> For more information regarding trauma and dissociation in the United Kingdom, you can read our articles The development of training and practice in the UK: Reflections on the last 3 decades and Pathways to skilled therapy for dissociative survivors in the United Kingdom
Observations on Dissociation and trauma in the UK
Written by Melanie Goodwin Director of First Person Plural
An historical overview of the availability of help, including therapy for people with childhood trauma related dissociation in the UK enables us to appreciate where we are today. Although there is currently some positive work happening within mental health in the NHS this often has little impact on this client group.Most authorites within the NHS now include trauma screening with patients, a very few include dissociation but in both cases rarely does it lead to suitable help. A lot of the learning and changes relating to dissociation over the last twenty-five years within the statutory, voluntary and private sectors has been led by therapists working in the private sector. They stumbled across their first DID client and quickly realised the need to resource themselves to be able to progress and survive this challenging work,Initially they became members of the ISSTD, and later several therapists were proactive in forming the ESTD. This made it easier to confer directly with their European colleagues Many of whom were facing similar challenges.
This group of private therapists continuously put their heads above the parapet through working with DID clients. They persevered in, trying to get the NHS to recognise and include screening for DID in general mental health assessments leading to the provision of long-term, DID focussed therapy. Some health authorities genuinely wanted to help those patients, who had seemed cases without hope and were willing to fund therapists working in the private sector if appropriate therapy was unavailable within the NHS. Others with DID needed to take a legal route involving solicitors before they were listened to and some were never heard. This was the beginning of NHS commissioning private therapy and supervision for their psychologists. In some ways not a lot has changed over this time! Those directly involved constantly endeavour to encourage the NHS to take responsibility for providing a holistic service, not just financing therapy. Ruptures can be caused when someone is NHS-funded for private therapy and needs to utilise other NHS resources, like short-term hospitalisation. If there is not a working partnership, the blame for this situation can all too easily be laid at the door of ‘bad’ therapy. This undermines many therapists who have been providing good therapy.
Educating the NHS and those working in private practice about complex dissociative disorders fell to a small body of people who were passionate about bringing lasting change. Therapists who were becoming experienced working with DID clients started offering training including the ISSTD introduction course. First Person Plural (FPP) a survivor led organisation was becoming well established and their ‘Understanding Dissociation’ days were fully booked quickly wherever offered including within the NHS. The Trauma and Abuse Group (TAG) was likewise offering training with experienced trainers within a supportive environment.
It soon became apparent there was a real thirst for trauma and DID information, appropriate services and training and there has been a steady growth in organisations and individuals providing this in the UK over the years.
The ESTD-UK offers a progressive, classroom-based training programme that includes input from FPP. This programme combines experienced clinicians and those with the lived experience making it unique in the UK. To enable their expertise to be more widely available at low cost, an online, modular programme offering foundation and specialised modules is in production. This will be supported by FPP’s two training films that received ESTD sponsorship.
The ESTD-UK hosts a listserv for members; a forum for new and experienced therapists to share their work, concerns, successes, and peer support.
The global financial constraints of the last few years continue to have a profound and detrimental impact on mental health services throughout the UK. Over the last twenty-five years there has been a growing understanding of the relationship between adult mental health, childhood trauma, dissociation, relationship issues caused through disrupted attachment, and effective treatment.
The differences in the developing brain that is constantly experiencing the impact of trauma and one that is not is being clinically proven through neuro imaging silencing the voices of disbelief and ridicule often aimed at DID. These developments endorse that behaviour modification alone does not enable the actual rewiring of the brain that needs to happen. The unavailability of longer term therapy supported by other resources has activated the return to the only provision being crisis interventions within the NHS, which often escalates the problems. As always, there are pockets of excellent help provided by experienced NHS staff including therapy. They really understand this client group’s needs but often are unable to meet them because of the rigidity of the restricted system they are working within.
The fragmentation between social and health providers often feels as if each is desperately trying to get you off ‘their patch’ while the continual threat of assessments and loss of benefits undermines, preventing any therapeutic input being as effective as it would otherwise. Many patients become frozen in time, they literally cannot afford to improve, because they will be deemed ‘fit for work’ long before they reach a place that is sustainable; we are currently living in a climate that fails to acknowledge and support people’s slower but genuine return to health and many continue to slip through the proverbial net.
Some people with complex mental health issues never quite fit the questionnaires used to identify the ‘problem’; they are then deemed too complex for treatment, so somehow do not exist. The suicide figures for people with childhood trauma-related dissociation are unavailable. If it is not diagnosed, how can it be a cause? So often, press reports record a lifetime of mental health problems, the revolving door patient, and name multiple diagnoses. We will never know if the possible primary diagnosis of DID in some of these cases was ever even considered.
This blanket overview sounds extremely bleak and remains so for many people although the provision for soldiers with PTSD is becoming established with much being learnt about the multi-needs of those who have been severely traumatised. There is an understanding that working with this level of trauma has to be done within a safe environment; you cannot expect someone to face and resolve their terrors made up of nightmare experiences in a few, fifty-minute sessions.
To summarise, some changes have taken place in the NHS over the last twenty-five years relating to trauma and DID. A growing number of GPs have an understanding and are willing to get their patients appropriate therapy through external commissioning. Many mental health teams understand that the health service fails this group of patients but manage to put in place an appropriate programme focusing on stabilisation with ongoing support.
Through my involvement in helping to plan an ‘Understanding Dissociation’ day for a NHS mental health team I begin to appreciate some of the enormous obstacles that have to be negotiated . The training is to help recognise complex dissociation, including DID, and to identify changes that can be integrated relatively seamlessly into existing procedures. It requires empowering, not overwhelming, by recognising and utilising their many existing strengths and identifying the positive benefits for all involved.
Some areas of concern that have the potential to highjack this training are: -
- Can it work if screening for trauma and dissociation is not automatically part of all mental health assessments?
- How can information be made available on each individual’s case and used by ALL involved including social workers, GPs, the mental health crisis team and those admitting someone to hospital?
- How can a private therapist who is commissioned by the NHS become a full and respected part of the whole mental health team involved in their client’s care?
The need for presenting continuity is essential for someone with DID; if those who are helping work in fragmented isolation, how can their patients ever begin to develop a more cohesive approach to life? The very nature of working with many different people, cancelled appointments, the continual changing structures of departments, makes it impossible for someone whose trust was destroyed as a child to begin to take the first steps towards health. What is seen as an expensive input by the NHS is defeated if addressing the practicalities is not prioritised. Good therapy is severely compromised if the time and room change weekly or if another appointment is cancelled by a harassed receptionist; as we know the foundation of lasting change is built on relationships developed through a growing ability to trust.
The irony is the increase in those who do understand this patient group’s needs and are frustrated because they are unable to address them. The distorted outcomes, because the process of collecting data to provide evidence does not reflect the continuous negative factors that outweigh the positive input. The need to include social and health provision giving a holistic overview if the client is to be able to maximise the services that are offered.
We are at a major crossroads; the ‘trend’ for the provision of ‘short term therapy only’ has to change. We need to move away from the climate of fear and confusion surrounding what is perceived as dependency if therapy that has the potential to bring about sustainable change is to become available. To address the institutionalised thinking and clinical language while developing a working partnership with people with complex needs rather than viewing them as the expensive enemy. Lack of money currently prevents radical changes happening quickly but a foundation of understanding and validation supported by appropriate help within a metaphorical holding environment is the positive beginning of the therapeutic journey for many until they are offered the long-term therapy they need.