone number, email address) with which to communicate about the study. Subject headers for all email communication referred to a “Women's Health Study” rather than mentioning SV. Transcripts of the interviews were de-identified, with a pseudonym used instead of the participant's name. Any unique, potentially identifiable details were removed from the transcript. The original study received ethics approval from The Royal Women's Hospital HREC (#15/05), with subsequent approval for the present sub-study received from The University of Melbourne HREC (#2022-21472-26659-1).
Results
Participants were aged between 20 and 60 years, with a median age of 40.6 years. The majority were employed, tertiary-educated and self-identified as Australian. Fifteen of the women were in a relationship at the time of the interview. Women had accessed a range of mental health services on their pathways to safety and care. These included both clinical and non-clinical services such as: psychologists, psychiatrists, private counsellors, psychiatric inpatient units, community mental health services, crisis teams, and telephone helplines. Many women had also sought mental health support from a general practitioner; however, we did not include these experiences in our analysis since the GP is not a specific mental health service. Alongside mental health care, participants had also accessed a range of services for other co-occurring issues such as alcohol and substance misuse, chronic pain, and relationship issues; many had also accessed specialist sexual assault services. We did not ask women about the specifics of their experiences of SV (although some volunteered this information during the interviews); nor did we ask them about the specific timing of when they accessed mental healthcare. Thus, the sample contains both women whose experiences of accessing mental health services was recent, and women who had sought help many years earlier. We acknowledge that this is a limitation caused by our original aim to explore women's help-seeking pathways or journeys to recovery.
Four themes were developed through the analysis process describing women's experiences accessing mental health services after SV: (a) It's in the past; (b) It's not a big deal; (c) Navigating a maze; and (d) We’re the experts, you do as we say. These themes are outlined below with supporting quotations from participants.
It's in the Past
Many of the victim/survivors in this study perceived that mental health practitioners responded poorly to patients with a history of personal trauma. Participants described clinical encounters where practitioners failed to appreciate the complexity of trauma, its emotional and psychological impacts, and how trauma can underlie many common mental health presentations. They [mental health professionals] don’t understand [trauma]. Unless they’ve done some specific study on it, they don’t really understand how it’s so multi-faceted and how it can change who you are, the way you relate to other people, the way that you relate to men, [even] the way you relate to food. (Participant 21)
It’s really hard trying to explain this stuff to the services, because they just straight out stereotype you. I could go in and be perfectly sane and just tell them about my life and they’ll label me as ‘insane’ because they just make these assumptions that I’m not well when I am and I’m just reacting healthily to my circumstances and my life during unhealthy times. (Participant 6)
Related to this, participants described situations where clinicians failed to investigate or inquire about whether vague physical symptoms or behaviors from victim/survivors could be attributed to their past experiences of sexual trauma. I was in a hospital … and I used to shower three times a night. All through my files there’s not one person [who] asked me why I showered three times a night … I shower because of the abuse. (Participant 12)
Even when their experiences of trauma were identified or disclosed, some victim/survivors felt that mental health professionals did not want to hear about them. Women variously described clinicians as being disinterested, disengaged, uncomfortable, overwhelmed, shocked and/or burnt out when listening to victim/survivors’ stories. …Then she [counsellor] said, ‘Look, I’m not interested in what happened to you in the past, we just need to figure out why you’re having these attacks’. For me it was kind of like, well we kind of need to talk about the past in order to figure out why this is happening. So, I didn’t see her again. (Participant 27)
It was also noted that some mental health services with which victim/survivors engaged did not take a trauma-informed approach to dealing with patients. A trauma-informed service should assume that any patient might have a history of trauma and respond accordingly across all levels of the organization. Yet, women reported harmful encounters with patient-facing staff such as having their appointments cancelled with little to no notice and receiving rude or inappropriate responses when they tried to re-book: You’d just get a letter going, oh well, sorry we’ve had to cancel your appointment and here’s another one in six months’ time. Look, it happens. … But then you sort of have to ring up and go, look, is there anything sooner … and you’re talking to this person, who really couldn’t give a shit [laughs]. You’re just another person. (Participant 19)
