It's Time to Stop Permitting Abuse

Sylvia Caras, Ph D

Expectations for a longer healthier lifetime are global. Research, technology, and guidelines have increased our sense of entitlement. There are insufficient assets anywhere to deliver enough care to meet these expectations. Prevention is the only next step.

The demand on the mental health system for treatment has also been increasing, even faster than population builds. More staff and more resources are allocated to repairing what psychiatry diagnoses. Somehow this mental health work load must be reduced.

There is a larger context for the work load. Today most attention is directed downstream at treatment and rehabilitation. But rescue medicine is not enough.

We can use primary prevention to reduce the number of people upstream, the number coming into the system and wanting services. Healthy lifestyles in healthy communities can reduce the impact of risk factors and create local peer support.

"Efforts to improve health, to change personal habits, and to work on unhealthy environmental and social determinants of injury and disease touch on some fundamental questions of morality and politics: the role of government, the place of health in individual and community life, the use of force or persuasion to change behavior, and the vision of society that lies behind a concern for health in the first place. These dimensions of the problem of promoting good health have not gone unremarked, but they have not been explored with the seriousness that they deserve." (1)

A serious gaze will help in not overlooking a risk factor for psychiatric diagnoses - abuse.

For, as Labonte reminds us, "It is at the more mundane level of how people treat each other that civil society and a common good are created and bases established for collective actions at higher political levels." (2)

Most abusers, not all, but most, are men. (3) Their mothers and wives and sisters often protect them at their own and the victim's expense. (4)

But in the executive summary of the US Surgeon General's Report on Mental Health, there is one mention of abuse and neglect, in the abstract fo the chapter on children. One mention, in 30 pages of summary. Yet the American Journal of Public Health reported this fall, "In any given year in the United States, more than 2 million wives are physically battered by husbands and nearly 3 million children are reported as victims of abuse." (5)

SAMHSA says that two-thirds in substance abuse treatment report physical, sexual or emotional abuse during childhood. (6)

Studies consistently confirm a 50-80% prevalence rate of sexual and physical abuse among persons who later acquire diagnoses of mental illness. (7)

So roughly 60 % of those diagnosed with mental illness or in substance abuse treatment report physical, sexual or emotional abuse.

Don't dismiss the evidence of the experiences behind these statistics. This essay would have more impact if I now told you stories, personal stories of the experiences of real people. I can't. I would disturb myself, and you too much. Think of little girls and big brothers, children and fathers, punishing mothers, think of rape, and incest, and beatings. Think of a lifetime with those memories. Try not to look away.

In 1990 there were an estimated 10 million adults in the US diagnosed with serious mental illness. (8) So then, statistically, some six million of those were abused. Try not to look away.

If abuse is causal and if in the next generation we reduce abuse enough to divert even 10%, we might save 600 000 people from a mental illness diagnosis. Even if we find out that abuse is not causal, merely correlative, we will have removed a variable, narrowed the research areas, and will be doing a social good. For is sexual abuse any less wrong if it does not lead to trauma and mental illness?

If abuse is not also a cause of chronic illness, we can learn what are the individual and cultural strengths that lead to resilience and to recovery?

Perhaps there is a parallel pre-disposition to being abusers and using substances and getting diagnosed with mental illness. What are the root causes of violence towards each other.

Indeed, the trauma of the abuse may cause the brain changes that are reported to display on brain imaging photos. But if that is the case we are only stopping symptoms. How much better to stop traumatizing those brains. Overlooking trauma and its after-effects can lead to wrong diagnosis and thus to wrong prescriptions for treatment.

Research has indeed found ventricle enlargements before medication treatment. They've concluded this defect links to schizophrenia. (9) I haven't seen that social histories were taken. I would like to know if it is trauma that has caused the enlargements, trauma perhaps caused by sexual abuse.

Or perhaps trauma causes frontal brain damage, damage that can cause emotion to lose its anchor in previous experience, leading, Brown speculates, to an absence of wisdom in the management of daily behavior. (10)

Now, we medicalize this persistent social problem of person-against- person violence by looking at the individual perpetrator and the individual victim. The focus on the individual leaves unexamined the community and family factors. It's time for intervention and prevention at the community level. In 2002, the theme for World Mental Health Day will be connected to mental health and violence, and specific action strategies may emerge.


Now, by de-emphasizing upstream risks like abuse we assure a steady downstream flow of problems and a concomitant increase in the size and costs of the behavioral health industry.

"When coping with the social problems caused by a lack of cohesion and social justice, there is a tendency to see new services as the answer, but in fact it is essential that the main causes of problems be confronted at a policy level which affects the well-being of the whole population." (11)

Proactive prevention is needed. Outrage is what's called for. Enough outrage to withdraw the social permission for abuse. Janet Reno says: "Violence is not inevitable, nor an abstract force against which we are powerless. We can end violence if we as individuals, as communities and as a nation decide not to condone it and not to remain passive." (12)

Ignoring the upstream perpetrators while shaming the individual victim is off the mark The shame belongs to society. Let us make not abusing each other our shared practice.

Sylvia Caras, 2001


1. Daniel Callahan, Promoting health and preventing disease: ethical demands and social challenges, in Callahan, Daniel, Ed, Promoting healthy behavior: How much freedom? Whose responsibility? 2000. Washington, DC: Georgetown University Press. p 168

2. Ronald Labonte, Health promotion and the common good: toward a politics of practice in Daniel Callahan, Freedom, Healthism, and Health Promotion: Finding the Right Balance, in Callahan, Daniel, Ed, Promoting healthy behavior: How much freedom? Whose responsibility? 2000, p 112. Washington, DC: Georgetown University Press.

3. Kerry Healey et al, Batterer Intervention: Program Approaches and Criminal Justice Strategies, 1998. Washington, DC: U.S. Department of Justice, Office of Justice Programs, National Institute of Justice http//

4. For one instance, Alison E. Gerencser, Family Mediationscreening for Domestic Abuse, 1995. Florida State University Law Review. http//

5. (AJPH Setp 2000 p 1473 book review)

6. http//

7. http//

8. Manderscheid, R W and Henderson M H, eds. Mental Health, United States, 1998, Washington, DC: Superintendent of Documents, U S Government Printing Office.

9. The search for causative factors, NARSAD Research Newsletter, 13:1, spring 2001, p 1

10. Warren S Brown, *Wisdom and Human Neurocognitive systems: perceiving and practicing the laws of life,* in Warren S Brown, ed, Understanding Wisdom, 2000, Philadelphia:Templeton Foundation Press, 2000. p 209

11. Richard Wilkinson, Unhealthy societies: the afflictions of inequality, quoted in the Newsletter of the Finnish Association for Mental Health, 2000

12. Janet Reno, The Nation's Health, APHA, August 2000, p 6

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