Rather than relying on administrative staff adhering to the principles of trauma-informed care, several participants expressed a desire for standard questioning to screen for trauma when accessing a new service. They felt that this would more effectively raise awareness about trauma and ensure that responses from patient-facing staff were sensitive to the particular needs of patients with trauma histories. A lot of the access points don’t actually ask you “Have you experienced trauma?” or something like that. (Participant 20) Ideally every single person who enters the mental health system would be screened for trauma in a really sensitive way. In a really sensitive, safe way, would be asked, ‘Have you ever experienced sexual harassment, sexual assault. Is that impacting you now on how you’re feeling?’ (Participant 4)
Concurrently, a number of victim/survivors suggested that more training is needed about trauma within the entire mental health system. This included fostering a better understanding of trauma and its effects and better assessment for trauma within service sessions. There was also a call for more robust implementation of trauma-informed care in mental health services. I mean, every mental health clinician needs training in trauma, needs to know how to screen for it, needs to know how to sensitively respond to it, needs to know how to validate it. Needs to know how to keep people physically and emotionally safe in admissions, yeah. (Participant 4)
On the other hand, practitioners who were perceived as responding well to trauma were described as sensitive, kind and gentle with service users. They had a solid understanding of the physical, emotional and psychological effects of trauma and its complexity. They were also able to identify trauma without the victim/survivor needing to explicitly state it, validating the trauma experience. Anything that validates your experience, regardless of who it is in the system … someone who is able to give you that [validation] feeling … a lot of the problems that survivors have is feeling like [someone is not] actually acknowledging that something … did happen to them. (Participant 23)
It's Not a Big Deal
In addition to having a poor understanding of trauma generally, women in this study believed that mental health practitioners also had a poor understanding of SV specifically. Practitioners were described as uneducated about what constitutes SV, having a rigid understanding and recognizing only the most extreme examples, such as physically violent rape. This led to them overlooking less overt experiences of SV, with some practitioners going so far as to invalidate them. One person might come in and say ‘I feel really horrible because I keep on getting sexually harassed …’ Then another person might come in and say ‘I was raped by my boyfriend and his friend last night.’ … ‘They’re two really different experiences. Someone who doesn’t really get the gravity of the first one could easily say [dismissively] ‘Oh, okay’, which has happened to me before. So I think that that’s really not okay’. (Participant 30)
Several instances of not being believed and being blamed for the SV were discussed by participants. In some cases, this eroded trust in the mental healthcare system and led to disengagement from services. I went to him [doctor] and I told him about [the SV] and he goes, ‘Oh yeah, it was your fault, wasn’t it. What were you doing going for a walk out there?’ (Participant 29)
The responses I got ranged from ‘I don’t believe it’, ‘You’ve got it wrong’, ‘No, that doesn’t happen’. (Participant 20)
Instead, victim/survivors in this study suggested that mental health professionals should actively affirm that SV is not acceptable and help them to stop self-blaming. I think women … need to be told first up … that this is not your fault, that you did not ask for this, irrespective of where you are and what you were wearing and any of that. (Participant 17)
Even when the SV was acknowledged, however, many victim/survivors discussed examples of practitioners who downplayed the experience and its long-term impacts. A variety of language and comments were used to imply this, such as telling victim/survivors that it was “not a big deal” and reminding them that others have it harder. It is therefore critical that women not only be believed but the impacts of their experience validated. Downplaying people’s problems—‘Get over it’—it’s not nice. (Participant 10)
Again, it comes back to that—being believed and people acknowledging that it was a terrible thing. (Participant 23)
He [psychiatrist] had told me over the years lots of times, ‘You haven’t got PTSD, you haven’t been in a war’. (Participant 29)
Women discussed a range of practices by service providers that were inappropriate and re-traumatizing given the nature of the experience of SV. The most extreme examples of this were from women who had been institutionalized due to the severity of their mental health symptoms. Several participants spoke of being locked in mixed-sex wards and being subjected to physical restraint during inpatient admissions. I was put into a locked ward with two psychotic men, who were very acutely psychotic. You know, they were very acutely psychotic, and they were very loud and they were very rude, they sexually harassed me, constantly. One of them would constantly come over and put his hand on my shoulder, he would constantly be trying to talk to me. (Participant 4)
They [hospital staff] discussed whether I should be handcuffed and tied down. That was really demoralizing. (Participant 5)
It was perceived as critically important that mental health practitioners create a safe, non-judgmental environment for victim/survivors to be able to disclose and discuss their SV experiences. Women wanted practitioners to recognize the shame associated with SV disclosure and appreciate the effort it could take to talk to someone. Just being able to be in a safe environment to just talk about it I think helps a lot. (Participant 27)
There’s a lot of shame around [SV] and it’s something that’s really hard to actually talk about and even to admit. So, I guess to even—I guess it’s understanding that it takes a lot for someone to actually approach those services in the first place. (Participant 21)
Having a mental health practitioner who really listened to women and understood the context and dynamics of SV was also strongly recommended by the participants; they felt that these qualities would foster trust and promote healing. If a woman has been attacked, assaulted, raped, stalked, harassed, they need to see someone that specializes in women’s health issues … that would be my advice; find someone who knows what they’re talking about. (Participant 26)
That element of trust—trusting that the person is listening to you and really gets what you’re talking about, understands it and has the right response—especially in those initial first few months. Oh my God, that’s just so important. You know? (Participant 23)
Participants spoke about mental health professionals who helped them to recognize and label their experiences of SV as being helpful to recovery. Participants described an ideal mental health system where victim/survivors were believed, made to feel safe and supported to regain their sense of self-worth and reduce self-blame. She [counsellor] helped me to sort out, in my own mind, what had happened and gave it the label sexual assault. I suppose it helped me to work that out for myself. (Participant 18)
I want [mental health practitioners] to make me feel good about myself. Give me some sort of protection that men aren’t going to rape me if I start to lose weight and feel good about myself and … stop blaming myself for everything. (Participant 17)
Navigating a Maze
Victim/survivors faced a number of difficulties accessing and navigating the mental health care system, which was described as a “maze” and likened to being “lost at sea”. Many participants admitted that they had limited awareness of available supports and suggested that services increase public awareness of their available resources. It was really difficult to access different services, and you didn't really know that they were there. You had to hear about it from a friend or something like that. (Participant 22)
Maybe if I had had a clearer understanding when I was younger of how to deal with stuff or how to go and get help I would've maybe not have been as affected as I have been. (Participant 11)
When they were aware of available services, victim/survivors discussed various structural barriers they faced in accessing them, such as transportation issues, long wait times and services not accepting walk-in patients. Many victim/survivors thus felt that they were not getting the help they needed. We want help and we shouldn’t have to beg for it. We shouldn’t have to go on our knees saying, ‘Please help me!’ (Participant 11)
I’d see counsellors or psychologists and they were all...none of them ‘fit’ properly… (Participant 1)
Having to repeat their stories at multiple points during their use of services was described by many victim/survivors as particularly distressing. Some felt that they were wasting their lives trying to find the right support and they were not considered worthy enough to bother helping. There’s a lot of re-traumatizing around having to tell the story or request things over and over and over again. So even if you have to go and do one of the—what do they call them? ‘Mental health care plans’ and they review them every six weeks and then you go over and over that again. (Participant 20)
I got sick of going to the doctors and saying how I felt … It just felt like, why, why do I keep going there and saying [the same things]? … I feel like a record going around in circles and I just don’t think that it’s fair … I feel like they wasted my life. I feel like I’ve been on an island shipwrecked. (Participant 11)
A key suggestion to change this was that services should share patient information—with full consent of the victim/survivor—so that women would not have to repeat their story at a new service. Stuff resurfaces and you’re rehashing over things that you’re trying to put behind you and accept and move on. So that is hard and file sharing would be brilliant. (Participant 25)
Mental health practitioners were criticized by participants for not following up with victim/survivors outside of formal sessions. Victim/survivors discussed a need for practitioners to follow up in a number of ways, such as an email after a session detailing what was discussed and calling to check in when victim/survivors did not come in for their appointment. I feel like … everything is done within the room, there’s nothing additional to the hour counselling session that you’re being given. (Participant 25)
It just felt like I got … How can I put it? Imagine if you were just in a big swirly ocean, do you know what I mean? … That’s how it felt. It just felt like I was trying to keep up with the current if you know what I mean and trying to keep myself afloat … but I think that all these people that I spoke to along the way didn’t—there was no follow-up. (Participant 11)
Victim/survivors also spoke about issues with the referral process between mental health services and specialist SV services. Often mental health services did not provide referrals at all, or if they did, these were convenient to the service rather than being individualized to the woman's needs. None of the people I approached had ever said ‘Have you heard of CASA [Centre Against Sexual Assault]?’ No one. It amazes me now. (Participant 21)
[Services need to provide] individualized, more holistic referral, not just ‘these are the people we use because we like them’. (Participant 15)
It was suggested that services needed to improve their communication with each other and work together to improve mental health practice, moving toward a multi-disciplinary approach to treatment and recovery.
The sexual assault services need to go into every mental health service and train the clinicians. Train them in a trauma informed approach. (Participant 4)
My psychiatrist, psychologist, my GP and any other medical health professionals that I go to, they’re all in contact with each other … That feels really safe. (Participant 22)
We Are the Experts, You Do as We Say
Participants expressed a number of concerns regarding the biomedical and highly clinical nature of some of the mental health services they accessed. It was suggested that mental health practitioners—particularly psychiatrists—could be too quick to medicate victim/survivors and label them with a clinical diagnosis, with less focus on addressing the SV directly. This left the women in this study feeling disempowered and silenced. They’re [psychiatrists] too quick to medicate … if a woman has a trauma-based experience and their illness is trauma-based, medicating them is not going to do anything [but] psychiatrists aren’t going to sit there and listen to their patients without medicating them. (Participant 26)
It’s like, you’re already trying to put me in all of these little boxes. Tick, tick, yeah you know, you fit in here and we’re going to put this, and I’m like ‘Oh actually I’d rather that you just talked to me and listened to what I have to say rather than trying to tell me what you think I have an issue with’. (Participant 30)
The medical model where we’ve got all the knowledge, we’re the experts and you do as we say and you’ll get well type thing [laughs] which really isn’t going to work for everyone. (Participant 20)
Standard modes of treatment, such as cognitive behavioral therapy (CBT), were not necessarily helpful for all victim/survivors, and thus participants recommended that treatment plans be individualized to each service user. I accept that [CBT is] evidence-based and it provides a really solid framework for people, but it doesn’t fit everybody. (Participant 7)
Similarly, women had differing preferences regarding the focus of their mental health treatment. Instead of sessions built around talking and discussion of experiences, some participants preferred a practical approach, including helpful strategies for dealing with and moving forward from trauma without being dismissive of it. This highlights again the need for individualized, flexible approaches to SV. So, when I went to this other psychologist her approach was very much, ‘Okay, let's develop some strategies just to cope with every day because this doesn’t have to be a part of your life every day’… I think I expected a bit more ‘Let's talk about how you’re feeling’… which I was just so over. I just wanted to put it in the past. I wanted to close that door. So, her really practical approach was helpful. (Participant 3)
Many women discussed the need for more empathetic responses from practitioners rather than the “expert-patient” dynamic that the biomedical model tended to facilitate. Rapport was considered critical for the practitioner-patient relationship to function effectively and to promote recovery and trust. Yet, many women felt that practitioners simply did not really listen. They feel that they have to emotionally distance themselves, but I still think that that’s not okay, because it comes across as them being robots and machines and people who I can’t even have a conversation with or connect to in any way. (Participant 6)
To be heard is the most lacking thing in the mental health [system]. They’re not interested. They’ve been trained, they know what they’re doing. No. Listen to what the person’s telling you. Hear what they're feeling. Hear what they’re going through. (Participant 12)
Discussion
This qualitative study explored the experiences of women victim/survivors of SV when accessing Australian mental health services. The findings suggest that there remain many issues with service provision, concentrated within four distinct areas: trauma-informed care; understanding the context and dynamics of SV; navigating and accessing services; and tailoring service provision to individuals. Although there is some overlap with research around service provision for victim/survivors of intimate partner violence (Rose et al., 2011; Sorrentino et al., 2021; Trevillion et al., 2012; 2014), our findings speak to the particular context of SV and its strong relationship with self-blame and shame (Bhuptani & Messman, 2021; Tarzia, 2020a), as well as identifying issues within the Victorian mental health system in particular.
Our finding that SV-related trauma is not asked about, understood, or adequately addressed by some mental health practitioners is consistent with existing local and international research on this topic (Ahrens et al., 2009; Lanthier et al., 2018; O’Dwyer et al., 2019; Salter et al., 2020; Starzynski et al., 2017; Watson et al., 2020). This neglect occurs despite the fact that trauma (particularly relating to SV) is known to be extremely prevalent in the lives of Australian women (Australian Institute of Health and Welfare, 2020) and is recognized as underpinning a multitude of common mental health diagnoses (Chen et al., 2010; Dworkin, 2020). Furthermore, trauma-informed care has been considered as best-practice in mental health settings for many years in Australia (Bateman et al., 2013; Victorian Government, 2021). Salter et al. (2020) have pointed to systemic, structural issues within the Australian healthcare system that impede the successful implementation of trauma-informed care in practice. For example: a highly structured, rigid service delivery model; a public funding system that limits the number of appointments available to patients; a lack of specialist trauma-informed services; and a limited understanding of trauma related to interpersonal violence. While our findings support the views of Kezelman and Stavropoulos (2012), Hughes et al. (2019) and others who strongly argue that practitioner awareness of trauma and routine assessment of patients is pertinent to good mental health practice, overcoming these structural issues will be essential to improving service delivery alongside increased practitioner training (Hegarty et al., 2016; Salter et al., 2020).
In addition to a lack of awareness about trauma more generally, our findings also point to some mental health service providers’ limited understanding of and harmful responses to disclosures of SV. Women reported receiving responses that were invalidating and disbelieving, particularly when their experiences of SV were not overtly physically violent. This did little to alleviate their feelings of shame and self-blame and left them feeling distressed and distrustful of services. International literature has pointed to the shortcomings in the mental health system's response to SV as far back as 1999. Campbell and Raja (1999) found that service providers recognize that they themselves can perpetrate “secondary victimization” against victim/survivors of SV by mis-attributing responsibility for SV to the victim/survivor. A study by Ahrens et al. (2009) found that clinicians sometimes indicated to victim/survivors that their accounts of SV did not meet the definition of rape. It is quite widely reported in the literature that professional services tend to blame victim/survivors, both within mental healthcare specifically (Starzynski et al., 2017) and in other professional settings (Martsolf et al., 2010). Lanthier et al. (2018) identified blaming reactions from service providers in ten articles included in their systematic review on “delayed disclosure” of SV, representing almost half of all included papers. Within psychiatric inpatient settings, our findings echo those of O’Dwyer et al., who reported numerous barriers to the delivery of “gender-sensitive care” (a variant of trauma-informed care with a gendered focus) for women victim/survivors of SV, including a lack of understanding about the complexity of women's experiences of SV and how the environment could be re-traumatizing (O’Dwyer et al., 2019, 2021). It is for these reasons that there has been a recent shift among researchers in the violence against women space to move from trauma-informed care toward trauma- and-violence-informed care (Hegarty et al., 2022; Public Health Agency of Canada). Trauma- and-violence-informed care recognizes not only the impacts of trauma but, specifically, the impacts of interpersonal violence-related trauma on health and wellbeing.
Participants in this study highlighted numerous challenges around service navigation and integration between mental health and other services. This finding has featured less prominently in the US literature on help-seeking after SV but has been acknowledged by researchers in the UK (Hughes et al., 2019). The fragmentation and siloing of the mental healthcare system is a well-recognized problem in Australia (Quadara, 2015; Salter et al., 2020; Victorian Government, 2021), although few studies to date have addressed the impact of these issues on victim/survivors’ help-seeking experiences after SV. It is true that a “care co-ordination” model has been implemented as a way to ensure that service users receive co-ordinated service delivery, irrespective of which service entry point victim/survivors access (Bateman et al., 2013). It should be noted that the interviews for this study took place several years ago, and so it is hoped that co-ordinated service delivery has improved to some extent. Yet, at the same time, clear pathways for how to implement and embed service coordination in the context of mental health services and specialist sexual assault services are still lacking.
The final theme that was developed from our analysis suggests that the mental health system in Australia remains influenced by a biomedical framework. There was a feeling that service providers lacked empathy and tended to view service users as “cases to be solved”, rather than as individuals who needed a strong relationship with their service provider in order to begin their journey toward wellbeing. Woody and Beldin (2012) similarly affirm that victim/survivors of SV show reluctance to engage with mental health and psychiatry due to their biomedical—rather than bio-psychosocial—view of health, with Hurley (2010) adding that services can be overly pathologizing of victim/survivors. Scholars in the UK (Hughes et al., 2019; Sweeney et al., 2019) have highlighted similar issues, but only a few studies have explored this in the Australian context (Humphreys & Thiara, 2003; O’Dwyer et al., 2019; Salter et al., 2020) and only one in relation to SV (O’Dwyer et al., 2019), of which all are consistent with our findings.
There are several implications of this research for mental health practice and service delivery, both in Australia and internationally. First, it is clear that—from the perspective of the women victim/survivors in this study—mental health service providers need to better understand the wide-reaching impacts of trauma and how it can underpin common mental health presentations, particularly for women. Related to this, the specific impacts of trauma related to SV and appropriate responses need to be emphasized in practitioner training (Hughes et al., 2019). Service responses that ignore a woman's history of SV, blame her for the violence or pathologize her trauma response may exacerbate or create new adverse outcomes for victim/survivors (Sweeney et al., 2019). Practical guidelines and recommendations for how to respond to women experiencing violence already exist, such as the World Health Organization's LIVES model (Listen, Inquire about needs, Validate, Enhance safety and Support and follow up) (World Health Organization, 2014) and the CARE model (Choice and control, Action and advocacy, Recognition and understanding and Emotional connection) which focuses on woman-centered care (Tarzia et al., 2020). Although these guidelines refer more broadly to violence against women rather than being specific to SV, the broad principles about what women need from healthcare responses are similar. These guidelines ought to form a core part of training for mental health practitioners. Another recommendation victim/survivors made was to have SV specialist service workers train mental health service providers, although this would need to be resourced in order to make it feasible and sustainable.
Service integration remains a problem across the mental health and specialist SV sectors in Australia (Hegarty et al., 2016; Salter et al., 2020). It is highly likely that similar issues exist elsewhere, although international research has not tended to focus on this problem as a specific issue for help-seeking after SV. Different service models (feminist versus biomedical) remain a barrier to effective collaboration and there are few examples of successful models globally on which to draw on to improve practice. Ensuring that the specialist SV sector works to meaningfully engage with mental health services despite the different frameworks for practice can improve the health and experiences of victim/survivors (Hegarty et al., 2016; Quadara, 2015). Meaningful consultation with women with lived experience of SV and mental health issues to co-design services (and co-produce research) is also critical to building more responsive, safe and effective services (Hughes et al., 2019; Oram, 2019; Sweeney et al., 2019).
Strengths and Limitations
Strengths of this study include the inclusion of rich and detailed data from 29 victim/survivors of SV. Using in-depth qualitative data places women's voices front and center in identifying issues for mental health service reform. Another strength was the joint coding process; three researchers worked collaboratively to thoroughly analyze the data, taking time to review and reflect on the analysis process over several weeks.
Our research comes with a few limitations. First, these interviews were conducted in 2016 but were analyzed in 2021, which suggests that the data may be outdated. Participants were recruited exclusively from Victorian health services; thus, the findings may not be as relevant to mental health systems in other Australian states and territories or internationally. The sample of participants was also lacking in diversity—the majority were tertiary-educated, employed, and identified as Australian. We also did not collect detailed data about participants’ experiences of mental health service access (e.g., timing of access). Finally, it is likely that those who elected to participate had strongly negative or strongly positive experiences, while those with neutral experiences would perhaps be less inclined to participate in research.
Conclusion
This study explored the experiences of women victim/survivors accessing Australian mental health services after adult SV. Our findings suggest that mental health service providers in Australia may lack understanding of trauma and its sequelae, as well as having a limited grasp of the specific experience of SV. Compounding this, service navigation issues and a lack of coordination between mental health and specialist SV services create unnecessary problems for victim/survivors seeking support. Finally, our findings suggest that the biomedical paradigm remains prominent within the mental healthcare system, leading to a tendency to label and diagnose mental health “disorders” rather than seeing the underlying trauma, the individual and their needs. A responsive, trauma-and-violence informed mental healthcare system is critical to best meet the complex mental health needs of victim/survivors of SV.
Footnotes
Acknowledgements
The authors would like to gratefully acknowledge the women who participated in this research for their contributions and insight.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors would like to acknowledge funding from Australia's National Research Organisation for Women's Safety (ANROWS) for the original research on which this article is based.
